The patient was a 43-year-old man who visited the emergency department with severe abdominal pain he had never had before 3 h after acute onset. His medical history included hypertension and recurrent episodes of severe postprandial or preprandial epigastric pain for a few years. The results of esophagogastroduodenoscopy, abdominal ultrasound, and CT were all unremarkable.
Abdominal examination revealed epigastric tenderness. No other abdominal findings, such as rebound tenderness or muscular defense, were observed. Contrast-enhanced abdominal CT revealed isolated SMA dissection with a thrombosed false lumen and celiac artery aneurysm (Fig. 1a, b). Two-day conservative treatment with fasting and blood pressure control showed no ischemic sign in the small intestine was observed. A sagittal view of the CT angiography showed extrinsic compression of the root of the celiac axis by the MAL (Fig. 1c), and 3D CT angiography showed proximal celiac axis stenosis and poststenotic dilatation (Fig. 1d). Further conservative treatment relieved his symptoms, and a 3-month follow-up CT showed disappearance of the SMA dissection. After treatment for the SMA dissection, intermittent epigastric pain persisted. Point tenderness with an echoic probe showed that the root of the celiac axis was associated with the most pain and that the symptom was thought to be due to MALS. He opted for laparoscopic MAL release 10 months after treatment for the SMA dissection.
The procedure was performed under general anesthesia. The patient was placed in a reverse Trendelenburg position with his legs spread apart. The first port of the videoscope was inserted via an open technique at the umbilicus. After the pneumoperitoneum was established, four operating ports were inserted. The left segment of the liver was retracted using a Nathanson Hook Liver Retractor (Yufu ITONAGA CO., LTD. Tokyo Japan). After division of the gastrohepatic ligament, the right crus of the diaphragm was identified, and the peritoneal line anterior to the right crus was opened. Thereafter, the greater omentum was divided, and the left gastric artery was exposed on the suprapancreatic surface. The stomach was raised and retracted ventrally, with taping on both sides of the left gastric artery. One suture was made for fixation of the stomach to the peritoneum. These procedures freed the surgeons’ and assistants’ hands and allowed for caudal-to-ventral MAL division with a good surgical view (Fig. 2a) [9].
After skeletonization of the vessels (common hepatic artery, splenic artery, and left gastric artery) and diaphragmatic crura, all tissues overlying the aorta, commonly referred to as the MAL (Fig. 2b), were divided in a caudal to ventral direction. The MAL was divided to the start of the celiac artery, ensuring that no surrounding musculo-fibrous or periganglionic tissue remained (Fig. 2c). The operative time was 152 min, and the amount of blood loss was 22 ml. The patient was discharged on postoperative day 2 but was readmitted on postoperative day 7 because of gastroparesis, which improved with conservative treatment and fasting.
After surgery, immediate symptomatic improvement was acquired. Enhanced CT performed 6 months after the surgery revealed no residual celiac axis stenosis or poststenotic dilatation (Fig. 3). At the 20-month follow-up, the patient showed no recurrence of symptoms.