Retroperitoneal endoscopic median arcuate ligament incision with interventional radiology: a case report and literature review

Compression of the celiac artery (CA) associated with median arcuate ligament compression syndrome can result in aneurysms at the pancreaticoduodenal arcade. If the aneurysm ruptures, treatment with interventional radiology (IVR) is recommended. Subsequently, the median arcuate ligament (MAL) should be incised to prevent the recurrence of the aneurysm. Retroperitoneal endoscopic MAL incision reduces the risk of adhesive bowel obstruction. However, there is few surgical landmark for retroperitoneal MAL incision. We used IVR to detect CA for MAL incision. CASE PRESENTATION: A 44-year-old man presented to our hospital with complaints of abdominal pain and clouding of consciousness. Contrast-enhanced computed tomography of the abdomen showed contrast leakage from pancreaticoduodenal artery aneurysm, and the CA was compressed by MAL, leading to the diagnosis of pancreaticoduodenal artery aneurysm rupture associated with median arcuate ligament compression syndrome. IVR was performed to block the blood flow to the aneurysm. After 2 months from life-saving IVR, we performed retroperitoneal endoscopic MAL incision with IVR. The patient was discharged 8 days after surgery. Echocardiography and contrast-enhanced computed tomography 2 months after discharge confirmed that the compression and flow of the CA had improved. CLINICAL DISCUSSION: In retroperitoneal endoscopic MAL incision, there has been few landmark to identify MAL and CA. Retroperitoneal procedure with IVR can identify MAL easily. This is a useful technique, and it is important to accumulate more cases to standardize the technique. CONCLUSION: Retroperitoneal endoscopic MAL incision with IVR has not been reported, this procedure can make it easier to detect MAL.