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. 2019 Dec 11;5(1):197.
doi: 10.1186/s40792-019-0758-7.

Laparoscopic treatment in a patient with median arcuate ligament syndrome identified at the onset of superior mesenteric artery dissection: a case report

Haruhiko Okada  1 , Kazuhisa Ehara  2 , Hisashi Ro  3   4 , Masaki Yamada  3 , Tetsuya Saito  3 , Naoki Negami  3 , Yasunori Ishido  3 , Masahiko Sato  3
Affiliations

Laparoscopic treatment in a patient with median arcuate ligament syndrome identified at the onset of superior mesenteric artery dissection: a case report

Haruhiko Okada et al. Surg Case Rep. .

Abstract

Background: Median arcuate ligament syndrome (MALS) is a rare clinical entity caused mainly by extrinsic compression of the celiac axis by the median arcuate ligament (MAL). Severe celiac artery stenosis can lead to the development of collateral circulation, aneurysms, and, rarely, superior mesenteric artery (SMA) dissection. The treatment of MALS involves the surgical release of the MAL. However, a standard procedure with the use of laparoscopy has not been established, and intraoperative complications can lead to severe vascular injury.

Case presentation: The patient was a 43-year-old man with MALS identified at the onset of SMA dissection. After treatment for the SMA dissection, he underwent laparoscopic MAL release. Using the technique of laparoscopic gastrectomy within the surgical field, we performed laparoscopic MAL release and ganglionectomy safely with a good view. Immediate symptomatic improvement was acquired, and no recurrence was observed at the 20-month follow-up.

Conclusion: We reported a rare case of MALS and SMA dissection. A horizontal 3D laparoscopic approach of the celiac axis allows for safe, meticulous, and radical MAL release and ganglionectomy.

Keywords: Laparoscopy; Median arcuate ligament syndrome; Superior mesenteric artery dissection.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
a, b Superior mesenteric artery dissection with the thrombosed false lumen is shown by arrow heads on an axial view (a) and a sagittal view (b) of contrast-enhanced CT. c Sagittal view of enhanced CT showing extrinsic compression of the root of celiac axis by the MAL (arrowhead). d 3D reconstruction of abdominal aortic angiotomography showing severe stenosis of the proximal segment of the celiac axis caused by extrinsic compression of the median arcuate ligament (arrow head) and poststenotic dilatation (arrow), and narrow true lumen of superior mesenteric artery(circle) from isolated dissection with a thrombosed false lumen
Fig. 2
Fig. 2
a Intraoperative image showing horizontal approach with retracting the stomach ventrally. S, stomach; P, pancreas; LGA, left gastric artery; SA, splenic artery. b Intraoperative image showing the fibers of the MAL. M, MAL; LGA, left gastric artery; SA, splenic artery; LC, left crus. c Intraoperative image showing the origin of the celiac artery freed from the MAL (arrow head). Ao, arota; CA, celiac artery; LGA, left gastric artery; SA, splenic artery
Fig. 3
Fig. 3
Follow-up (6 months) 3D aortic reconstruction showing a normal caliber of the celiac artery, without evidence of stenosis (arrow head) or poststenotic dilatation (arrow)
See this image and copyright information in PMC

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