Celiac artery compression by the median arcuate ligament constitutes a rare surgical condition known as median arcuate ligament syndrome (MALS). Predominantly affecting females, it often presents as prolonged abdominal pain, particularly after meals, resembling symptoms of foregut ischemia [1]. The primary treatment involves surgically releasing the celiac artery from the surrounding compressive connective tissue, ideally performed using minimally invasive techniques [2]. Here, we present a case of MALS treated with robotic surgery.

A 50-year-old male patient presented with a 3-month history of recurrent epigastric abdominal pain, accompanied by vomiting, diarrhea, and malaise. Abdominal computed tomography (CT) revealed characteristic findings of the syndrome, including celiac artery stenosis and dilatation of the gastroduodenal artery collaterals. An elective median arcuate ligament release was planned.

The patient was positioned supinely, and pneumoperitoneum was established via a Veress needle inserted at Palmer’s point. Four ports were sequentially placed transversely in the upper abdomen. An 8-mm camera port was positioned two fingerbreadths to the right of the umbilicus, while the remaining working ports were 8 mm and placed approximately 8 mm apart. The patient was then tilted into a slight anti-Trendelenburg position, and the da Vinci X robotic system (Intuitive Surgical, Inc.) was docked. Dissection of the lesser sac facilitated identification of the celiac artery. The connective tissue at the level of the median arcuate ligament was dissected circumferentially in a craniodorsal direction. Meticulous dissection was also performed to remove the surrounding nerve tissue of the celiac plexus.

The overall length of the operation was 160 minutes, with no blood loss. Postoperative duplex ultrasound imaging revealed an end-diastolic flow velocity of 38 cm/sec. The patient had an uneventful postoperative course and was discharged on the first postoperative day, reporting symptom improvement at the first follow-up visit.

MALS is an extremely rare condition, with an estimated incidence of two cases per 100,000 people [3]. This low incidence, coupled with the nonspecific gastrointestinal symptoms associated with the disease, often results in a prolonged clinical course with a challenging diagnosis [4]. Indeed, there are currently no clearly defined diagnostic criteria, with a combination of imaging modalities typically proving useful [5]. Impingement on the proximal aspect of the celiac artery, along with collateral vessel dilatation, may be demonstrated on CT, while celiac artery blood flow velocities exceeding 200 cm/sec on duplex ultrasonography strongly suggest MALS [6].

A high index of suspicion is thus necessary in patients presenting with unexplained gastrointestinal discomfort disproportionate to clinical examination findings, which are often unrevealing. Once a diagnosis is established, surgical management should be pursued to alleviate pressure on the celiac axis. Previous investigations have indicated that laparoscopic surgery is superior to open conventional surgery, offering comparable efficacy with reduced perioperative morbidity [7].

Robotic approaches theoretically capitalize on the advantages of laparoscopic surgery. The enhanced flexibility of the endowrist system of robotic platforms may facilitate tissue dissection in acute angles if necessary, allowing for more precise dissection. This may be particularly beneficial in ablating the nerve tissue of the celiac plexus, which is believed to contribute significantly to chronic splanchnic pain perception. In experienced hands, both minimally invasive approaches yield comparable outcomes, as long as an adequate extent of dissection is achieved that completely releases the celiac artery from nearby compressive connective tissue [2]. However, the robotic approach may aid in mitigating the learning curve associated with the procedure, which is especially advantageous given the limited number of cases available for experience building.

In conclusion, we present the case of a 50-year-old male patient with intractable gastrointestinal symptoms suggestive of MALS. We highlight the aspects of minimally invasive management using a robotic approach, which can be successfully employed in such cases, yielding excellent outcomes.

Ethical statement

Written informed consent was received by the patient.

Authors’ contributions

Conceptualization: MTM, EF

Methodology: DP

Software: NK, LP

Validation: GK

Investigation: MP

Data curation: NB

Writing–original draft: DP

Writing–review & editing: All authors

All authors read and approved the final manuscript.

Conflict of interest

All authors have no conflicts of interest to declare.

Funding/support

None.

Data availability

The data presented in this study are available upon request to the corresponding author.

Supplementary materials

Supplementary materials can be found via https://doi.org/10.7602/jmis.2024.27.3.181.