Robotic median arcuate ligament release prior to pancreatoduodenectomy

Celiac artery stenosis presents significant risks in pancreatoduodenectomy (PD), including elevated incidences of postoperative hepatic ischemia and clinically relevant pancreatic fistulae. Addressing this stenosis preoperatively is crucial to avoid complication. While stenosis predominantly arises from vasculopathy, managed with stenting, median arcuate ligament syndrome (MALS) is an atypical cause characterized by the median arcuate ligament's extrinsic compression of the celiac artery. Pre-PD surgical release of this ligament has demonstrated nearly 90% success rate in resolving ischemic complications. The celiac axis can be decompressed through open or minimally invasive techniques. Robotic-assisted celiac artery decompression is an attractive approach due to superior visualization and enhanced dexterity, which facilitate the complex dissection required at the diaphragmatic hiatus. The patient is a 49-year-old male diagnosed with pancreatic adenocarcinoma, who also exhibited severe celiac axis stenosis on preoperative imaging. Median arcuate ligament release prior to PD was pivotal in preventing hepatic ischemia consequent to the ligation of the gastroduodenal artery during PD and in re-establishing normal arterial flow to the upper gastrointestinal tract, thereby circumventing otherwise preventable complications. The patient underwent an uneventful robotic PD following the median arcuate ligament release. Robotic-assisted median arcuate ligament release prior to pancreatoduodenectomy is a safe and effective technique for decompression of celiac axis stenosis. This procedure facilitates meticulous dissection while minimizing postoperative complications and helps to circumvent otherwise preventable outcomes.