Introduction: This video illustrates the role of laparoscopy for the treatment of median arcuate ligament syndrome (MALS). MALS is a rare form of mesenteric ischemia caused by compression of the celiac axis by the MAL of the diaphragm. Endovascular stent placement is a treatment option for MALS, but symptoms often recur. Surgical management involves dividing the MAL and any other periaortic tissue causing compression. This can be performed as an open operation, especially if vascular reconstruction is anticipated, or by a laparoscopic approach.

Methods: A 39 year old female presented with a 1 year history of postprandial abdominal pain and severe diarrhea. Her symptoms began 3 months after undergoing laparoscopic gastric bypass, and she was dependant on narcotics for pain control and TPN for nutrition. She has a history of coronary artery disease, hypertension, ulcerative colitis, and two laparoscopic abdominal procedures. Laboratory data were unremarkable except for an albumen of 1.8 and mild anemia. Upper GI series revealed a small gastrogastric fistula. Upper endoscopy demonstrated a small anastomotic ulcer and lower endoscopy showed chronic colitis. CT angiogram demonstrated celiac axis compression consistent with MALS. She underwent laparoscopic correction of her gastrogastric fistula followed by division of the MAL.

Results: She was tolerating a regular diet at 2 months follow-up, and her albumen increased from 1.8 to 2.4. Her postprandial abdominal pain and diarrhea have resolved.

Conclusion: Laparoscopic MAL release is a safe, effective, and reproducible treatment option for MALS, even when performed concurrent with another procedure.