Technique and outcomes of robot-assisted median arcuate ligament release for celiac artery compression syndrome Stijn J. J. Thoolen, BS,a Walderik J. van der Vliet, BS,a Tara S. Kent, MD,a Mark P. Callery, MD,a Martin J. Dib, MD,a Allen Hamdan, MD,b Marc L. Schermerhorn, MD,b and A. James Moser, MD,a Boston, Mass 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 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. (J Vasc Surg 2015;-:1-7.)

Median arcuate ligament (MAL) syndrome (MALS), also known as celiac artery compression syndrome, is a rare condition first described by Harjola in 1963.1 The symptom profile attributed to MALS typically occurs in From the Institute for Hepatobiliary and Pancreatic Surgerya and the Division of Vascular and Endovascular Surgery,b Beth Israel Deaconess Medical Center, Harvard Medical School. This study received funding from the John F. Fortney Charitable Pancreatic Cancer Research Group, Griffith Family Foundation, Alliance of Families Fighting Pancreatic Cancer, and Project Purple. Author conflict of interest: A.J.M. received an educational grand from Intuitive in November 2012 for an unrelated Webinar on training and credentialing for robotic pancreatic surgery. Additional material for this article may be found online at www.jvascsurg.org. Reprint requests: A. James Moser, MD, Institute for Hepatobiliary and Pancreatic Surgery, Beth Israel Deaconess Medical Center, Stoneman 9, 330 Brookline Ave, Boston, MA 02215 (e-mail: ajmoser@bidmc. harvard.edu). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2015 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2014.10.084

young women2 who present with postprandial epigastric pain (80%), weight loss (48%), nausea (9.7%), and diarrhea (7.5%).3 The etiology of MALS remains controversial4 but has been attributed to visceral ischemia and neurogenic causes. Variability in the presenting symptoms and the unpredictable response to surgical treatment, combined with the morbidity of the open surgical approach, has led to skepticism about its clinical significance.5,6 Furthermore, unrecognized MALS might become clinically significant during pancreatoduodenectomy in up to 4% patients after division of the gastroduodenal artery and require intraoperative management for hemodynamic compromise in the celiac distribution.7 The MAL is a fibrous band of the diaphragmatic crus surrounding the origin of the celiac artery. Low insertion of the ligament or high takeoff of the celiac axis, or both, can cause extrinsic compression of the celiac artery.8 Compression of the celiac artery by the MAL was identified in 34% of individuals from the overall population in an autopsy study.9 Surgical division of the MAL is the most widely accepted treatment during open MAL release, although concurrent celiac bypass or patch angioplasty is often 1

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performed simultaneously due to the morbidity of reintervention for residual stenosis.3 A minimally invasive approach may alter the risk-to-benefit ratio of simultaneous celiac bypass and permit a stepwise approach to treating celiac stenosis with less overall morbidity. A laparoscopic approach has been described with favorable morbidity and faster recovery compared with open but suffers from a high risk of conversion (9.1%) for serious technical causes such as arterial bleeding (7.4%) and pneumothorax (2.5%).3,10 The robot-assisted minimally invasive approach combines high-definition three-dimensional visualization with superior manual dexterity and precision to permit circumferential dissection around the celiac plexus and control of bleeding, potentially creating superior surgical outcomes with fewer emergent conversion events. METHODS Study population and design The Institutional Review Board at Beth Israel Deaconess Medical Center (BIDMC) approved this retrospective study of robot-assisted MAL release between September 2012 and December 2013. Patient consent was not required for this retrospective case review. Exclusion criteria included ostial stenosis or atherosclerosis of the celiac trunk, celiac artery aneurysm, prior revascularization, including celiac bypass grafts or endovascular stents, and Ehlers-Danlos syndrome. All patients with suspected MALS were referred by their primary care physician or a gastroenterologist to the BIDMC Division of Gastroenterology for further assessment. Diagnostic evaluation for all patients excluded more common pathologies by means of upper and lower endoscopy, gallbladder ultrasound imaging, blood and breath testing for Helicobacter pylori, and celiac disease, as indicated, in addition to gastric emptying studies. Patients with suspected MALS then underwent computed tomography (CT) or magnetic resonance (MR) angiography and were evaluated by a multidisciplinary team of vascular (M.S., A.H.) and pancreatic surgeons (A.J.M., T.S.K., M.P.C.) according to the BIDMC clinical pathway for celiac artery compression syndrome. Celiac duplex imaging was required before and after surgery. Although some patients undergo psychologic testing before their referral, the BIDMC clinical pathway does not require a psychologic evaluation or cessation of narcotics among patients with typical symptoms and duplex studies consistent with MALS. Nine patients underwent robot-assisted (DaVinci Si, Intuitive Surgical, Sunnyvale, Calif) release of the MAL during the study period, and their medical records were reviewed to evaluate short-term postoperative morbidity and treatment efficacy. Patient characteristics included age, gender, body mass index (BMI), American Society of Anesthesiologists Physical Status Classification score, Charlson Comorbidity Index,11 and history of abdominal surgery. Postprandial abdominal pain, history of weight loss, fear of eating, nausea, vomiting, diarrhea, and bloating were recorded before and after surgery.

Fig 1. Placement of robot and assistant ports for release of median arcuate ligament (MAL). A, Assistant port; MCL, midclavicular line; R, robot port; SUL, superior iliac spine-umbilical line.

Clinical success was defined as complete resolution of abdominal symptoms after surgery. Clinical failure included no change in symptoms and patients reporting improved but persistent and less severe symptoms. Morbidity and readmission were monitored for 90 days. Findings on diagnostic imaging (CT or MR angiography, conventional arteriography, and mesenteric duplex ultrasound imaging) were collected. Peak systolic velocity (PSV) >200 cm/s in the celiac artery on mesenteric duplex imaging indicated celiac stenosis >70%.12 Provocative maneuvers with inspiration and expiration were performed during all mesenteric duplex ultrasound procedures. Statistical analysis Distribution characteristics for each outcome variable were checked for normalcy. None of the outcome variables were distributed normally and are therefore displayed as median and range. Statistical significance of changes in PSV on mesenteric duplex imaging where assessed using the Wilcoxon signed rank test. Values of P < .05 were considered significant. Operative technique Patients are placed supine on a split-leg operating table, with the left arm tucked. The chest is taped to the table, and the feet are supported by padded footrests. The steps of the operative technique are shown the Video (online only). Step 1: Trocar placement. Robotic (8 mm) and laparoscopic (5 mm) trocars are inserted according to Fig 1, with the exception of a 12-mm assistant trocar (A2) in the right or left abdomen depending on body habitus. The liver retractor port is located in the right anterior axillary line to expose the origin of the left gastric artery. The assistant ports permit caudal and posterior retraction of the

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Fig 2. Operative steps for release of median arcuate ligament (MAL). a, The gastrohepatic omentum has been opened, the left gastric vein divided, and a yellow vessel loop has been placed around the left gastric artery (LGA) to retract the left gastric pedicle. This maneuver exposes the celiac plexus investing the celiac trunk, which is being divided with the cautery hook. b, The celiac neural plexus has been divided, exposing the adventitia of the celiac artery. The hook is used to divide the left crus of the diaphragm to expose the aorta where the window of exposure afforded by retraction of the left gastric artery is maximal, in case the left inferior phrenic artery must be controlled. c, The laparoscopic suction is used to push the splenic artery origin posteriorly, and the entire celiac trunk is coming into view. The crossing fibers of the diaphragmatic crura MAL are being divided with the cautery hook on top of the celiac origin to expose the supraceliac aorta. d, The completed operative field, with the robotic grasper retracting the splenic artery origin and the left gastric pedicle. The celiac origin is skeletonized circumferentially, as are the proximal common hepatic and splenic arteries. The silk tie demonstrates the divided left gastric vein. The left and right crura, MAL, investing nerve plexus, and the bilateral celiac ganglia have been dissected completely free from adjacent vessels.

left gastric artery and passage of vascular suture and packing material in case of arterial bleeding. Step 2: Exposure of the celiac trunk. The robot is docked with the patient in steep reverse Trendelenburg position. The camera is positioned to look over the superior border of the pancreas to the left of the midline so that the entire origin of the celiac from the aorta is in view. The hepatogastric ligament is divided, and the left gastric artery is encircled with a vessel loop for retraction. The left gastric vein is ligated and divided to prevent inadvertent rupture during retraction. The celiac lymph nodes are dissected free of the common hepatic and celiac arteries. Caudal and leftward traction on the left gastric artery exposes the celiac artery. Step 3: Ligation of the phrenic vessels and identification of the aorta. Given posterior and caudal retraction of the celiac artery by the MAL (“fishhook” deformity), the course of the anterior wall of the celiac cannot be safely ascertained (Fig 2, a). Dissection along the anterior surface of the celiac toward the aorta may cause inadvertent anterior injury of the celiac near its origin. Dissection proximally from the common hepatic artery along the side of the celiac is safer, but the inferior phrenic arteries must be protected or suture ligated with 4-0 monofilament suture to prevent bleeding near the celiac origin, which can be brisk and confused with celiac or aortic injuries. Step 4: Division of the MAL and circumferential lysis of the celiac ganglia. The vessel loop around the left gastric artery is used to expose the length of the celiac artery

during circumferential (or at least 300 ) division of diaphragmatic muscle and nerve fibers (Fig 2, b). We expose a 2-cm margin of aorta around the celiac origin (Fig 2, c). The adventitia of the celiac trunk should be free of overlying nerve and muscle fibers at the conclusion of the procedure (Fig 2, d). RESULTS Preoperative demographics and symptoms. The study cohort consisted of nine patients (six women). Median age was 46 years (range, 18-77 years), and the median BMI was 21.6 kg/m2 (range, 18-26 kg/m2). No patients had serious comorbidities as measured by the Charlson Comorbidity Index. All patients except one had an American Society of Anesthesiologists score of 70%. Two patients demonstrated retrograde flow in the common hepatic

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Table I. Demographics and symptom profile of study cohort Patient 1 2 3 4 5 6 7 8 9

Age, years

Gender

BMI, kg/m2

40 60 49 77 56 22 45 18 45

Female Female Female Male Female Male Female Female Male

22.5 22.2 18.0 26.1 18.7 18.8 21.2 25.7 21.8

Pain syndrome Postprandial Postprandial Postprandial Postprandial Postprandial Postprandial Postprandial Postprandial Postprandial

pain, pain, pain, pain, pain, pain, pain, pain, pain,

weight weight weight weight weight weight weight weight weight

loss, loss, loss, loss loss, loss, loss, loss, loss,

nausea, vomiting, diarrhea nausea, diarrhea, bloating fear of eating, diarrhea nausea, bloating bloating fear of eating, diarrhea, bloating fear of eating, nausea, vomiting, diarrhea nausea

BMI, Body mass index.

Table II. Preoperative imaging characteristics of the celiac artery Patient 1 2 3 4 5 6 7 8 9

Response to respiration Expiration None Expiration Expiration Inspiration Expiration Expiration Expiration Expiration

Fishhook deformity

Post-stenotic dilatation

Yes yes No yes No Yes Yes Yes No

artery consistent with collateralization through the gastroduodenal and superior mesenteric arteries (Table II). Perioperative outcomes. The nine robot-assisted procedures were completed without conversion. Median operative time was 140 minutes (range, 100-169 minutes), with an estimated blood loss of 70%. The

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Table III. Clinical response and duplex outcomes of surgical treatment Celiac artery PSV, cm/s Patient 1 2 3 4 5 6 7 8 9

Preoperative

Postoperativea

306 637 280 452 557 263 324 453 238

Not Available 195 184 251 252 128 212 199 203

Postoperative symptom profile Resolved Improved Improved Resolved Resolved Improved Improved Improved Resolved

pain, diarrhea pain, nausea pain pain pain

PSV, Peak systolic velocity. a P < .05 by Wilcoxon signed rank.

long-term durability of their pain relief is unknown, given the short follow-up in this early report. However, we speculate that symptom relief may be attributed to the neurolysis of the celiac artery rather than normalization of blood flow through the celiac artery. Hypertrophic neural ganglia and thickened lymphatics are a universal intraoperative finding in this population. Although there is still no consensus on the pathophysiology of MALS, multiple hypotheses have been proposed, including foregut ischemia secondary to reduced flow through the celiac axis resulting in “steal syndrome” through collaterals from the superior mesenteric artery. Other explanations implicate a neurologic origin, including compression by the celiac ganglion and direct stimulation of celiac pain fibers resulting in splanchnic vasoconstriction and ischemia.4 The diagnosis of MALS is controversial because it remains a diagnosis of exclusion. Extrinsic compression of the celiac artery is present in up to 34% in cadaveric studies.7 Moreover, the high incidence of MALS casts universal doubt on symptoms merely associated with celiac artery compression. The BIDMC clinical pathway for patients with suspected MALS begins with a referral to the Division of Gastroenterology and a diagnostic evaluation to exclude common causes of abdominal pain by means of upper and lower endoscopy, gallbladder ultrasound imaging, blood and breath testing for H pylori and celiac disease, as indicated, and gastric emptying studies, followed by cross-sectional imaging with CT or MR arteriography to exclude foregut cancers and more common vascular conditions. The evaluation of patients with suspected MALS should be undertaken by a multidisciplinary team, including gastroenterology and vascular surgery. Reproducible selection criteria for treating MALS are not defined, and symptoms may not improve.13 The fishhook deformity of the celiac artery and absence of calcifications or wall irregularities help to distinguish MALS from more common causes of celiac stenosis such as atherosclerosis.14,15 Preoperative functional confirmation by celiac artery duplex during respiratory motion is critical. Stenosis of the celiac axis due to MALS is typically less apparent during inspiration. Increased celiac artery

blood flow velocity on mesenteric duplex ultrasound imaging during deep expiration is also typical.12,15,16 Several treatments for MALS13 have been described, including release of the MAL with other concomitant procedures as well as endovascular and open celiac bypass grafts.17,18 Open surgical division of the MAL remains the gold standard but is associated with a collected 6.5% rate of major postoperative complications3 and a minimum hospital stay of w5 days.18 To circumvent the morbidity of reintervention for persistent symptoms and residual stenosis, 25% of open MAL releases are performed in combination with reconstruction of the celiac artery.3 Minimally invasive MAL release allows for a first step in treating MALS without the higher risk concomitant vascular bypass of uncertain benefit. The necessity of additional procedures can be determined later, possibly preventing significant additional treatment burden. The first minimally invasive approach was described by Roayaie et al19 in 2000, and multiple series have since been published,2,20 including the largest series of 16 patients by Baccari et al.21 A recent review by Jimenez et al3 demonstrated seven laparoscopic case series reporting outcomes of 121 patients, with symptomatic improvement in 116 patients but a 9.1% conversion rate due to potentially life-threatening complications such as bleeding and pneumothorax.3 The authors cited the “learning curve” of this low-incidence procedure as a contributory factor in conversions for bleeding from the supraceliac aorta. The first robot-assisted minimally invasive procedure for MALS was reported by Jaik et al22 in 2007, and nine additional cases have been reported since.23-26 Outcomes included one conversion to an open operation due to hemorrhage from an aortic injury. Potential advantages of robotassisted approaches to celiac artery compression include increased dexterity and three-dimensional visualization, which we believe are particularly advantageous during dissection along the fishhook deformity, where the MAL can be both tenacious and relatively indistinguishable from the anterior wall of the vessel. The third robotic arm can be used to apply pressure or occlude bleeding while the vascular suture is passed by the assistant to the remaining two arms for repair of the celiac or the inferior phrenic arteries, which may bleed briskly and mimic a rent in the aorta or the celiac. Although these advantages are specific to the robot, proper placement of the assistant ports for suction and the passing of needles is critical to the safe adoption of this technique. Excellent suturing skills are a prerequisite to prevent small holes in the supraceliac aorta from being enlarged by passing needles through normal visceral vessels without haptic feedback.26 Owing to the low incidence of MALS, most surgeons will remain on the learning curve of this procedure and should function within a multidisciplinary team that aligns the potential operative risk with its intended benefit. Other drawbacks of the robotic technique include higher initial costs due to training and equipment expense.27 The relative cost of the robot-assisted technique compared with the laparoscopic approach must be addressed in a

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prospective study to identify the total expenditure per patient caused by the additional costs of conversions and associated complications. A clinical trial of this nature is premature during the current design phase of the minimally invasive approach and may not be feasible due to the relative rarity of this indication. We expect that further standardization of the robotic technique will improve outcomes and reduce conversion rates consistent with the improved technical capability to control bleeding. Given the retrospective design and relatively short period of follow-up, a placebo effect of surgical intervention cannot be completely excluded. However, the time course of symptom improvement after robotic MALS in this study did not correspond to a classic placebo effect. Although three patients demonstrated complete relief of celiac stenosis by postoperative PSV criteria and eventually experienced complete relief of preoperative symptoms during their follow-up visits, none were better at the first postoperative visit. All five patients subsequently experienced ongoing improvement in their symptoms during followup that was unrelated to the presence or absence of residual celiac stenosis according to duplex criteria. As a result of these observations, we speculate that symptom relief may be related to celiac neurolysis in addition to improved flow through the celiac artery. This series presents a standardized surgical technique for robot-assisted division of the MAL and celiac ganglion neurolysis among patients with suspected MALS. Symptomatic outcomes are consistent with published series, with potentially improved safety due to the elimination of conversions related to bleeding. Observed perioperative morbidity was minimal, but limited follow-up prevents evaluation of late recurrences and delayed reinterventions in these patients. The cohort was selected based on multidisciplinary evaluation and the availability of expert mesenteric duplex imaging, which may bias the results of this retrospective single-institution study. The operations were performed by a particularly high-volume team of advanced minimally invasive surgeons that performs nearly 100 pancreas and liver resections annually and for whom the celiac vascular dissection is a frequent event. CONCLUSIONS These data indicate that robot-assisted MAL release can be done safely and effectively, with positive short-term outcomes and minimal morbidity for patients with MALS. We are deeply indebted to the robotic operating team at BIDMC for their personal investment in these outcomes, including Melissa Jones, Sheryl Wiggins, Beth Person, and Elena Canacari, as well as to Dr Lorenzo Anez-Bustillos, without whom these data would not exist. AUTHOR CONTRIBUTIONS Conception and design: ST, WV, TK, MC, MD, AH, MS, AM Analysis and interpretation: ST, WV, AH, MS, AM Data collection: ST, WV, TK, MC, MD, AH, MS, AM

Writing the article: ST, WV, AM Critical revision of the article: ST, WV, TK, MC, MD, AH, MS, AM Final approval of the article: ST, WV, TK, MC, MD, AH, MS, AM Statistical analysis: ST, WV, AM Obtained funding: AM Overall responsibility: AM ST and WV contributed equally to this work. REFERENCES 1. Harjola PT. A rare obstruction of the coeliac artery. Report of a case. Ann Chir Gynaecol Fenn 1963;52:547-50. 2. Duffy AJ, Panait L, Eisenberg D, Bell RL, Roberts KE, Sumpio B. Management of median arcuate ligament syndrome: a new paradigm. Ann Vasc Surg 2009;23:778-84. 3. Jimenez JC, Harlander-Locke M, Dutson EP. Open and laparoscopic treatment of median arcuate ligament syndrome. J Vasc Surg 2012;56: 869-73. 4. Bech FR. Celiac artery compression syndromes. Surg Clin North Am 1997;77:409-24. 5. Szilagyi DE, Rian RL, Elliott JP, Smith RF. The celiac artery compression syndrome: does it exist? Surgery 1972;72:849-63. 6. Plate G, Eklof B, Vang J. The celiac compression syndrome: myth or reality? Acta Chir Scand 1981;147:201-3. 7. Farma JM, Hoffman JP. Nonneoplastic celiac axis occlusion in patients undergoing pancreaticoduodenectomy. Am J Surg 2007;193:341-4; discussion: 344. 8. Loukas M, Pinyard J, Vaid S, Kinsella C, Tariq A, Tubbs RS. Clinical anatomy of celiac artery compression syndrome: a review. Clin Anat 2007;20:612-7. 9. Annalise KS, Bridger J. A cadaveric study of the anatomical variation of the origins of the celiac trunk and the superior mesenteric artery: role in median arcuate ligament syndrome? Clin Anat 2013;26:971-4. 10. Tulloch AW, Jimenez JC, Lawrence PF, Dutson EP, Moore WS, Rigberg DA, et al. Laparoscopic versus open celiac ganglionectomy in patients with median arcuate ligament syndrome. J Vasc Surg 2010;52: 1283-9. 11. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373-83. 12. Moneta GL, Lee RW, Yeager RA, Taylor LM Jr, Porter JM. Mesenteric duplex scanning: a blinded prospective study. J Vasc Surg 1993;17: 79-84; discussion: 85-6. 13. Reilly LM, Ammar AD, Stoney RJ, Ehrenfeld WK. Late results following operative repair for celiac artery compression syndrome. J Vasc Surg 1985;2:79-91. 14. Horton KM, Talamini MA, Fishman EK. Median arcuate ligament syndrome: evaluation with CT angiography. Radiographics 2005;25:1177-82. 15. Aschenbach R, Basche S, Vogl TJ. Compression of the celiac trunk caused by median arcuate ligament in children and adolescent subjects: evaluation with contrast-enhanced MR angiography and comparison with Doppler US evaluation. J Vasc Interv Radiol 2011;22:556-61. 16. Erden A, Yurdakul M, Cumhur T. Marked increase in flow velocities during deep expiration: a duplex Doppler sign of celiac artery compression syndrome. Cardiovasc Intervent Radiol 1999;22:331-2. 17. Matsumoto AH, Angle JF, Spinosa DJ, Hagspiel KD, Cage DL, Leung DA, et al. Percutaneous transluminal angioplasty and stenting in the treatment of chronic mesenteric ischemia: results and longterm followup. J Am Coll Surg 2002;194(1 Suppl):S22-31. 18. Grotemeyer D, Duran M, Iskandar F, Blondin D, Nguyen K, Sandmann W. Median arcuate ligament syndrome: vascular surgical therapy and follow-up of 18 patients. Langenbecks Arch Surg 2009;394:1085-92. 19. Roayaie S, Jossart G, Gitlitz D, Lamparello P, Hollier L, Gagner M. Laparoscopic release of celiac artery compression syndrome facilitated by laparoscopic ultrasound scanning to confirm restoration of flow. J Vasc Surg 2000;32:814-7.

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20. Vaziri K, Hungness ES, Pearson EG, Soper NJ. Laparoscopic treatment of celiac artery compression syndrome: case series and review of current treatment modalities. J Gastrointest Surg 2009;13:293-8. 21. Baccari P, Civilini E, Dordoni L, Melissano G, Nicoletti R, Chiesa R. Celiac artery compression syndrome managed by laparoscopy. J Vasc Surg 2009;50:134-9. 22. Jaik NP, Stawicki SP, Weger NS, Lukaszczyk JJ. Celiac artery compression syndrome: successful utilization of robotic-assisted laparoscopic approach. J Gastrointestin Liver Dis 2007;16:93-6. 23. Meyer M, Gharagozloo F, Nguyen D, Tempesta B, Strother E, Margolis M. Robotic-assisted treatment of celiac artery compression syndrome: report of a case and review of the literature. Int J Med Robot 2012;8:379-83. 24. Relles D, Moudgill N, Rao A, Rosato F, DiMuzio P, Eisenberg J. Roboticassisted median arcuate ligament release. J Vasc Surg 2012;56:500-3.

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25. Do MV, Smith TA, Bazan HA, Sternbergh WC 3rd, Abbas AE, Richardson WS. Laparoscopic versus robot-assisted surgery for median arcuate ligament syndrome. Surg Endosc 2013;27:4060-6. 26. El-Hayek KM, Titus J, Bui A, Mastracci T, Kroh M. Laparoscopic median arcuate ligament release: are we improving symptoms? J Am Coll Surg 2013;216:272-9. 27. Antoniou GA, Riga CV, Mayer EK, Cheshire NJ, Bicknell CD. Clinical applications of robotic technology in vascular and endovascular surgery. J Vasc Surg 2011;53:493-9.

Submitted Sep 8, 2014; accepted Oct 22, 2014.

Additional material for this article may be found online at www.jvascsurg.org.

Technique and outcomes of robot-assisted median arcuate ligament release for celiac artery compression syndrome.

Celiac artery compression by the median arcuate ligament (MAL) is a potential cause of postprandial abdominal pain and weight loss that overlaps with ...
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