The MALS was first described by Harjola in 1963  and consisted of the extrinsic compression of the celiac trunk by fibers of the median arcuate ligament. MALS causes abdominal symptoms such as postprandial epigastric abdominal pain, weight loss, and abdominal bruit. In 1965, Dunbar reported the release of the median arcuate ligament in 13 patients with promising results . Subsequently, in 2000, Roayaie reported the first case of laparoscopic arcuate ligament release . Recently, laparoscopic management of MALS has been reported. Its advantages include a relatively short operative time, less pain and blood loss, shorter hospital stay, early oral intake initiation, low possibilities of infections, and better visualization of the surgical field . In 2007, Jaik reported the first robot-assisted approach , and a similar technique has been reported with excellent results [6, 7].
Symptomatic MALS is an indication of median arch ligament release. Surgical or endovascular treatment indicates asymptomatic MALS with aneurysms in collateral vessels. However, the indication for treatment in asymptomatic cases is unknown. Likewise, the treatment for asymptomatic MALS in patients with gastric cancer who are indicated for surgery is also unknown. As far as we can find in PubMed, there is only one case of gastric cancer complicated with MALS, in which laparoscopic distal gastrectomy and median arch ligament release were performed simultaneously . The patient in this literature was a 62-year-old woman with asymptomatic MALS who underwent median arch ligament release at the same time as her gastric cancer surgery because adhesions would make surgery difficult if surgery for MALS were needed after gastrectomy. In our case, the patient was a 70-year-old woman with asymptomatic MALS who underwent a median arch ligament release performed simultaneously with laparoscopic gastrectomy for the same reason because of the possibility that she would need MALS surgery in the future.
Asymptomatic MALS is often followed up, and we did not find any article reporting the frequency of developing abdominal pain or pancreatic head aneurysms in the future. Therefore, the frequency is probably low, and elderly patients will likely die of other diseases while remaining asymptomatic. Consequently, we believe prophylactic surgery for asymptomatic MALS should be reserved for gastric cancer surgery only in elderly patients with many residual diseases or risk factors, such as liver cirrhosis. Although the patient, in this case, was rather elderly (70 years old), we judged that she had no additional illnesses and few risk factors.
In this case, gastric cancer surgery performed was distal gastrectomy with D1 dissection and R-Y reconstruction; D1 dissection does not require No.9 lymph node dissection, but in this case, No.9 lymph node was dissected when the median arch ligament was exposed, providing an excellent visual field. Most gastric cancers indicated for surgery require D1 + or D2 dissection, and we believe that simultaneous MALS surgery would be more reasonable to dissect the No.9 lymph node. In addition, R-Y or B-II reconstruction may make reoperation for MALS easier than B-1 reconstruction, in which the remnant stomach is attached to the celiac axis. In this case, the patient underwent R-Y reconstruction, and if No.9 lymph node had been preserved, reoperation for MALS might have been possible without solid adhesions.
The patient underwent median arch ligament release simultaneously with laparoscopic gastrectomy under excellent visual field in short time. When MALS is found concurrent with gastric cancer, simultaneous surgery should be considered if symptomatic. Even if MALS is asymptomatic, if the patient is young, the release of the median arch ligament may be necessary for the future. The patient has few risk factors and requires D1 + or D2 dissection, and simultaneous MALS surgery may be considered. If simultaneous MALS surgery is not performed, R-Y or B-II reconstruction may be preferable instead of B-I reconstruction to avoid adhesions. The safety of laparoscopic surgery for both gastrectomy and median arch ligament resection has been reported, and simultaneous laparoscopic surgery is also considered acceptable. Given the widespread use of robotic surgery for gastric cancer and the good results of robotic surgery for median arch ligament release, simultaneous surgery may be considered in robotic surgery.