Median Arcuate Ligament Syndrome Following Trauma

The case involved a thirty-three-year-old male with a seventeen-year history of postprandial nausea, vomiting, and epigastric pain. He also suffered from chronic abdominal pain from a past motorcycle accident.

The previous workup included a negative EGD. An abdominal CT and mesenteric artery duplex revealed evidence of left renal vein compression and hemodynamically significant distal celiac artery stenosis. The patient had several days of complete resolution of his symptoms following a celiac plexus block. Therefore, the patient was diagnosed with median arcuate ligament (MAL) syndrome.

Operation

After placing the patient in reverse Trendelenburg position, a 7cm upper midline incision was made, and the peritoneal cavity was entered. A self-retaining retractor was used to improve the visualization. Next, the liver was retracted cephalad, and the pancreas was retracted caudad. The retractions exposed the lesser sac. The lesser sac was opened sharply and appeared to be quite inflamed, which is relatively common for these cases.

The common hepatic artery was subsequently identified and dissected, freeing it of soft tissue attachments and inflamed neural tissue. Dissection was performed back to the bifurcation of the splenic artery and mobilized along with a significant distance. A substantial number of inflamed nerves were noted. Dissection then proceeded back along the celiac artery until the left gastric artery could be identified. It was then freed laterally toward the stomach, removing all the adhesed nerves and inflamed tissue.

Circumferential dissection then moved to retrograde along the celiac artery. Dissection proceeded until a notably tight MAL was observed in the patient. The ligament was compressing the celiac artery and adjacent structures. Correspondingly, the tight fibrous band was released and removed using harmonic energy.

The crus of the diaphragm was very soft and pliable and was spared. As before, all the adjacent inflamed lymphatic and neural tissues were excised from this area using harmonic energy. Dissection and removal of inflamed tissue then progressed back to the spine on both sides of the aorta. The celiac ganglion did not appear to be involved in the compression process.

The patient was extubated and taken to the recovery room in stable condition. The patient tolerated a low-fat diet on a postoperative day one (POD1). This was a tremendous change from preoperative postprandial symptoms. The pain was well-controlled, and with the return of bowel function on POD2, the patient was discharged home.

Discussion

The MAL syndrome is a fairly rare condition with a tedious diagnostic workup. Some groups propose intraoperative abdominal cavity exploration to rule out other causes of the pain. Our workup includes a CT scan, celiac plexus block, and mesenteric artery duplex scan. Although in the past we preferred a laparoscopic approach, we now find open procedures to be more effective. Open procedures allow for better dissection and neurolysis in critical areas around the celiac and other arteries. The study by Kruchareon et al. showed no statistical difference in postoperative pain between open, laparoscopic, and robotic approaches for MAL release. Another observed improvement is the achievement of successful results with only a MAL release, without any dissection of the crura.

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