Laparoscopic Surgery via an Inferior Pancreatic Border Approach for Median Arcuate Ligament Syndrome after Distal Gastrectomy: A Case Report.

introductionMedian arcuate ligament syndrome (MALS) is a relatively rare condition characterized by compression of the celiac artery and neural plexus by the median arcuate ligament. The definitive treatment is surgical division of the median arcuate ligament, which can be performed via open, laparoscopic, or retroperitoneoscopic surgery. In laparoscopic surgery, this approach commonly involves reaching the root of the celiac artery from the superior border of the pancreas to divide the median arcuate ligament. We herein report a case of MALS following gastrectomy, in which the median arcuate ligament was successfully divided using a laparoscopic approach from the inferior border of the pancreas. CASE PRESENTATION: A 67-year-old man who had undergone open distal gastrectomy and D2 lymph node dissection for gastric cancer 16 years prior presented to the emergency department with a chief complaint of sudden, severe epigastric pain. A thorough examination led to the diagnosis of acute cholangitis and pancreatitis due to retroperitoneal hematoma compression, for which percutaneous transhepatic cholangial drainage (PTCD) was performed. Additionally, MALS was identified and considered as the underlying cause of retroperitoneal hematoma. Conservative treatment resulted in hematoma shrinkage and improvement in cholangitis and pancreatitis, allowing the patient to be discharged. However, because of the possibility of symptom recurrence, the patient was referred to our department for surgical intervention. Given the history of gastrectomy, an approach from the superior border of the pancreas was deemed to be challenging. Instead, we accessed the root of the celiac artery from the inferior border of the pancreas, successfully dividing the median arcuate ligament and confirming the improved blood flow.

conclusionsMALS is a rare condition for which a standardized surgical approach remains to be established. In cases of adhesions in the upper abdomen, an approach from the inferior border of the pancreas may be a viable option and could contribute to improved surgical outcomes.