Median arcuate ligament syndrome (MALS) is characterized by chronic reproducible post-prandial abdominal pain resulting in food fear and weight loss. External compression of the proximal celiac artery by this fibrous arch at the aortic hiatus results in decreased blood flow and intestinal ischemia. Treatment options range from simple observation to laparotomy +/- reconstruction. Recently, minimally invasive surgery for MALS has been reported in the adult literature. MALS in children, however, has not been well described.

We present two otherwise healthy teenage girls with greater than 9 months of classic symptoms of intermittent abdominal pain, food fear, and weight loss. Diagnosis was confirmed both by arterial duplex with high proximal celiac artery velocities as well as CT angiogram showing proximal celiac artery compression.

Laparoscopic median arcuate ligament release with intra-operative duplex was performed in our two children with successful return to normal velocities in the proximal celiac arteries. Both have had complete symptom resolution in subsequent follow-up.

Median arcuate ligament syndrome can be found in otherwise healthy children. Diagnosis can be confirmed with non-invasive studies if a high index of suspicion exists. Minimally invasive techniques can appropriately treat this syndrome with immediate results seen both objectively by duplex as well as subjectively with symptom resolution. We suggest that laparoscopic median arcuate ligament release should be considered a potential standard of care for this difficult to diagnose entity.