Presented by Alejandra M Casar Berazaluce, MD; Alexander Gibbons, MD; and Jaimie D Nathan, MD from Cincinnati Children's Hospital Medical Center at the IPEG - International Pediatric Endosurgery Group 28th Annual Congress for Endosurgery in Children.
Scientific Video Session l: Coolest Tricks
Moderators: Carroll Harmon, MD & Holger Till, MD
Median Arcuate Ligament Syndrome is a chronic abdominal pain syndrome characterized by epigastric pain, nausea, and vomiting that leads to anorexia and weight loss. It is a diagnosis of exclusion, hypothesized to be caused by compression of the celiac artery and celiac plexus by the median arcuate ligament at the junction of the right and left diaphragmatic crura. Due to the presence of an identifiable mechanical constriction, the management of MALS is surgical. In this video, we present the key features of the robotic approach for its release in the pediatric population.
Type: video · 4 min · posted 2019-03-22 Canonical: https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290 ## Chapters - [0:03](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=3) MALS Pathophysiology and Diagnosis - [1:02](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=62) Surgical Approach and Initial Dissection - [2:25](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=145) Complete Release Technique - [4:08](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=248) Complications and Management ## Statements - "Median arcuate ligament syndrome is characterized by epigastric pain, nausea, and vomiting" (clinical) [0:10](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=10) - "Pain in MALS is usually worse after meals and eventually leads to anorexia and weight loss" (clinical) [0:18](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=18) - "MALS is a diagnosis of exclusion" (clinical) [0:25](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=25) - "MALS is hypothesized to be caused by compression of the celiac artery and celiac plexus by the median arcuate ligament" (clinical) [0:25](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=25) - "The median arcuate ligament is a fibrous band at the intersection of the left and right diaphragmatic crura" (clinical) [0:25](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=25) - "CTA, MRA, and conventional angiography are useful imaging modalities for identifying celiac compression in MALS diagnosis" (clinical) [0:39](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=39) - "Dynamic flow changes in MALS can be evaluated by duplex ultrasound, with flow restriction worsening during expiration due to changes in diaphragm position" (clinical) [0:51](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=51) - "The treatment for MALS is surgical release due to the presence of a mechanical constriction" (guideline) [1:02](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=62) - "Robotic 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" (opinion) [1:08](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=68) - "Dissection in robotic MALS surgery is approached through a window in the lesser omentum" (clinical) [1:27](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=87) - "Early identification of the celiac trifurcation is a key step in MALS surgery" (clinical) [1:33](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=93) - "Ganglionectomy is performed during dissection of fibrous bands and perivascular connective tissue in MALS surgery" (clinical) [1:41](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=101) - "Dissection proceeds from distal to proximal towards the origin of the celiac axis" (clinical) [1:54](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=114) - "Some cases require dissection of right crural fibers to reach the base of the median arcuate ligament" (clinical) [2:06](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=126) - "The median arcuate ligament can be divided by standard hook electrocautery, bipolar energy devices, or vessel sealing devices" (clinical) [2:25](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=145) - "Residual celiac trunk tortuosity may be present after initial median arcuate ligament release" (clinical) [2:54](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=174) - "Dissection continues along the anterior wall of the aorta down to the preadventitial plane from caudal to cranial for around 4 centimeters" (clinical) [3:01](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=181) - "Circumferential 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" (clinical) [3:19](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=199) - "Significant improvement in celiac trunk appearance is observed after complete circumferential dissection" (clinical) [3:59](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=239) - "Median arcuate ligament release can be accomplished safely in the pediatric population with good results when following proper technique" (opinion) [4:08](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=248) - "MALS surgery carries the risk of injury to important vessels" (clinical) [4:18](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=258) - "Complications in robotic MALS surgery can be addressed minimally invasively due to the exposure and visualization provided by the approach" (opinion) [4:25](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=265) - "An 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" (clinical) [4:35](https://library.globalcastmd.com/watch/robotic-assisted-release-of-the-median-arcuate-ligament-for-pediatric-mals-1290?t=275) ## Transcript Robotic assisted release of the median arcuate ligament for pediatric mouse. Median narcoate ligament syndrome is a chronic abdominal pain syndrome characterized by epigastric pain, nausea, and vomiting. The pain is usually worse after meals and eventually leads to anorexia and weight loss. It 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 diagnosis, including CTA, MRA, and conventional angiography. Dynamic flow changes can also 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 MSS is surgical release. Our institution offers robotic mouth surgery due to the 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 addition to the benefits provided by a minimally invasive approach. In this case, dissection is approached through a window in the lesser momentum. Attention is directed towards early identification of the celiac trifurcation. Ganglionectomy is performed as encountered during the dissection of other fibrous bands and perivascular connective tissue. Dissection proceeds from distal to proximal towards the origin of the celiac axis. This case required dissection of right coral fibers to reach the base. The median arcuate ligament is then identified and divided. This can be accomplished by standard hook electrocautery, bipolar energy devices, or, as demonstrated here, a vessel sealing device. Notice the residual celiac trunk tortuosity after this release. Dissection continues along the anterior wall of the aorta down to the preadventitial plane from caudal to cranial for around 4 centimeters. Circumferential dissection down to the preadventitial plane must also be accomplished around the origins of the left gastric artery, the common hepatic artery, and the splenic artery, in addition to the celiac trunk. Notice the significant improvement after this step is completed. Following these keys to success, release can be accomplished safely in the pediatric population with good results. Like any other surgical intervention near critical anatomy, this procedure comes with the risk of injury to important vessels. Fortunately, with the great exposure and visualization provided by this approach, complications can still be addressed minimally invasively. In this example, an avulsion of a small aortic branch is controlled with steady pressure applied via suction irrigator, temporized with a clip, and ultimately repaired with pledgeted sutures intracorporeally, allowing for safe completion of the intervention. --- Not medical advice · citation policy: https://library.globalcastmd.com/ai