Median Arcuate Ligament Syndrome: Diagnostic Challenges and Outcomes Following Laparoscopic Decompression

BACKGROUND AND AIM: Median arcuate ligament syndrome (MALS) is an uncommon vascular compression disorder caused by extrinsic compression of the celiac artery and surrounding neural plexus by the median arcuate ligament. Diagnosis is frequently delayed because of nonspecific symptoms and the presence of incidental radiological celiac artery compression in asymptomatic individuals. By providing detailed clinicoradiological correlation and operative outcome data, this study aimed to contribute to the growing body of evidence regarding the diagnosis and management of this uncommon but clinically significant disorder. METHODS: This retrospective cohort study was conducted at a tertiary care teaching hospital to evaluate the clinical presentation, radiological findings, operative characteristics, and postoperative outcomes of patients undergoing laparoscopic median arcuate ligament release between January 2024 and December 2025. Demographic, clinical, radiological, operative, and follow-up data were analyzed. Computed tomography angiography (CTA) was used to assess celiac artery compression and associated vascular changes. Clinical success was defined as complete resolution or substantial improvement of symptoms without requirement for reintervention. RESULTS: A total of 10 patients underwent laparoscopic median arcuate ligament release and met all inclusion criteria. The mean age was 36.5±16.8 years, and six patients (60%) were male. The median duration of symptoms prior to diagnosis was 18 months (range: 4-72 months). Postprandial abdominal pain was the predominant presenting symptom, occurring in 90% of patients. CTA demonstrated characteristic celiac artery compression in all patients, with severe stenosis (>70%) identified in seven patients (70%). All procedures were completed laparoscopically without conversion to open surgery. Mean operative time was 118±24 min, and mean hospital stay was 5.2±2.1 days. One patient presented with severe gastric ischemia requiring concomitant gastric fundal resection. At a median follow-up of 12 months, complete symptom resolution was achieved in six patients (60%), while three patients (30%) experienced significant symptomatic improvement, resulting in an overall favorable outcome rate of 90% (95% CI: 55.5-99.7%). Mean visual analog scale pain scores improved from 8.1±0.7 preoperatively to 2.3±1.3 at follow-up. CONCLUSIONS: MALS remains an underrecognized cause of chronic postprandial abdominal pain associated with substantial diagnostic delay. Careful clinicoradiological assessment and multidisciplinary evaluation facilitate accurate diagnosis and appropriate patient selection. Laparoscopic median arcuate ligament release is a safe and effective treatment strategy, providing durable symptom relief in the majority of patients. The occurrence of severe gastric ischemia in one patient underscores the potential consequences of delayed diagnosis. Larger prospective multicenter studies are required to validate radiological severity classifications and identify predictors of surgical success.