Page 51 - World Journal of Laparoscopic Surgery

CASE REPORT
Role of Intraoperative Indocyanine Green Mapping in

Laparoscopic Management of Median Arcuate Ligament

Syndrome

2
1
Reshma Bhoir , Vishakha R Kalikar , Roy Patankar 3
AbstrAct
Median arcuate ligament syndrome also known as Dunbar syndrome is caused by compression of the celiac axis by the median arcuate ligament.
It typically presents with postprandial epigastric pain, weight loss, and vomiting, with the incidence being two cases per lakh in the third to
the fifth decade.
Keywords: Arcuate, Indocyanine, Laparoscopic, Median.
World Journal of Laparoscopic Surgery (2021): 10.5005/jp-journals-10033-1436

IntroductIon 1,2 Department of Minimal Access Surgery, Zen Hospital, Chembur,
Median arcuate ligament syndrome (MALS) is uncommon, caused Mumbai, Maharashtra, India
by external compression of the celiac artery by the median arcuate 3 Department of Minimal Access and GI Surgery, Zen Multispeciality
ligament. Symptoms are postprandial abdominal pain, vomiting, Hospital, Mumbai, Maharashtra, India
and weight loss. 1,2–5 It is mainly a diagnosis of exclusion. A computed Corresponding Author: Vishakha R Kalikar, Department of Minimal
tomography (CT) scan, magnetic resonance angiogram, or Access Surgery, Zen Hospital, Chembur, Mumbai, Maharashtra, India,
sometimes angiogram is used to confirm the change in the shape Phone: +91 09975634405, e-mail: vish.kalikar@gmail.com
of the celiac arteries and in the stenosis and poststenotic dilatation How to cite this article: Bhoir R, Kalikar VR, Patankar R. Role of
along with an abdominal Doppler. Several treatment options have Intraoperative Indocyanine Green Mapping in Laparoscopic
been described in the management of MALS, including transluminal Management of Median Arcuate Ligament Syndrome. World J Lap
dilatation, surgical division of median arcuate ligament, or arterial Surg 2021;14(1):52–54.
6

bypass surgery. However, the traditional treatment option includes Source of support: Nil
7,8
surgery—open, laparoscopic, or robotic. Minimally invasive Conflict of interest: None
surgical approaches, though technically challenging, have gained
popularity in the management of MALS owing to its benefit of
lesser postoperative pain and shorter hospital stay. We present
a patient diagnosed to have MALS and treated successfully with surgIcAl tecHnIque
laparoscopic decompression with intraoperative indocyanine green The patient was in a split-leg position with the surgeon standing
(ICG) mapping of the arteries and the ligaments. in between the legs and the monitor at the head end of the
patient. The camera system used is a 1588 Stryker system. A
10-mm viewing port was placed two-third one-third between
cAse HIstory the umbilicus and the xiphisternum. A 5-mm Nathanson retractor
A 70-year-old gentleman presented with epigastric pain— was used to retract the liver., another 10-mm working port in the
increasing after meals, vomiting—nonbilious in nature, and left subcostal midclavicular line, and a 5-mm port right subcostal
weight loss of 5 kg for 5 months. No epigastric bruits on physical midclavicular line with a 5-mm retracting port in the left anterior
examination. The patient had no medical comorbidities and no axillary line at the level of the umbilicus. An additional 5-mm port
previous surgeries. Routine blood investigations and stool exam was placed in the right paraumbilical region, midclavicular line as
were normal. Upper gastrointestinal endoscopy was suggestive shown in Figure 1. We began the dissection by opening the pars
of a hiatus hernia. Ultrasonography of the abdomen was normal. flaccida and defining the right crus. The stomach was retracted
Contrast-enhanced computed tomography of the abdomen with to the left for better visualization. The left gastric artery was
angiography was suggestive of significant (50–75%) stenosis of delineated and looped with a vascular loop and retracted and
the celiac trunk ostium from its origin with poststenotic mild dissection followed up to the trifurcation of the celiac trunk. The
dilatation of the celiac trunk. A Doppler study of the abdomen trifurcation was identified using intraoperative ICG, which was
was done in supine and erect postures and in the post-inspiratory administered by the anesthetist, 5 mg, and flushed with 10 mL of
and post-expiratory phases. It showed high velocities in the celiac normal saline. After delineating trifurcation, dissection was carried
trunk on inspiration and expiration in supine position (500 and out with ultrasonic shears till the origin of the celiac artery and
426 cm/s) and mildly high velocities in erect position (307 cm/s), the aorta as seen in Figure 2. A dense band over the celiac trunk
classical of MALS. was identified and confirmed by injecting intravenous ICG dye.
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