A paper in the February 2013 issue of the Journal of the American College of Surgeons describes 15 cases of median arcuate ligament syndrome treated with laparoscopic surgery.
Median arcuate ligament syndrome (MALS) is somewhat controversial. It is said to be due to impingement of the median arcuate ligament (a portion of the diaphragmatic crura) on the celiac artery causing a narrowing. Symptoms are abdominal pain after eating, nausea and weight loss. It is often diagnosed in patients who have been worked up for many other suspected problems without finding anything.
The paper notes that 10% to 60% of people without postprandial pain have narrowing of the celiac artery.
The abstract reports resolution of the pain for 14 of the 15 patients who had the surgery as well as a significant mean decrease in celiac velocity indicating resolution of the narrowed area postoperatively.
It also mentions that one patient required conversion to open surgery but doesn't say why.
On reading the paper, one learns that the conversion to open occurred in the only case that was done with robotic assistance.
The authors state that the 2 mm injury to the aorta was the result of the robotic instrument being too large and "the absence of haptic feedback," which is robot-speak for "you can't feel anything."
That is one drawback of the robot. With robotic instruments the sense of touch is simply not present. Although the fingertips used in old-fashioned open surgery are much more sensitive than instruments used in standard laparoscopic surgery, those instruments do enable the surgeon to at least feel some variations in tissues
The aortic tear led to two liters of blood loss and an operative time of just under 8 hours.
The abstract says all but one patient had complete resolution of pain, but the paper says the amount of decrease in the Doppler celiac velocity "did not correspond to the degree of symptom resolution."
And you can see that the differences in preop (red) and postop (green) velocities are pretty modest in 7 of the 10 patients who had them measured even though mean difference was significant at a p of 0.005. In addition, the postop values all hover around 200 cm/sec, which, in the presence of symptoms, was the threshold for doing the operation.
In fairness, of the 13 patients who were interviewed, all said they were satisfied with the outcome of the surgery and would go through it again.
In some ways, MALS reminds me of internal mammary artery ligation, which was once touted as a cure for angina pectoris. Over 50 years ago a clever study was done. Incisions were made, but the arteries were not ligated. Patients reported that their angina improved. So the sham operation was as good as ligating the arteries for relieving pain.
It might be time for such a trial in MALS (without the robot), but there might be some IRB issues.
Thanks to Dr. Michael Burchett for alerting me to the MALS paper.
A version of this post appeared on the Skeptical Scalpel site two months ago.
Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 900 page views per day, and he has over 6300 followers on Twitter.