Robotic-Assisted Release of the Median Arcuate Ligament for Pediatric MALS

Median arcuate ligament syndrome is a chronic abdominal pain syndrome characterized by epigastric pain, nausea, and vomiting.

The pain in MALS is usually worse after meals and eventually leads to anorexia and weight loss.

MALS is a diagnosis of exclusion hypothesized to be caused by compression of the celiac artery and celiac plexus by the median arcuate ligament, a fibrous band at the intersection of the left and right diaphragmatic crura.

Multiple imaging modalities are useful in identifying celiac compression for MALS diagnosis, including CTA, MRA, and conventional angiography.

Dynamic flow changes in MALS can be evaluated by duplex ultrasound, with flow restriction worsening during expiration due to changes in the position of the diaphragm.

Due to the presence of a mechanical constriction, the treatment for MALS is surgical release.

Robotic MALS surgery offers improved 3-dimensional visualization, flexibility and end or wrist motion for challenging angles, elimination of tremor, and scaling of motion for fine dissection in a limited space.

In robotic MALS surgery, dissection is approached through a window in the lesser omentum.

Early identification of the celiac trifurcation is a key step in robotic MALS surgery.

Ganglionectomy is performed as encountered during the dissection of fibrous bands and perivascular connective tissue in MALS surgery.

Dissection in MALS surgery proceeds from distal to proximal towards the origin of the celiac axis.

Some MALS cases require dissection of right crural fibers to reach the base of the celiac artery.

Division of the median arcuate ligament can be accomplished by standard hook electrocautery, bipolar energy devices, or a vessel sealing device.

Residual celiac trunk tortuosity may persist after initial median arcuate ligament release.

Dissection must continue along the anterior wall of the aorta down to the pre-adventitial plane from caudal to cranial for around 4 centimeters.

Circumferential dissection down to the pre-adventitial plane must be accomplished around the origins of the left gastric artery, the common hepatic artery, the splenic artery, and the celiac trunk.

Significant improvement in celiac trunk appearance is observed after complete circumferential dissection.

Following proper surgical technique, median arcuate ligament release can be accomplished safely in the pediatric population with good results.

MALS surgery carries the risk of injury to important vessels due to proximity to critical anatomy.

With the exposure and visualization provided by the robotic approach, vascular complications in MALS surgery can be addressed minimally invasively.

An avulsion of a small aortic branch during MALS surgery can be controlled with steady pressure applied via suction irrigator, temporized with a clip, and repaired with pledgeted sutures intracorporeally.