Laparoscopic repair of iatrogenic celiac artery injury during median arcuate ligament release: A retrospection and tips at troubleshooting

Abstract

Median arcuate ligament (MAL) syndrome or celiac artery (CA) compression syndrome previously treated mainly by vascular surgeons using the open approach is now being increasingly performed by general surgeons with training in advanced laparoscopy. Although this approach has all the advantages of minimal access surgery, the procedure is fraught with serious complications like injury to major vascular structures during dissection. Vascular injury by far is the major cause of conversion to open procedure. Herein, we report a laparoscopic repair of iatrogenic CA injury by intra-corporeal suturing during MAL release. We also elaborate the causes, the preventive measures that can be applied to avoid such catastrophic occurrences in future. To the best of our knowledge, this is the first report of a laparoscopic repair of CA bleed during MAL release.

INTRODUCTION

Vascular injuries are a rare but dreaded complication of laparoscopic median arcuate ligament (MAL) release with reported incidence of 9.1%.[1] These are the major causes for immediate conversion to laparotomy. We herein describe our report of iatrogenic injury to the celiac artery (CA) during laparoscopic MAL release that was managed by intracorporeal suturing and retrospect on what measures can help to prevent this serious iatrogenic complication.

TECHNICAL REPORT

A 48-year-old female with no comorbidities and body mass index 24.5 presented with symptoms of post-prandial abdominal pain for 8 years associated with weight loss of 5 kg over 1 year. Upper gastrointestinal endoscopy was normal. Contrast-enhanced computed tomography (CT) scan of the abdomen was suggestive of MAL syndrome [Figure 1a].

Figure 1.

(a) Contrast-enhanced computed tomography scan showing severe focal stenosis of celiac artery (white arrow), post-stenotic dilatation (blue arrow) and hooked shaped configuration of celiac trunk (red arrow), (b) Ports (blue arrow: Camera port, liver retraction), (c) Branches of celiac artery cleared of fibrofatty tissue (blue arrow: Fibrofatty tissue, red arrow: Left gastric artery), (d and e) Dissection and division of thickened median arcuate ligament (MAL) fibres with harmonic shears (white arrow: Aorta, black arrow: Crural angle), (f) Division of deepest MAL fibres over celiac artery near crural angle (black arrow: deepest MAL fibers)

After an informed consent, she was planned for laparoscopic MAL release.

Laparoscopic ports were placed as shown in Figure 1b. The left gastric artery (LGA), common hepatic and the splenic arteries were dissected free of fibrofatty tissue till CA [Figure 1c]. The LGA was looped and retracted. The MAL fibres at the crural angle were divided exposing the aorta [Figure 1d and e]. The fibrofatty and neuronal tissues around origin of CA were dissected and divided using harmonic shears (HS). While dividing the deepest MAL fibres [Figure 1f], there was iatrogenic injury to the CA [Figure 2a]. The rent in the CA was identified, immediately grasped and occluded with the left-hand atraumatic grasper, [Figure 2b] pressure applied with gauze and the collected blood was sucked out to have a clear vision. Firm grasp over the rent was maintained. The injured vessel was repaired with 4-0 polypropylene (17.5 mm needle, half circle taper cut), taking two figures of eight sutures carefully, taking care not to stenose the vessel [Figure 2c-h]. At the end of repair [Figure 3a and b], free pulsations of the CA were noted [Figure 3c]. Cruroplasty was performed using interrupted 2-0 polyester sutures [Figure 3d and e], leaving a gap above the origin of the CA to avoid any compression [Figure 3f]. The video of management of celiac artery bleed is available on https://youtu.be/Oa-kUYrDQbU [Video 1].

Figure 2.

(a) Bleed from celiac artery (white arrow), (b) Rent on celiac artery immediately grasped. Suction done for clear vision, (c-e) Repair of celiac artery rent using 4-0 polypropylene sutures, (f-h) Repair of celiac artery with second figure of eight sutures (white arrow: suture repaired celiac artery)

Figure 3.

(a and b) Completed closure of rent over celiac artery (white arrow: Repaired celiac artery, red arrow: Looped left gastric artery), (c) Origin of celiac artery (white arrow), (d and e) Crural closure with 2-0 polyester, (f) Completed median arcuate ligament release, celiac artery repair and crural closure (white arrow: Gap left between celiac artery origin and the crural closure)

The blood loss was 200 ml and the total operating time was 110 min. The patient was haemodynamically stable throughout the procedure. She was started on oral liquids on 1^st day and was discharged on 3^rd post-operative day on soft diet. She was on injection low molecular weight heparin for 7 days. At 1 year follow up, she was asymptomatic and CT angiography done did not show evidence of CA compression.

DISCUSSION

Vascular injuries are a known and sometimes lethal complication of laparoscopic MAL release with a reported incidence of 9.1%.[1] In a series by Jimenez et al.,[1] 9.1% in the laparoscopic group required conversion to open surgery in view of bleeding. Roseborough[2] reported 27% conversion rate due to vascular injuries which was repaired by primary closure, patch angioplasty and aortoceliac bypass. These high conversion rates may be attributed to the learning curve associated with laparoscopic approach, lack of tactile feedback, lack of depth comprehension and limited instrument manoeuvrability in narrow space. Shin et al.[3] demonstrated that both laparoscopic and robotic-assisted techniques were similar, but the laparoscopic approach demanded a more proficient assistant. Robotic system offers magnified three-dimensional vision and allow increased fluency and precision within a confined space. The use of the third arm minimises the need for assistant retraction.[4] The operative controls enable motion scaling, tremor elimination and wristed movements with added degrees of motions over standard laparoscopy makes robotic platform safer compared to laparoscopy in successfully accomplishing this advanced minimally access procedure. To the best of our knowledge, this is the first report of a laparoscopic repair of CA bleed during MAL release.

Prevention of these injuries should be the goal of every surgeon. Some measures that could be implemented are:

• Retrograde dissection: The two approaches to the division of the MAL are antegrade dissection from the aorta downwards and retrograde dissection by tracing the CA backwards from its branches. Dissection around the aorta is technically difficult and carries the risk of bleeding from injury to the aorta or branch vessels. The retrograde dissection may be safer

• Division of MAL and exposure of CA: Dissection and division of the MAL should be under vision. The use of 45° telescope may be useful. It is advisable to dissect the fibrous tissues, compression bands and neuronal tissues layer by layer using Maryland and then divide them with a hook or HS. The tightest ligament that causes compression on the CA is the deepest one. All the tight fibrous bands should be dissected to the point where the aorta is exposed through denudation of the CA wall. Tight bands are often adherent to and indistinguishable from the CA wall which might be prone to injury during dissection.[4] The placement of tape around the LGA and giving traction towards the left side of the patient facilitates the exposure of CA. These manoeuvres significantly enable visualisation of the CA[5]

• Energy sources: The active blade of the HS should be away from the vessel and must be on low setting. If hook is used for dividing the compression bands, it must be on a lower setting at 20, to prevent lateral spread. The hook must be applied in bursts rather than as continuous current

• Intraoperative ultrasonography (IOU): While there is no consensus on the use of IOU, it helps measure pre-and post-decompression flow velocity and to objectively demonstrate a return to normal peak systolic velocities. This makes sure that there is no remnant or iatrogenic stenosis post-repair.[6,7]

In our case, although the dissection was carried out from the branches of CA in the retrograde manner, the dissection and division of the thick and fibrous MAL in its deepest part was carried out entirely with HS. The bleed from the CA occurred while dissecting the deepest and thick fibrous compression bands over the CA. It should have been dissected with Maryland, the fibres had to be lifted and divided under vision with HS with active blade away from the vessel. The settings of the HS should have been on lower side. In our case, we had used 30° telescope. The use of 45° telescope would have aided in enhanced vision. We did not have the facility of IOU to delineate the CA and to check the completeness of MAL release.

CONCLUSION

Iatrogenic CA injury is a dreaded complication of laparoscopic MAL release. Wide exposure, meticulous dissection, careful and limited use of energy sources during vascular dissection is the key to prevent injury. Although it demands immediate conversion to open repair in majority of the cases, it can be managed safely by laparoscopic approach in experienced hands.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.