Median arcuate ligament syndrome (MALS) is an extremely rare disease that affects the median arcuate ligament. It occurs as a result of focal stenosis of the celiac artery due to compression by the median arcuate ligament. This causes unintentional weight loss and upper abdominal discomfort after eating. MALS can be effectively treated by dividing the arcuate ligament [1]. This procedure is increasingly being performed laparoscopically because of improvements in laparoscopic methods [2,3]. This video article presents a patient with MALS who was successfully treated using a laparoscopic approach.

A 33-year-old male presented with complaints of postprandial upper abdominal pain for the past 3 months. He gradually reduced his food intake in order to avoid pain, which led to him losing 6 kg of weight during this time. Abdominal ultrasound and gastroscopy results were unremarkable. Contrast-enhanced three-dimensional computed tomographic angiography of the abdomen showed characteristic compression of the celiac artery by thickened median arcuate ligament causing a ‘J’ shaped course of the artery with poststenotic dilatation and dilated branches of the celiac artery through its collaterals. Hence, the patient was diagnosed with MALS. Informed consent was obtained from the patient and laparoscopic ligament division was performed.

Operative procedure

The patient was positioned in a supine posture with both legs split and by 30° of head-end elevation while under general anesthesia. Pneumoperitoneum was induced with a Veress needle at Palmar’s point. A 10-mm camera port was inserted 3 cm above the umbilicus, two 5-mm ports in the left upper abdomen, and a 5-mm port in the right upper abdomen. The left lobe of the liver was retracted using Nathanson’s retractor. Laparoscopy was performed with a 30° scope. Using a monopolar hook dissector, the pars flaccida was opened and proceeded till right diaphragmatic crus. The left gastric vein and artery were identified and looped with an umbilical tape. Diaphragmatic fibers on the supraceliac aorta were dissected and 4 cm of same was exposed. Branches of the celiac artery were dissected towards its origin. These steps led to the visualization of the thickened median arcuate ligament along with the nervous plexus around the celiac artery. The celiac artery was freed after the median arcuate ligament was meticulously hooked and divided. A Supplementary Video of the operative procedures has been provided (available online).

The duration of the surgery was 140 minutes. The patient was discharged uneventfully on postoperative day 2. Following surgery, the patient’s symptoms were alleviated. The patient had gained weight and was pain-free at the 2-month follow-up visit.

The right and left crus of diaphragm on either side of the aortic hiatus is surrounded anteriorly by a fibrous band which constitutes the MAL. The crus of diaphragm has its origin from L1 to L4 vertebrae along its anterior aspect. The celiac axis branches off the abdominal aorta varyingly between vertebral levels D11 and L1 [4]. The compression of the celiac artery by the median arcuate ligament leads to the development of localized stenosis, which in turn causes MALS. This stenosis may result from an aberrant inferior diaphragm insertion or an abnormally superior celiac artery origin [5].

The compression of celiac artery by the median arcuate ligament occurs in 10% to 25% of the general population. It is often asymptomatic and noticed incidentally. However, only 1% of these individuals experience MALS [5], which requires treatment. MALS is a diagnosis of exclusion [5]. Our patient had the most typical signs of postprandial upper abdominal discomfort and unintentional weight loss.

MALS is treated via decompression of the celiac artery. The mainstay of treatment is surgery. The various options include [6]: celiac artery decompression, celiac artery reconstruction, and celiac artery endovascular stenting. According to Rubinkiewicz et al. [7], who examined the long-term outcomes of 186 MALS patients over a 12-year period, celiac artery decompression and celiac ganglionectomy is the most commonly used MALS treatment due to its favorable long-term outcomes. The release of median arcuate ligament results in celiac artery decompression [1]. To confirm median arcuate ligament release, the diaphragmatic fibers should be dissected, exposing up to 4 centimeters of the supraceliac aorta. Celiac artery decompression can now be accomplished laparoscopically owing to recent advancements in laparoscopic methods [2,3]. In this particular case, we decompressed the celiac artery effectively using a laparoscopic approach.

The laparoscopic and open approaches for treating MALS performed between 1963 and 2012 were compared in a study by Jimenez et al. [8], and it was discovered that 85% of patients experienced postoperative symptom relief. The authors reported that the late recurrence rates between laparoscopic and open surgery (5.7% vs. 6.8%) were not statistically different. Additionally, compared to the open group, the postoperative morbidity was lower in the laparoscopy group [8]. It should be noted that less intraoperative blood loss and a shorter hospital stay are benefits of laparoscopic surgery [9]. Our patient’s epigastric discomfort was relieved after a laparoscopic median arcuate ligament release, and 2 months later, he had gained weight.

In conclusion, we reported a 33-year-old man who had successful laparoscopic treatment for MALS. With the benefits of laparoscopy and lower morbidity, laparoscopic median arcuate ligament release may replace open surgery as a gold standard method for treating MALS.

Ethical statements

This study was approved by the Institutional Review Board of Apollp Hospitals in Chennai, India (No. AMH-C-S-031/04-23). Informed consent was obtained from the patient.

Authors’ contributions

Conceptualization: SA

Resources: PM

Validation: LJ, SS, TE

Writing–original draft: SA

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 reasonable request to the corresponding author.

Supplementary materials

Supplementary materials can be found via https://doi.org/10.7602/jmis.2024.27.1.44.