SS03 - Open versus Laparoscopic Median Arcuate Ligament Release: A Single-Institution Experience

Objectives: Median arcuate ligament syndrome (MALS) is a rare condition characterized by a spectrum of gastrointestinal symptoms such as abdominal pain, nausea, vomiting, and weight loss. It arises from the compression of the celiac artery and/or the celiac nerve plexus by the median arcuate ligament. Although the open surgical division of the median arcuate ligament fibers has long been the mainstay of treatment, laparoscopic median arcuate ligament release (MALR) is increasingly employed. The optimal treatment modality and its associated outcomes remain unclear. This study reviews our institution’s experience comparing open versus laparoscopic MALR.

Methods: A retrospective review was conducted of patients who underwent open or laparoscopic MALR at our institution between 2001 and 2024. Collected data included demographic characteristics, presenting symptoms, history of abdominal surgery, diagnostic evaluations, intraoperative need for additional interventions, postoperative complications, hospital length of stay (LOS), and symptoms resolution.

Results: 271 patients underwent MALR: 120 (44.3%) via open surgery and 151 (55.7%) via the laparoscopic approach, with a higher frequency of laparoscopic procedures performed in recent years (Figure 1). Both groups had comparable body mass index (BMI) and gender distribution. Patients in the laparoscopic group were younger (35.7 ± 16.7 years vs 40.1 ± 15.9 years, p = 0.028) (Table 1). Dynamic duplex ultrasound (DUS), magnetic resonance angiography (MRA), provocative mesenteric angiogram, and celiac plexus block (CPB) were significantly more frequently used in the laparoscopic group. However, positivity rates did not differ between groups. Conversion from laparoscopic to open surgery occurred in seven cases (4.6%): three due to bleeding, two due to anatomical complexities, and two requiring celiac patch angioplasties. Additional intraoperative interventions, including aorto to celiac bypass and celiac patch angioplasty, were more common in the open group (12.5% vs 2.0%, p < 0.001). Open MALR was associated with a higher rate of postoperative ileus (9.2% vs 0.7%, p < 0.001) and a longer hospital LOS (4.6 ± 1.7 days vs 1.7 ± 1.3 days, p < 0.001). At a median follow-up of 4.3 months, postoperative symptom relief was greater in the open group for pain (84.2% vs 71.5%, p=0.014) and nausea (94.8% vs 84.9%, p=0.23).

Conclusions: Although open MALR is associated with higher complication rates and longer LOS, it results in better postoperative symptom relief for pain and nausea compared to laparoscopic MALR.