Robotic Release of Median Arcuate Ligament Syndrome: A Case Series

Median arcuate ligament syndrome (MALS) is a rare condition caused by compression of the celiac artery by the median arcuate ligament (MAL), resulting in postprandial discomfort and abdominal pain. Surgical decompression remains the definitive treatment. We present a series of three patients with MALS, including a 22-year-old male, a 73-year-old male, and a 46-year-old female, managed with robotic median arcuate ligament release (MALR). All patients underwent diagnostic imaging with computed tomography angiography, demonstrating celiac artery stenosis with a characteristic hook-shaped appearance, as well as celiac artery duplex ultrasound revealing increased flow velocities with expiration. All procedures were performed using a robotic approach. After abdominal access and insufflation, the esophageal hiatus was exposed, the lesser omentum was opened, and the angle of His was dissected. The esophagus was encircled for retraction, allowing clear identification of the right and left crura and exposure of the aorta to the level of the celiac axis. Careful adhesiolysis enabled the complete release of the MAL along with surrounding neural and fibrous tissue. This case series highlights the importance of considering MALS in patients with chronic postprandial abdominal pain and demonstrates the feasibility of the robotic approach in offering enhanced visualization, precision, and dexterity to support the paucity of literature on the effectiveness of robotic MALR.