Elements of Complexity in the Surgical Anatomy of Laparoscopic Median Arcuate Ligament Release

BackgroundVascular injury is a feared complication of minimally invasive median arcuate ligament (MAL) release. The identified elements of variant anatomy that predispose to injury.MethodsBetween August 2018 and March 2025, 64 patients underwent laparoscopic (51) or robotic (13) median arcuate ligament release operation. Surgical anatomy was prospectively recorded with respect to variants of vascular and visceral anatomy.ResultsOnly 17 cases (27%) had no observed anatomical variant. Visceral arterial variants occurred in 15 cases (23%), and included: Accessory left hepatic artery in 8 (requiring division in 6); common hepatic artery (CHA) variants were observed in 2 cases and included replaced CHA and early origin CHA; 5 left gastric artery (LGA) variants included early origin (N = 3) or duplicated LGA (N = 2). One or both IPA originated from the celiac artery in 32 cases (50%), of which anterior origin off the celiac was seen in 20 cases (31%). Both IPA originated separately from the anterior celiac in 2 cases, and from a common trunk in 9 cases (14%). One IPA arising from the anterior celiac was observed in 8 cases (13%). The coronary vein (CV) inserted into the portal vein superior to the CHA in 6 cases (9%), and coursed parallel to the CHA in 16 cases (25%). A high riding pancreas necessitating retraction was seen in 9 cases (14%).ConclusionMost patients undergoing median arcuate ligament release have elements of complexity that increase the difficulty of operation or increase operative risk.