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BACKGROUND: The median arcuate ligament syndrome is a rare disorder which results from compression of the celiac artery by aberrant diaphragmatic muscular or fibrous bands. The syndrome is characterized by post-prandial abdominal pain, nausea, vomiting and weight loss. Surgical management has included complete division of the median arcuate ligament. This procedure has been performed by laparotomy and laparoscopy. We hypothesized that a robotic laparoscopic approach would be superior by virtue of three-dimensional visualization and greater instrument maneuverability at the point of surgery.
METHODS: A 24 year old female with history of post-prandial abdominal pain, nausea, and vomiting underwent robotic laparoscopic division of the arcuate ligament. The syndrome was diagnosed by pre-operative computed tomography, magnetic resonance angiography, and duplex ultrasonography which demonstrated extrinsic compression at the origin of the celiac artery as well as increased velocity of blood flow in the celiac artery upon expiration. Five laparoscopic trocars were used. The celiac artery and branch vessels were completely skeletonized. The compression of the celiac artery appeared to result from an elongation of the left limb of the esophageal crus of the diaphragm.
RESULTS: Post-operative course was uncomplicated. A post-operative computed tomographic angiography (CTA) scan of the abdomen demonstrated no residual stenosis. The patient's symptoms improved dramatically in the immediate post-operative period. Post-prandial abdominal pain resolved immediately after surgery but nausea persisted an additional 4 months.
CONCLUSION: Robotic surgical systems present a significant technological advance to conventional laparoscopic instruments. This advance is most notable in the management of patients with median arcuate ligament syndrome who require highly accurate instrument movement and three-dimensional visualization in a very confined space.