Over the years, I have treated many patients experiencing the debilitating symptoms of median arcuate ligament syndrome. Many have come to me after having been misdiagnosed, suffering for years without answers due to symptoms that mimic other conditions. Fortunately, my understanding of this condition and application of advanced minimally invasive techniques allow me to help my patients find long-awaited relief from MALS.
What is Median Arcuate Ligament Syndrome?
Median arcuate ligament syndrome (MALS) is an uncommon and often misunderstood condition in which abnormal diaphragmatic fibers rest lower than normal and press against the celiac artery and the celiac plexus nerves. Because the celiac artery supplies blood to organs such as the stomach, liver, and pancreas, this compression can cause a wide range of symptoms that are frequently mistaken for irritable bowel syndrome (IBS), appendicitis, gastritis, gallstones, peptic ulcer disease and other gastrointestinal conditions.
Symptoms
Many individuals with MALS experience upper abdominal pain after eating, nausea, vomiting, bloating, diarrhea or constipation, heartburn, fatigue, and unintentional weight loss. The pain may radiate to the chest or back. These symptoms overlap with conditions like IBS, gallstones, gastritis, peptic ulcer disease, and appendicitis, making accurate diagnosis challenging. MALS is most commonly seen in women between the ages of 20 and 40 who may or may not have had weight loss without trying. While its exact cause is unknown, anatomical variations and possible hereditary components may contribute.
Diagnosis
To diagnose MALS, I carefully evaluate a patient’s symptoms and medical history followed by a physical exam, which immediately can rule out the uncommon conditions of costochondritis (inflammation of the cartilage between the ribs and sternum) and xyphodynia (inflammation of the lower sternal bone). I then employ advanced imaging tools including Magnetic Resonance Angiography (MRA) to look for signs of celiac artery compression, CT Angiography (CTA) to identify compression or narrowing, and importantly, Doppler ultrasound, to assess blood flow.
In some patients in whom the diagnosis still remains unclear or who have the condition and are reluctant to have surgery, a celiac ganglion block, performed by interventional radiology can help determine whether symptoms are related to nerve compression.
For more information on the symptoms that may occur when the celiac artery and plexus nerves are compressed, and how I diagnose this condition, please visit our Median Arcuate Ligament Syndrome (MALS) page.
For patients who require surgical intervention, my team and I perform a technique called laparoscopic celiac artery release. After making incisions that are approximately ¼ of an inch in length (5mm), I first inflate the abdomen with carbon dioxide and then insert a trocar into the belly button (umbilicus). The trocar, similar in size to a small, hollow pen, allows me to insert a camera (laparoscope) with a light into the abdomen. This camera offers a magnified view of the abdominal cavity on a video monitor. I then add several other similar five millimeter trocars which allow other instruments to be inserted: for example, scissors, graspers, coagulators and suturing devices.
I locate the median arcuate ligament that is pressing on the artery and nerves. Next, I carefully dissect and separate the ligament fibers to release pressure on the artery, and release or excise nerves around the celiac artery to ensure full decompression. In very rare cases, when the artery has been significantly damaged by long-term compression, a stent, placed by a vascular surgeon, may be needed to restore proper blood flow. You’ll find more information about Medican Arcuate Ligament surgery on our MALS procedure page.
How Patients Benefit From This Laparoscopic Approach
The procedure is less invasive than traditional open surgery, so patients have minimal pain, barely visible scars, reduced risk of infection, and a faster recovery—often allowing patients to return home the same day (ambulatory surgery) or on occasion a one night hospital stay. With a compassionate, patient-centered approach and a strong record of successful outcomes, I have provided patients suffering from MALS with an accurate diagnosis, effective treatment, and improved quality of life.
Please visit the About Dr. Vine page to learn more about my areas of expertise, education, training, and my approach to patient care.
Dr. Vine is an attending Surgeon and Clinical Professor of Surgery at the Icahn School of Medicine at Mount Sinai Hospital. His office is located at 1010 5th Avenue at the Laparoscopic Surgical Center of New York. Please fill out our Contact Us form to request a consultation.