title: Technique and outcomes of robot-assisted median arcuate ligament release for celiac artery compression syndrome.
abstract: OBJECTIVE
  Celiac artery compression by the median arcuate ligament (MAL) is a potential cause of postprandial abdominal pain and weight loss that overlaps with other common syndromes. Robotic technology may alter the current paradigm for surgical intervention. Open MAL release is often performed with concurrent bypass for celiac stenosis due to the morbidity of reintervention, whereas the laparoscopic approach is associated with high rates of conversion to open due to bleeding. We hypothesized that a robot-assisted technique might minimize conversion events to open, decrease perioperative morbidity, and defer consideration of vascular bypass at the initial operative setting.
  
  
  METHODS
  We retrospectively analyzed patients treated for MAL syndrome by a multidisciplinary team at a tertiary medical center between September 2012 and December 2013. Diagnosis was based on symptom profile and peak systolic velocity (PSV) >200 cm/s during celiac artery duplex ultrasound imaging. All patients underwent robot-assisted MAL release with simultaneous circumferential neurolysis of the celiac plexus. Postoperative celiac duplex and symptom profiles were reassessed longitudinally to monitor outcomes.
  
  
  RESULTS
  Nine patients (67% women) were evaluated for postprandial pain (100%) and weight loss (100%). All patients had celiac stenosis by mesenteric duplex ultrasound imaging (median PSV, 342; range, 238-637 cm/s), and cross-sectional imaging indicated a fishhook deformity in five (56%). Robot-assisted MAL release was completed successfully in all nine patients (100%) using a standardized surgical technique. Estimated blood loss was <50 mL, with a median hospital stay of 2 days (range, 2-3 days). No postoperative complications of grade ≥3, readmissions or reoperations were observed. All patients (100%) improved symptomatically at the 25-week median follow-up. Three patients experienced complete resolution on postoperative celiac duplex ultrasound imaging, and six patients showed an improved but persistent stenosis (PSV >200 cm/s) compared with preoperative velocities (P < .05 by Wilcoxon signed rank). No patients required additional treatment.
  
  
  CONCLUSIONS
  Robot-assisted MAL release can be performed safely and effectively with avoidance of conversion events and minimal morbidity. Potential factors contributing to success are patient selection by a multidisciplinary team and replication of the open surgical technique by means of robot-assisted dexterity and visualization. The need for delayed reintervention for persistently symptomatic celiac stenosis is uncertain.
authors.affiliation: Institute for Hepatobiliary and Pancreatic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
authors.forename: Stijn J J
authors.initials: SJ
authors.lastname: Thoolen
authors.affiliation: Institute for Hepatobiliary and Pancreatic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
authors.forename: Walderik J
authors.initials: WJ
authors.lastname: van der Vliet
authors.affiliation: Institute for Hepatobiliary and Pancreatic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
authors.forename: Tara S
authors.initials: TS
authors.lastname: Kent
authors.affiliation: Institute for Hepatobiliary and Pancreatic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
authors.forename: Mark P
authors.initials: MP
authors.lastname: Callery
authors.affiliation: Institute for Hepatobiliary and Pancreatic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
authors.forename: Martin J
authors.initials: MJ
authors.lastname: Dib
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
authors.forename: Allen
authors.initials: A
authors.lastname: Hamdan
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
authors.forename: Marc L
authors.initials: ML
authors.lastname: Schermerhorn
authors.affiliation: Institute for Hepatobiliary and Pancreatic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. Electronic address: ajmoser@bidmc.harvard.edu.
authors.forename: A James
authors.initials: AJ
authors.lastname: Moser
mesh_terms: D000328:Adult; D000368:Aged; D002445:Celiac Artery / Q000002:abnormalities* / Q000601:surgery; D003251:Constriction, Pathologic / Q000601:surgery*; D003299:Cooperative Behavior; D005260:Female; D006801:Humans; D033183:Interdisciplinary Communication; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D000074742:Median Arcuate Ligament Syndrome; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000379:methods*