Technique and outcomes of robot-assisted median arcuate ligament release for celiac artery compression syndrome Stijn J.J. Thoolen, BS, Walderik J. van.

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Technique and outcomes of robot-assisted median arcuate ligament release for celiac artery compression syndrome Stijn J.J. Thoolen, BS, Walderik J. van der Vliet, BS, Tara S. Kent, MD, Mark P. Callery, MD, Martin J. Dib, MD, Allen Hamdan, MD, Marc L. Schermerhorn, MD, A. James Moser, MD Journal of Vascular Surgery Volume 61, Issue 5, Pages 1278-1284 (May 2015) DOI: 10.1016/j.jvs.2014.10.084 Copyright © 2015 Society for Vascular Surgery Terms and Conditions

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. Journal of Vascular Surgery 2015 61, 1278-1284DOI: (10.1016/j.jvs.2014.10.084) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

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. Journal of Vascular Surgery 2015 61, 1278-1284DOI: (10.1016/j.jvs.2014.10.084) Copyright © 2015 Society for Vascular Surgery Terms and Conditions