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

Who's speaking

• Speaker 1

Chapters

• 0:03MALS Pathophysiology and Diagnosis — Definition of median arcuate ligament syndrome, clinical presentation, anatomic basis, and diagnostic imaging modalities.
• 1:02Surgical Approach and Initial Dissection — Rationale for robotic approach, dissection through lesser omentum, identification of celiac trifurcation, ganglionectomy, and division of the median arcuate ligament.
• 2:25Complete Release Technique — Circumferential dissection of celiac trunk and branches to preadventitial plane, demonstration of improved vessel tortuosity after release.
• 4:08Complications and Management — Discussion of vascular injury risk and demonstration of minimally invasive repair of an aortic branch avulsion.

Key claims

• 0:10Median arcuate ligament syndrome is characterized by epigastric pain, nausea, and vomiting — Speaker 1
• 0:18Pain in MALS is usually worse after meals and eventually leads to anorexia and weight loss — Speaker 1
• 0:25MALS is a diagnosis of exclusion — Speaker 1
• 0:25MALS is hypothesized to be caused by compression of the celiac artery and celiac plexus by the median arcuate ligament — Speaker 1
• 0:25The median arcuate ligament is a fibrous band at the intersection of the left and right diaphragmatic crura — Speaker 1
• 0:39CTA, MRA, and conventional angiography are useful imaging modalities for identifying celiac compression in MALS diagnosis — Speaker 1
• 0:51Dynamic flow changes in MALS can be evaluated by duplex ultrasound, with flow restriction worsening during expiration due to changes in diaphragm position — Speaker 1
• 1:02The treatment for MALS is surgical release due to the presence of a mechanical constriction — Speaker 1
• 1:08Robotic MALS surgery provides improved 3D visualization, flexibility and end or wrist motion for challenging angles, elimination of tremor, and scaling of motion for fine dissection in a limited space — Speaker 1
• 1:27Dissection in robotic MALS surgery is approached through a window in the lesser omentum — Speaker 1
• 1:33Early identification of the celiac trifurcation is a key step in MALS surgery — Speaker 1
• 1:41Ganglionectomy is performed during dissection of fibrous bands and perivascular connective tissue in MALS surgery — Speaker 1
• 1:54Dissection proceeds from distal to proximal towards the origin of the celiac axis — Speaker 1
• 2:06Some cases require dissection of right crural fibers to reach the base of the median arcuate ligament — Speaker 1
• 2:25The median arcuate ligament can be divided by standard hook electrocautery, bipolar energy devices, or vessel sealing devices — Speaker 1
• 2:54Residual celiac trunk tortuosity may be present after initial median arcuate ligament release — Speaker 1
• 3:01Dissection continues along the anterior wall of the aorta down to the preadventitial plane from caudal to cranial for around 4 centimeters — Speaker 1
• 3:19Circumferential dissection down to the preadventitial plane must be accomplished around the origins of the left gastric artery, common hepatic artery, splenic artery, and celiac trunk — Speaker 1
• 3:59Significant improvement in celiac trunk appearance is observed after complete circumferential dissection — Speaker 1
• 4:08Median arcuate ligament release can be accomplished safely in the pediatric population with good results when following proper technique — Speaker 1
• 4:18MALS surgery carries the risk of injury to important vessels — Speaker 1
• 4:25Complications in robotic MALS surgery can be addressed minimally invasively due to the exposure and visualization provided by the approach — Speaker 1
• 4:35An avulsion of a small aortic branch can be controlled with steady pressure via suction irrigator, temporized with a clip, and repaired with pledgeted sutures intracorporeally — Speaker 1

Cases discussed

• 1:27Pediatric patient undergoing robotic median arcuate ligament release with intraoperative complication