A New Laparoscopic Manoeuvre in Median Arcuate Ligament Syndrome

The manuscript has been presented orally in V. National Gastroenterological Surgery Congress, 05-08 April 2017 in Antalya/Turkey Address for Correspondence: Dr. Selçuk Gülmez, Department of Gastroenterological Surgery, University of Health Sciences, Kartal Koşuyolu High Specialized Training and Research Hospital, İstanbul, Turkey Phone: +90 553 084 62 15 e-mail: [email protected] Received: 30 April 2017 Accepted: 4 August 2017 • DOI: 10.4274/balkanmedj.2017.0596 Available at www.balkanmedicaljournal.org Cite this article as: Gülmez S, Aday U, Senger AS, Gündeş E. A New Laparoscopic Manoeuvre in Median Arcuate Ligament Syndrome. Balkan Med J 2017;34:590-2 ©Copyright 2017 by Trakya University Faculty of Medicine / The Balkan Medical Journal published by Galenos Publishing House. To the Editor, Median Arcuate Ligament syndrome is a rare cause of chronic gastrointestinal ischemia (1). Anatomically, median arcuate ligament is a musculofibrous structure uniting both diaphragmatic crura from the front at the aortic hiatus level (2). Abnormally downward located median arcuate ligament lies at the pathophysiology of this disease, and intestinal angina symptoms characterized by postprandial pain, nauseavomiting and weight loss manifest themselves due to chronic compression the celiac artery (3). Median Arcuate Ligament syndrome requires surgical treatment in symptomatic patients (4). The conversion rate of Median Arcuate Ligament syndrome remains between 13% and 27%, and the main reason for conversion is haemorrhaging related to vascular damage (5). Standardization of the technique will contribute to decreasing these rates, but no standard surgical technique has yet been set. The most critical stage of this procedure proves to be the dissection of truncus coeliacus. Therefore, our aim in this case report was to share our technique enabling the safe dissection of truncus coeliacus. A 20-year-old female patient presented to our clinic with complaints of classic Median Arcuate Ligament syndrome symptoms. The patient’s physical examination, preoperative laboratory results, gastroscopy and abdominal ultrasonography were normal. Her abdominal computed tomography showed suspected truncus coeliacus compression, magnetic resonance angiography was performed in order to confirm the diagnosis, and the findings were concordant with median arcuate ligament-related arterial stenosis of 2 mm and post-stenotic dilatation (Figure 1). The patient was informed about the procedure and written consent was obtained. Median arcuate ligament was seperated by decompression laparoscopically and was started on oral intake on the first postoperative day, and all her existing complaints were eliminated. The patient was discharged from our clinic on the fourth postoperative day. She had no complaints in the follow-up control done 6 months after discharge. Laparoscopic technique: Ports were placed and the patient was laid in the 30° reverse-Trendelenburg position (Figure 2). The right crus was found by opening up the gastrohepatic Department of Gastroenterological Surgery, University of Health Sciences, Kartal Koşuyolu High Specialized Training and Research Hospital, İstanbul, Turkey Selçuk Gülmez, Ulaş Aday, Aziz Serkan Senger, Ebubekir Gündeş