Role of Intraoperative Indocyanine Green Mapping in Laparoscopic Management of Median Arcuate Ligament Syndrome

Reshma Bhoir¹, Vishakha R Kalikar², Roy Patankar³

¹Department of Minimal Access Surgery, Zen Hospital, Chembur, Mumbai, Maharashtra, India

²Department of Minimal Access Surgery, Zen Hospital, Chembur, Mumbai, Maharashtra, India

³Department of Minimal Access and GI Surgery, Zen Multispeciality Hospital, Mumbai, Maharashtra, India

Corresponding Author: Vishakha R Kalikar, Department of Minimal Access Surgery, Zen Hospital, Chembur, Mumbai, Maharashtra, India, Phone: +91 09975634405, e-mail: vish.kalikar@gmail.com

How to cite this article: Bhoir R, Kalikar VR, Patankar R. Role of Intraoperative Indocyanine Green Mapping in Laparoscopic Management of Median Arcuate Ligament Syndrome. World J Lap Surg 2021;14(1):52–54.

Source of support: Nil

Conflict of interest: None

ABSTRACT

Median arcuate ligament syndrome also known as Dunbar syndrome is caused by compression of the celiac axis by the median arcuate ligament. It typically presents with postprandial epigastric pain, weight loss, and vomiting, with the incidence being two cases per lakh in the third to the fifth decade.

Keywords: Arcuate, Indocyanine, Laparoscopic, Median.

World Journal of Laparoscopic Surgery (2021): 10.5005/jp-journals-10033-1436

INTRODUCTION

Median arcuate ligament syndrome (MALS) is uncommon, caused by external compression of the celiac artery by the median arcuate ligament. Symptoms are postprandial abdominal pain, vomiting, and weight loss.¹,²–⁵ It is mainly a diagnosis of exclusion. A computed tomography (CT) scan, magnetic resonance angiogram, or sometimes angiogram is used to confirm the change in the shape of the celiac arteries and in the stenosis and poststenotic dilatation along with an abdominal Doppler. Several treatment options have been described in the management of MALS, including transluminal dilatation, surgical division of median arcuate ligament, or arterial bypass surgery.⁶ However, the traditional treatment option includes surgery—open, laparoscopic, or robotic.⁷,⁸ Minimally invasive surgical approaches, though technically challenging, have gained popularity in the management of MALS owing to its benefit of lesser postoperative pain and shorter hospital stay. We present a patient diagnosed to have MALS and treated successfully with laparoscopic decompression with intraoperative indocyanine green (ICG) mapping of the arteries and the ligaments.

CASE HISTORY

A 70-year-old gentleman presented with epigastric pain— increasing after meals, vomiting—nonbilious in nature, and weight loss of 5 kg for 5 months. No epigastric bruits on physical examination. The patient had no medical comorbidities and no previous surgeries. Routine blood investigations and stool exam were normal. Upper gastrointestinal endoscopy was suggestive of a hiatus hernia. Ultrasonography of the abdomen was normal. Contrast-enhanced computed tomography of the abdomen with angiography was suggestive of significant (50–75%) stenosis of the celiac trunk ostium from its origin with poststenotic mild dilatation of the celiac trunk. A Doppler study of the abdomen was done in supine and erect postures and in the post-inspiratory and post-expiratory phases. It showed high velocities in the celiac trunk on inspiration and expiration in supine position (500 and 426 cm/s) and mildly high velocities in erect position (307 cm/s), classical of MALS.

SURGICAL TECHNIQUE

The patient was in a split-leg position with the surgeon standing in between the legs and the monitor at the head end of the patient. The camera system used is a 1588 Stryker system. A 10-mm viewing port was placed two-third one-third between the umbilicus and the xiphisternum. A 5-mm Nathanson retractor was used to retract the liver., another 10-mm working port in the left subcostal midclavicular line, and a 5-mm port right subcostal midclavicular line with a 5-mm retracting port in the left anterior axillary line at the level of the umbilicus. An additional 5-mm port was placed in the right paraumbilical region, midclavicular line as shown in Figure 1. We began the dissection by opening the pars flaccida and defining the right crus. The stomach was retracted to the left for better visualization. The left gastric artery was delineated and looped with a vascular loop and retracted and dissection followed up to the trifurcation of the celiac trunk. The trifurcation was identified using intraoperative ICG, which was administered by the anesthetist, 5 mg, and flushed with 10 mL of normal saline. After delineating trifurcation, dissection was carried out with ultrasonic shears till the origin of the celiac artery and the aorta as seen in Figure 2. A dense band over the celiac trunk was identified and confirmed by injecting intravenous ICG dye. Complete adhesiolysis was done using a monopolar hook and a harmonic scalpel, taking care not to injure any major blood vessels. Complete release with 4-cm clearance over celiac, left gastric, and common hepatic arteries was done. Vascular stenosed segment and poststenotic dilatation appreciated after ICG mapping as seen in Figure 3 and 4. No dark band was appreciated encasing the vessels. A total of three injections of 5 mg of ICG were given; first at delineation of the trifurcation, second at the time of band visualization, and third post band trifurcation. Dissection-op time was 124 minutes and blood loss was minimal. The postoperative period was characterized by complete relief of symptoms. The patient was discharged on postop day 3. Repeat CT angiography was done postop at 2 weeks, which was normal. The patient was completely symptom free at 1-month follow-up.

Fig. 1: Port positions

Fig. 2: Visualization of trifurcation

Fig. 3: Post-median arcuate ligament release

Fig. 4: Post-median arcuate ligament release, ICG mode

DISCUSSION

MALS was first described by Harjola in 1963.² Once diagnosed, there are several options for the treatment of MALS: celiac artery decompression and celiac ganglionectomy,⁷ celiac artery decompression and reconstruction, celiac artery decompression and dilatation, and celiac artery decompression and celiac artery endovascular stenting. However, with increasing reports on laparoscopic or robotic approaches, the focus now has been shifted to comparison between open and laparoscopic decompression of MALS, of which minimally invasive surgical approach offers immediate postop pain relief and shorter hospital stay,⁸,⁹ earlier oral feeds, minimal risks of postop complications,¹⁰ decreased blood loss, and better cosmetic outcome. We have published a paper on MALS previously, where we have encountered difficulty with the identification of the trifurcation. The use of ICG for intraoperative mapping for MALS has only been reported only once in the literature before.¹¹ It is useful in identifying the trifurcation and celiac axis as well as minimizing the risk of iatrogenic injury in otherwise risky dissection by clearly observing the location of the celiac axis and its major branches and confirmation of completion of dissection and to confirm the completion of division of the median arcuate ligament.

ICG dye is an iodophor and following its intravenous injection, it has shown negligible renal, peripheral, lung, or cerebrospinal fluid uptake of the dye.¹² ICG is a fluorescent agent with a peak spectral absorption and emission at 800 to 810 nm in blood or plasma. The principle of fluorescence imaging is to illuminate the tissue of interest with light at the excitation wavelength and observe it at longer emission wavelengths. ICG operates at near-infrared (NIR) wavelengths, at which tissues appear more translucent, thus providing information on deeper lying blood vessels and tissues. ICG is the only clinically approved dye for NIR fluorescence imaging.¹⁶,¹⁷ Fluorescence imaging is a relatively new and rapidly evolving modality used in the intraoperative setting to delineate the vasculature and lymphatic drainage or demarcate between tumor and normal tissue.¹³–¹⁵ In recent studies, its clinical application has been tested in the treatment of cancer, laparoscopic procedures, and reconstructive colorectal and vascular surgeries.¹⁶,¹⁷,¹⁸

CONCLUSION

ICG mapping and NIR mapping may minimize the risk of injuring the celiac trunk and are useful to prevent injury to trifurcation and confirm the completeness of the median arcuate ligament division.

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© Jaypee Brothers Medical Publishers. 2021 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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© The Author(s). 0000 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.