Median Arcuate Ligament Release with Celiac Gangliotomy
Procedure Snapshot
- Indication: Median arcuate ligament syndrome (MALS) — chronic postprandial pain from extrinsic compression of the celiac artery with a possible neurogenic component.
- Expected duration: 2–4 hours (laparoscopic).
- Special instruments: Harmonic scalpel, laparoscopic liver retractor, vessel loops, Doppler probe.
- Robotic (Celisnki setup) subxyphoid liver retractor, from patient right to left: bipolar maryland, camera, monopolar hook, tip up grasper, LLQ assist port for laparoscopic suction
Step Workflow
- Exposure
- Supine, general anesthesia.
- Four 5 mm ports (subxiphoid, umbilical, bilateral lateral).¹
- Retract stomach anterior–superiorly; divide the gastrocolic ligament to expose the superior border of the pancreas and celiac axis.¹
- Dissection
- Divide pars flaccida and peritoneum anterior to the right crus; identify left gastric, splenic, and common hepatic arteries and trace to the celiac origin.¹
- Divide median arcuate ligament fibers compressing the artery.
- Skeletonize the celiac trunk; divide surrounding neural tissue to perform celiac ganglionectomy.¹
- Hemostasis & Completion
- Confirm restored pulsatility and full release.
- Avoid subadventitial injury to the celiac trunk and bleeding from the left gastric artery (common early-conversion sources).¹
- Irrigate and close ports.
- Adjunct/Combined Approaches
- Residual stenosis > 30 % or gradient > 10 mm Hg after release → postoperative balloon angioplasty ± stent.¹
- Avoid pre-release stenting (reported celiac thrombosis when stented before release).¹
- Open conversion for bleeding occurred in 20 % early in laparoscopic experience.¹
Key Pimp Questions
-
Q: Classic symptom triad for MALS?
A: Postprandial epigastric pain, weight loss, and epigastric bruit.² -
Q: Why add celiac gangliotomy?
A: Addresses a neurogenic pain component by interrupting sympathetic plexus fibers around the celiac axis.¹ -
Q: Laparoscopic vs open — objective advantages?
A: Faster feeding (1.0 day vs 2.8 days) and shorter hospital stay (2.0 vs 7.0 days) with similar symptom relief.¹ -
Q: When do you treat residual stenosis?
A: If residual > 30 % or gradient > 10 mm Hg after release (angioplasty ± stent).¹ -
Q: What percent of population would have compression of celiac trunk on imaging if you screened the population? A: Somewhere from 5-50%. . . not all compression is MALS
Critical Anatomy
- Landmarks: Aortic hiatus, celiac trunk, left gastric, splenic, and common hepatic arteries; diaphragmatic crura.
- Danger zones: Celiac trunk (subadventitial dissection risk), left gastric artery (bleeding/possible conversion), pancreas (avoid deep inferior dissection).¹
- Alternate anatomy: Replaced left hepatic artery, most common first branch of celiax trunk is phrenic arteries (supply bottom third of esophagus)
Informed Consent Highlights
- Risks (source after each figure):
- Intraoperative bleeding requiring conversion ~ 20 % (laparoscopic early series).¹
- Persistent/recurrent pain 38 % lap vs 50 % open.¹
- Need for postoperative angioplasty ± stent if residual stenosis persists.¹
- Possible injury to pancreas or visceral vessels.¹
- Benefits:
- Immediate pain relief 100 % lap vs 83 % open.¹
- Narcotic cessation 88 % lap vs 100 % open.¹
- Faster oral intake (POD 1) and shorter LOS (~ 2 days) with laparoscopy.¹
Post-Op Considerations
- Diet: Advance on POD 1 for laparoscopic cases.¹
- Monitor: Recurrent pain usually appears ~ 3–4 months post-op; evaluate with CTA/angiography.¹
- Follow-up imaging: Duplex / CTA at ~ 6 months reasonable based on series data.¹
- Avoid: Pre-release stenting due to thrombosis risk.¹
Clinical Pearls
- Relief likely has a neurogenic contribution; some patients have persistent pain despite a patent celiac artery.¹
- Dynamic inspiratory/expiratory CTA or duplex helps confirm compression.²
- Long-term data show better durable relief when decompression + revascularization (76 %) vs decompression alone (53 %).³
- Consider diagnostic celiac plexus block pre-op to confirm neurogenic element.²
Quick Reference Table
| Parameter | Laparoscopic | Open |
|---|---|---|
| Time to feeding | 1.0 day¹ | 2.8 days¹ |
| Length of stay | 2.0 days¹ | 7.0 days¹ |
| Conversion rate | 20 %¹ | — |
| Immediate symptom relief (POD 1) | 100 %¹ | 83 %¹ |
| Persistent pain at follow-up | 38 %¹ | 50 %¹ |
| Narcotic cessation at follow-up | 88 %¹ | 100 %¹ |
Quick-Reference Cards
Symptoms & Diagnosis
- Typical triadPostprandial epigastric pain, weight loss, epigastric bruit.²
- Who gets it?Female > male (often 20–50 yrs).²
- CTA/MRACeliac narrowing that worsens on expiration (dynamic compression).²
- DuplexVelocity increase on expiration; improves with inspiration.²
- Adjunct testsGastric tonometry / celiac plexus block to confirm neurogenic component.²
Indications for Surgical Release
- Symptomatic MALSTypical postprandial pain ± weight loss with imaging-confirmed compression.²
- Hemodynamic criteriaPressure gradient > 10 mm Hg if measured.¹
- Exclusion workupNegative GI evaluation prior to referral.¹
- Response to blockPain relief after celiac plexus block predicts benefit.²
Post-Op Angioplasty / Stent — When?
- Residual stenosis> 30 % after release → balloon angioplasty.¹
- Pressure gradient> 10 mm Hg → angioplasty ± stent.¹
- Recurrent symptomsPersistent pain + imaging stenosis → consider stent.¹
- Important caveatAvoid pre-release stenting (thrombosis risk reported).¹
References
- Tulloch AW, Jimenez JC, Lawrence PF, et al. Laparoscopic versus open celiac ganglionectomy in patients with median arcuate ligament syndrome. J Vasc Surg. 2010; 52: 1283–1289.
- Tang H et al. Median Arcuate Ligament Syndrome: An Updated Review of Diagnosis and Management. Front Surg. 2024; PMCID: PMC11354951.
- Reilly LM, Ammar AD, Stoney RJ, Ehrenfeld WK. Late results following operative repair for celiac artery compression syndrome. J Vasc Surg. 1985; 2: 79–91.