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Gunjiganvi M, Marthandam S, Murugesan R, Palaniappan R. Feasibility and safety of robotic-assisted surgical approach in median arcuate ligament syndrome-a systematic review. J Robot Surg 2024; 18:318. [PMID: 39122880 DOI: 10.1007/s11701-024-02067-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Accepted: 07/27/2024] [Indexed: 08/12/2024]
Abstract
Median arcuate ligament syndrome (MALS) is rare syndrome and is diagnosis of exclusion. Though first robotic median arcuate ligament release (MALR) was described in 2007, there are only a few case reports (CR), case series (CS), and retrospective cohort studies (RCS) in the published literature. The purpose of this study was to assess the feasibility and safety of robotic-assisted MALR (r-MALR). PubMed, Embase, and Cochrane databases were searched (last search December 2023) for articles reporting r-MALR. All studies including CR, CS, RCS reporting technical feasibility (operating time and rate of conversions), safety (intra-operative complications, blood loss, post-operative complications), and outcome (length of stay [LoS]) were included (PROSPERO: CRD42024502792). A total of 23 studies (8-CR, 5-CS, 10-RCS) with total 290 patients were available in the literature. Except 1-RCS, all studies reported age and mean age for CR was 40.38 ± 17.7, 36.08 ± 15.12 for CS, 39.72 ± 7.35 years for RS; except 2-RCS, all studies reported gender distribution and there were 57 males and 214 females. Operating time: 3-CR, 4-CS, 9-RCS reported operating time, and mean time was 111 ± 54, 131.69 ± 7.51, 117.34 ± 35.03 min, respectively. Conversion rate: All studies reported data on conversion and only four (1.37%) cases were converted-one to laparoscopic approach, three to open approach (1-inadvertent celiac arteriotomy, 2-reasons not mentioned). Intraoperative complications: only 5-CR, 4-CS, and 9-RCS reported data on intra-operative complications, and there were only 6 complications (1.5%): 1-inadvertent celiac arteriotomy converted to open; 3-unnamed vascular injuries (2 managed robotically, 1 converted to open); 1-bleeding managed robotically; there were no other reported injuries. Estimated blood loss ranged from 5 to 30 ml. Post-operative complications: 5-CR, 4-CS, 8-RCS described post-operative complications in 21 (7%) patients. Twenty cases were grade I, one was grade IIIa, and all managed successfully. LoS stay: 2-CR, 4-CS, 10-RCS reported LoS and overall, it was 2 days. r-MALR is reasonable, technically feasible, safe, and has acceptable outcomes. In addition, robotic approach provided superior vision, improved dexterity, precise, and easy circumferential dissection.PROSPERO registration: The protocol was registered in the PROSPERO database (CRD42024502792).
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Affiliation(s)
| | | | | | - Raj Palaniappan
- Department of Bariatrics and Metabolic Surgery, Apollo Hospitals, Chennai, India
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Štádler P, Dorosh J, Dvořáček L, Vitásek P, Matouš P, Lin JC. Review and current update of robotic-assisted laparoscopic vascular surgery. Semin Vasc Surg 2021; 34:225-232. [PMID: 34911628 DOI: 10.1053/j.semvascsurg.2021.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/06/2021] [Accepted: 10/08/2021] [Indexed: 11/11/2022]
Abstract
The field of vascular surgery is constantly evolving and is unsurpassed in its innovation and adoption of new technologies. Endovascular therapy has fundamentally changed the treatment paradigms for aneurysm and occlusive disease. As we continue to make advances in not only endovascular therapy, but also robotic surgery, artificial intelligence, and minimally invasive surgery, it is important that the vascular community stay at the forefront. Topics include the advantages of laparoscopic and robotic surgery over open surgery for aortic procedures, robotic versus laparoscopic aortic surgery, patient candidacy for robotic-assisted aortic surgery, and how to increase training and adoption of robotic-assisted laparoscopic aortic surgery. Future growth includes the development of new platforms and technologies, creation and validation of curriculum and virtual simulators, and conduction of randomized clinical trials to determine the best applications of robotics in vascular surgery.
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Affiliation(s)
- Petr Štádler
- Na Homolce Hospital, Department of Vascular Surgery, Prague, Czech Republic
| | | | - Libor Dvořáček
- Na Homolce Hospital, Department of Vascular Surgery, Prague, Czech Republic
| | - Petro Vitásek
- Na Homolce Hospital, Department of Vascular Surgery, Prague, Czech Republic
| | - Pavel Matouš
- Na Homolce Hospital, Department of Vascular Surgery, Prague, Czech Republic
| | - Judith C Lin
- Michigan State University College of Human Medicine, 4660 S. Hagadorn Road, Suite 600, East Lansing, MI 48823.
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Salem A, Aly A, Al-Aghil A, Soliman M, Carino G. Celiac Artery Compression Syndrome Presenting As Recurrent Diabetic Ketoacidosis: A Diagnostic Challenge. Cureus 2021; 13:e17818. [PMID: 34660028 PMCID: PMC8499675 DOI: 10.7759/cureus.17818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2021] [Indexed: 11/05/2022] Open
Abstract
Celiac artery compression syndrome (CACS), also known as median arcuate ligament syndrome, can sometimes represent a diagnostic challenge. Here, we present the case of a 29-year-old man who presented with recurrent diabetic ketoacidosis (DKA), abdominal pain, and vomiting thought to be due to cyclical vomiting syndrome. However, the lack of a clear precipitant for DKA, the presence of chronic gastrointestinal symptoms, and a revealing physical examination of abdominal bruit led to clinical suspicion of CACS and its diagnosis after appropriate investigations. While angiography has traditionally been considered the gold standard diagnostic test, hemodynamic and geometric ultrasound criteria can, however, be diagnostic. The patient was managed by releasing the celiac artery through robotic surgery and serial monitoring as an outpatient revealed resolution of his symptoms and no further readmissions for DKA. This case highlights how a presumptive and erroneous diagnosis (cyclical vomiting syndrome) can misguide clinicians, especially when dealing with a rare diagnosis of exclusion.
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Affiliation(s)
- Amr Salem
- Internal Medicine, Brown University, Providence, USA
| | - Ahmed Aly
- Internal Medicine, Alexandria Faculty of Medicine, Alexandria, EGY
| | - Ameen Al-Aghil
- Critical Care Medicine, Brown University, Rhode Island, USA
| | - Mohanad Soliman
- Pulmonary Critical Care, University of Arizona College of Medicine - Phoenix, Phoenix, USA
| | - Gerardo Carino
- Pulmonary and Critical Care, Brown University, Providence, USA
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Clinico-pathologic findings in patients with median arcuate ligament syndrome (celiac artery compression syndrome). Ann Diagn Pathol 2021; 52:151732. [PMID: 33798927 DOI: 10.1016/j.anndiagpath.2021.151732] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/19/2021] [Indexed: 12/11/2022]
Abstract
Median Arcuate Ligament Syndrome (MALS) is a rare entity characterized by severe post-prandial epigastric pain, nausea, vomiting, and/or weight loss. Symptoms have been attributed to vascular compression (celiac artery compression syndrome, CACS), but it remains controversial whether they could be secondary to neural compression. Literature review identified rare description of pathologic findings in surgery journals. The clinico-pathologic findings of four MALS patients who underwent robotic or laparoscopic surgery in our hospital are described. All our patients were female with a median age of 32.5 (range 25-55 years), and a median BMI of 23.5 kg/m2. They presented with chronic often post-prandial abdominal pain (4/4), nausea (3/4), emesis (2/4), anorexia (1/4), and weight loss (1/4). Two patients had a history of Crohn's disease. At intraoperative exploration, the celiac artery and adjacent nerves and ganglia were encased and partially compressed by fibrotic tissue in each patient. In each case laparoscopic excision of fibrotic tissue, celiac plexus and ligament division and was performed; celiac plexus nerve block was also performed in one patient. After surgical intervention, symptoms improved in three of the patients whose specimens show periganglionic and perineural fibrosis with proliferation of small nerve fibers. Our findings support neurogenic compression as a contributing factor in the development of pain and other MALS symptoms, and favor the use of MALS rather than CACS as diagnostic terminology. To further study the pathogenesis of this unusual syndrome, surgeons should submit all tissues excised during MALS procedures for histopathologic examination.
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Abstract
Background: Compression of the celiac artery by the median arcuate ligament results in median arcuate ligament syndrome (MALS). Using a consecutive cohort of patients with MALS, this study evaluated the efficacy and safety of robotic median arcuate ligament release (MALR). Methods: A retrospective chart review was performed on patients who underwent robotic MALR from August 2012 to April 2018. Patient workup included history and physical examination, mesenteric Doppler ultrasound, and CT (Computed Tomography) scan. Outcomes included pain improvement, length of stay, operation duration, narcotic use, and postoperative complications. Results: Twenty-seven patients met inclusion criteria. Two thirds of the cohort were female and the mean age was 49 ± 15.5 years. Postprandial abdominal pain was the most common preoperative symptom (25/27, 93%). CT (Computed Tomography) was performed in 24 (89%), and celiac stenosis > 70% was observed in all. Operative duration was 95 minutes on average (range, 53–358 minutes), and in 24/27 (89%) patients, estimated blood loss was < 100 mL. Eighty-one percent of patients were discharged the day of surgery (22/27). Two cases were converted to open, with only one major complication occurring. At 30 or more days postoperation, 17 patients (68%) had full, 1 (4%) partial, and 1 (4%) no symptom resolution, 6 (24%) had symptom recurrence after initially having resolution. Fifty-six percent achieved narcotic liberation 9/16 (56%). Conclusions: Robotic MALR is a safe option for treatment of MALS with high response rates, early hospital discharge, and opportunity for narcotic liberation.
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Affiliation(s)
- Colton Fernstrum
- Department of Surgery, College of Human Medicine, Michigan State University, Grand Rapids, MI
| | - Michael Pryor
- Department of Surgery, College of Human Medicine, Michigan State University, Grand Rapids, MI
| | - G Paul Wright
- Department of Surgery, College of Human Medicine, Michigan State University, Grand Rapids, MI
| | - Andrea M Wolf
- Department of Surgery, College of Human Medicine, Michigan State University, Grand Rapids, MI
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Short- and intermediate-term clinical outcome comparison between laparoscopic and robotic-assisted median arcuate ligament release. J Robot Surg 2019; 14:123-129. [DOI: 10.1007/s11701-019-00945-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 02/25/2019] [Indexed: 12/27/2022]
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Khrucharoen U, Juo YY, Sanaiha Y, Chen Y, Jimenez JC, Dutson EP. Robotic-assisted laparoscopic median arcuate ligament release: 7-year experience from a single tertiary care center. Surg Endosc 2018; 32:4029-4035. [DOI: 10.1007/s00464-018-6218-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 05/09/2018] [Indexed: 11/28/2022]
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Podda M, Gusai GP, Balestra F, Argenio G, Pulighe F, Di Saverio S, De Nisco C. Robotic-assisted approach to Median Arcuate Ligament Syndrome with left gastric artery originating directly from the aorta. Report of a case and review of the current mini-invasive treatment modalities. Int J Med Robot 2018; 14:e1919. [DOI: 10.1002/rcs.1919] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 01/23/2018] [Accepted: 04/01/2018] [Indexed: 01/07/2023]
Affiliation(s)
- Mauro Podda
- Department of General, Emergency and Robotic Surgery; San Francesco Hospital; Italy
| | - Gian Pietro Gusai
- Department of General, Emergency and Robotic Surgery; San Francesco Hospital; Italy
| | - Francesco Balestra
- Department of General, Emergency and Robotic Surgery; San Francesco Hospital; Italy
| | - Giulio Argenio
- Department of General and Oncological Surgery; SS Antonio e Biagio e Cesare Arrigo Hospital; Alessandria Italy
| | - Fabio Pulighe
- Department of General, Emergency and Robotic Surgery; San Francesco Hospital; Italy
| | - Salomone Di Saverio
- Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District Bologna, Italy and Consultant Surgeon; Addenbrookes Hospital - University of Cambridge; UK
| | - Carlo De Nisco
- Department of General, Emergency and Robotic Surgery; San Francesco Hospital; Italy
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Thoolen SJJ, van der Vliet WJ, Kent TS, Callery MP, Dib MJ, Hamdan A, Schermerhorn ML, Moser AJ. Technique and outcomes of robot-assisted median arcuate ligament release for celiac artery compression syndrome. J Vasc Surg 2015; 61:1278-84. [PMID: 25600337 DOI: 10.1016/j.jvs.2014.10.084] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 10/22/2014] [Indexed: 11/17/2022]
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.
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Affiliation(s)
- Stijn J J Thoolen
- Institute for Hepatobiliary and Pancreatic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Walderik J van der Vliet
- Institute for Hepatobiliary and Pancreatic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Tara S Kent
- Institute for Hepatobiliary and Pancreatic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Mark P Callery
- Institute for Hepatobiliary and Pancreatic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Martin J Dib
- Institute for Hepatobiliary and Pancreatic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Allen Hamdan
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - A James Moser
- Institute for Hepatobiliary and Pancreatic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
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Schöller A, Sugár I, Szeberin Z, Ondrejka P, István G, Vörös A. [Laparoscopic treatment of median arcuate ligament syndrome (MALS) -- case report]. Magy Seb 2014; 67:99-102. [PMID: 24873765 DOI: 10.1556/maseb.67.2014.3.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CASE REPORT The authors report a case of a 34-year-old woman who had postprandial abdominal pain for years. During the course of her examination lactose intolerance and hiatus hernia was diagnosed. After ineffective conservative treatment CT angiography (CTA) and digital substraction angiography (DSA) was performed and showed significant celiac artery stenosis. Percutaneous transluminal angioplasty (PTA) was unsuccessful as extravasal mechanical compression was present, therefore, laparoscopic decompression and surgical division of MAL fibres were carried out. The postoperative period was characterized by a complete relief of previous symptoms and repeated CTA showed normal blood flow. DISCUSSION The authors emphasize the importance of the measurement of peak velocity of celiac trunk with Colour Duplex abdominal ultrasonography, the examination has 100% sensitivity and 83% specificity. The Duplex ultrasonography is less expensive than the "gold standard" diagnostic methods like CT and DS angiography, and can lead us to early diagnosis. Laparoscopic surgery is safe and low expense method for celiac artery decompression, however, sometimes it is difficult to reveal the exact reason and thus setting up the proper operation plan.
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Affiliation(s)
| | - István Sugár
- Semmelweis Egyetem II. Sz. Sebészeti Klinika Budapest
| | | | - Pál Ondrejka
- Semmelweis Egyetem II. Sz. Sebészeti Klinika Budapest
| | - Gábor István
- Semmelweis Egyetem II. Sz. Sebészeti Klinika Budapest
| | - Attila Vörös
- Semmelweis Egyetem II. Sz. Sebészeti Klinika Budapest Magyar Honvédség Egészségügyi Központ I. Sz. Sebészeti Osztály Budapest
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Laparoscopic versus robot-assisted surgery for median arcuate ligament syndrome. Surg Endosc 2013; 27:4060-6. [PMID: 23846363 DOI: 10.1007/s00464-013-3061-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 06/09/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Median arcuate ligament syndrome (MALS) is an uncommon disorder characterized by postprandial abdominal pain, weight loss, and vomiting related to the compression of the celiac artery by the median arcuate ligament. This syndrome has been classically treated with an open surgical approach. More recently, laparoscopic and robotic approaches have been used. We present our outcomes with laparoscopic and robot-assisted treatment of MALS. METHODS We performed a retrospective review of all patients treated for MALS from March 2006 to August 2012 at a single institution. RESULTS A total of 16 patients with MALS were treated: 12 patients via a laparoscopic approach and 4 patients via a robot-assisted approach. Patient characteristics and comorbidities were similar between groups. We experienced no intraoperative or perioperative conversions, complications, or deaths. The mean operative time for the laparoscopic approach was significantly shorter than for the robotic approach (101.7 vs. 145.8 min; P = 0.02). However, we found no significant difference in length of hospital stay (1.7 vs. 1.3 days, P = 0.23). The mean length of follow-up for laparoscopically treated patients was 22.2 months and for robotically treated patients it was 20 months. Eight patients (67 %) in the laparoscopic group and two patients (50 %) in the robotic group had full resolution of their abdominal pain. Three patients in the laparoscopic group and two patients in the robotic group ceased chronic narcotic use after surgery. CONCLUSIONS Both laparoscopic and robotic approaches to MALS treatment can be performed with minimal morbidity and mortality. The laparoscopic approach was associated with a significantly shorter operative time. While innovative, the true advantages to robot-assisted MALS surgery are yet to be seen.
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