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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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Upshaw W, Richey J, Ravi G, Chen A, Spillers NJ, Ahmadzadeh S, Varrassi G, Shekoohi S, Kaye AD. Overview of Median Arcuate Ligament Syndrome: A Narrative Review. Cureus 2023; 15:e46675. [PMID: 37942382 PMCID: PMC10629207 DOI: 10.7759/cureus.46675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/07/2023] [Indexed: 11/10/2023] Open
Abstract
Median arcuate ligament syndrome (MALS) is a rare disorder caused primarily by compression of the celiac trunk by the median arcuate ligament (MAL). This disorder typically results in patients presenting with bloating, weight loss, nausea, vomiting, and abdominal pain. The MALS diagnosis is one of exclusion, as the disorder has no specific diagnostic criteria. Imaging modalities are often utilized to assist in making the diagnosis, such as ultrasound, computed tomography angiography (CTA), and magnetic resonance angiography (MRA). These imaging modalities typically reveal a stenosed celiac artery with post-stenotic dilation in patients. This disorder is usually treated by dividing the MAL, thus relieving the compression of the celiac artery. The surgery may be done through either an open approach or a minimally invasive approach, which can be either laparoscopic or robot-assisted. Most patients respond well to this treatment, though certain factors that predict a poorer response to treatment include elderly age, a history of alcohol abuse, and psychiatric illness.
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Affiliation(s)
- Will Upshaw
- Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - John Richey
- Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Gurjot Ravi
- Medicine, Ross University School of Medicine, Shreveport, USA
| | - Adrian Chen
- Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Noah J Spillers
- Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Shahab Ahmadzadeh
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | | | - Sahar Shekoohi
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Alan D Kaye
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
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Jonas JP, Rössler F, Ghafoor S, Kobe A, Pfammatter T, Schlag C, Gutschow CA, Petrowsky H, Müller PC, Oberkofler CE. Surgical therapy of celiac axis and superior mesenteric artery syndrome. Langenbecks Arch Surg 2023; 408:59. [PMID: 36690823 PMCID: PMC9870837 DOI: 10.1007/s00423-023-02803-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/20/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Compression syndromes of the celiac artery (CAS) or superior mesenteric artery (SMAS) are rare conditions that are difficult to diagnose; optimal treatment remains complex, and symptoms often persist after surgery. We aim to review the literature on surgical treatment and postoperative outcome in CAS and SMAS syndrome. METHODS A systematic literature review of medical literature databases on the surgical treatment of CAS and SMAS syndrome was performed from 2000 to 2022. Articles were included according to PROSPERO guidelines. The primary endpoint was the failure-to-treat rate, defined as persistence of symptoms at first follow-up. RESULTS Twenty-three studies on CAS (n = 548) and 11 on SMAS (n = 168) undergoing surgery were included. Failure-to-treat rate was 28% for CAS and 21% for SMAS. Intraoperative blood loss was 95 ml (0-217) and 31 ml (21-50), respectively, and conversion rate was 4% in CAS patients and 0% for SMAS. Major postoperative morbidity was 2% for each group, and mortality was described in 0% of CAS and 0.4% of SMAS patients. Median length of stay was 3 days (1-12) for CAS and 5 days (1-10) for SMAS patients. Consequently, 47% of CAS and 5% of SMAS patients underwent subsequent interventions for persisting symptoms. CONCLUSION Failure of surgical treatment was observed in up to every forth patient with a high rate of subsequent interventions. A thorough preoperative work-up with a careful patient selection is of paramount importance. Nevertheless, the surgical procedure was associated with a beneficial risk profile and can be performed minimally invasive.
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Affiliation(s)
- J P Jonas
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - F Rössler
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - S Ghafoor
- Department of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - A Kobe
- Department of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - T Pfammatter
- Department of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - C Schlag
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - C A Gutschow
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - H Petrowsky
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - P C Müller
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - C E Oberkofler
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland.
- Vivévis AG-Visceral, Tumor, Robotic Surgery, Clinic Hirslanden, Zurich, Switzerland.
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Milone M, Manigrasso M, Anoldo P, D’Amore A, Elmore U, Giglio MC, Rompianesi G, Vertaldi S, Troisi RI, Francis NK, De Palma GD. The Role of Robotic Visceral Surgery in Patients with Adhesions: A Systematic Review and Meta-Analysis. J Pers Med 2022; 12:jpm12020307. [PMID: 35207795 PMCID: PMC8878352 DOI: 10.3390/jpm12020307] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/08/2022] [Accepted: 02/14/2022] [Indexed: 12/17/2022] Open
Abstract
Abdominal adhesions are a risk factor for conversion to open surgery. An advantage of robotic surgery is the lower rate of unplanned conversions. A systematic review was conducted using the terms “laparoscopic” and “robotic”. Inclusion criteria were: comparative studies evaluating patients undergoing laparoscopic and robotic surgery; reporting data on conversion to open surgery for each group due to adhesions and studies including at least five patients in each group. The main outcomes were the conversion rates due to adhesions and surgeons’ expertise (novice vs. expert). The meta-analysis included 70 studies from different surgical specialities with 14,329 procedures (6472 robotic and 7857 laparoscopic). The robotic approach was associated with a reduced risk of conversion (OR 1.53, 95% CI 1.12–2.10, p = 0.007). The analysis of the procedures performed by “expert surgeons” showed a statistically significant difference in favour of robotic surgery (OR 1.48, 95% CI 1.03–2.12, p = 0.03). A reduced conversion rate due to adhesions with the robotic approach was observed in patients undergoing colorectal cancer surgery (OR 2.62, 95% CI 1.20–5.72, p = 0.02). The robotic approach could be a valid option in patients with abdominal adhesions, especially in the subgroup of those undergoing colorectal cancer resection performed by expert surgeons.
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Affiliation(s)
- Marco Milone
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.D.); (M.C.G.); (G.R.); (S.V.); (R.I.T.); (G.D.D.P.)
- Correspondence: ; Tel.: +39-333-299-3637
| | - Michele Manigrasso
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (M.M.); (P.A.)
| | - Pietro Anoldo
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (M.M.); (P.A.)
| | - Anna D’Amore
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.D.); (M.C.G.); (G.R.); (S.V.); (R.I.T.); (G.D.D.P.)
| | - Ugo Elmore
- Department of Surgery, San Raffaele Hospital and San Raffaele Vita-Salute University, 20132 Milan, Italy;
| | - Mariano Cesare Giglio
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.D.); (M.C.G.); (G.R.); (S.V.); (R.I.T.); (G.D.D.P.)
| | - Gianluca Rompianesi
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.D.); (M.C.G.); (G.R.); (S.V.); (R.I.T.); (G.D.D.P.)
| | - Sara Vertaldi
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.D.); (M.C.G.); (G.R.); (S.V.); (R.I.T.); (G.D.D.P.)
| | - Roberto Ivan Troisi
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.D.); (M.C.G.); (G.R.); (S.V.); (R.I.T.); (G.D.D.P.)
| | | | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.D.); (M.C.G.); (G.R.); (S.V.); (R.I.T.); (G.D.D.P.)
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Dembinski J, Robert B, Sevestre MA, Freyermuth M, Yzet T, Dokmak S, Regimbeau JM. Celiac axis stenosis and digestive disease: Diagnosis, consequences and management. J Visc Surg 2020; 158:133-144. [PMID: 33191149 DOI: 10.1016/j.jviscsurg.2020.10.005] [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: 10/23/2022]
Abstract
Arterial blood flow to the organs of the upper abdomen is provided by the celiac axis (CA) and the superior mesenteric artery (SMA) that communicate between each other via the gastro-duodenal artery, the anterior and posterior pancreatico-duodenal arcades, the branches of the dorsal pancreatic artery and inconsistently, though a supplementary arcade that connects the CA and the SMA (arcade of Bühler). Celiac axis stenosis may or may not have a hemodynamic impact on the splanchnic circulation. Hemodynamically significant CA stenosis can be asymptomatic, or symptomatic with variables clinical consequences. Management depends on whether the mechanism of stenosis is extrinsic or intrinsic. When upper gastrointestinal interventional radiology or surgery is indicated, stenosis can pose technical difficulties or create severe ischemia requiring good understanding of this entity in the planning of operative steps and adapted management. Management of CA stenosis is therefore multidisciplinary and may involve interventional radiologists, gastrointestinal surgeons, vascular surgeons as well as medical physicians. Even though the prevalence of CA stenosis is relatively low (between 5 and 10%) and irrespective of its etiology, surgeons, radiologists and physicians must be aware of it because it can intervene in the management of upper gastrointestinal disease. It must be sought, and treatment must be adapted to each particular situation to avoid potentially severe complications.
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Affiliation(s)
- J Dembinski
- Department of Digestive Surgery, University Hospital of Amiens Picardie et Université de Picardie Jules Verne, 1, rue du Professeur Christian Cabrol, 80054 Amiens, France; Clinical research unit SSPC (Simplifications des Soins des Patients Complexes) UR UPJV 7518, University of Picardie Jules Verne, Amiens, France
| | - B Robert
- Radiology Department, University Hospital of Amiens Picardie and Picardie Jules Verne University, Amiens, France
| | - M-A Sevestre
- Vascular Medicine Department, University Hospital of Amiens Picardie and Picardie Jules Verne University, Amiens, France
| | - M Freyermuth
- Vascular Surgery Department, University Hospital of Amiens Picardie and Picardie Jules Verne University, Amiens, France
| | - T Yzet
- Radiology Department, University Hospital of Amiens Picardie and Picardie Jules Verne University, Amiens, France
| | - S Dokmak
- Department of Hepatobiliary Surgery and Liver Transplantation, Assistance Publique-Hôpitaux de Paris and Paris University, Clichy, France
| | - J-M Regimbeau
- Department of Digestive Surgery, University Hospital of Amiens Picardie et Université de Picardie Jules Verne, 1, rue du Professeur Christian Cabrol, 80054 Amiens, France; Clinical research unit SSPC (Simplifications des Soins des Patients Complexes) UR UPJV 7518, University of Picardie Jules Verne, Amiens, France.
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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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Roberts B, Pevsner R, Alkhoury F. Robotic Approach for Median Arcuate Ligament Release in Pediatrics. J Laparoendosc Adv Surg Tech A 2019; 30:92-96. [PMID: 31859596 DOI: 10.1089/lap.2019.0337] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Median arcuate ligament (MAL) syndrome is a rare cause of chronic abdominal pain in adults and children. Release of the MAL has traditionally been performed open or laparoscopically. There have not been any published cases to our knowledge of robotic-assisted MAL release in pediatric patients. Patients and Methods: Two adolescent patients, aged 12 and 15 years, at our institution underwent robotic-assisted MAL release. The procedure involved dissecting the MAL muscle fibers and overlying scar tissue. Patients stayed inpatient postoperatively overnight and with an average outpatient follow-up of 10 months. Results: Both patients had immediate pain relief postoperatively and at 10-month follow-up had no recurrent symptoms. No complications were associated with the procedure. Conclusion: The increasing role of robotic surgery as a new surgical technique is gaining momentum for many procedures. This new approach for MAL release in the pediatric population was explored by our institution. It was found to be successful, safe, and reproducible for future patients.
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Affiliation(s)
- Bailey Roberts
- Department of Pediatric Surgery, Nicklaus Children's Hospital, Florida International University, Herbert Wertheim College of Medicine, Miami, Florida
| | - Rachel Pevsner
- Department of Pediatric Radiology, Nicklaus Children's Hospital, Florida International University, Herbert Wertheim College of Medicine, Miami, Florida
| | - Fuad Alkhoury
- Department of Pediatric Surgery, Nicklaus Children's Hospital, Florida International University, Herbert Wertheim College of Medicine, Miami, Florida
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