腹腔镜治疗中弓韧带压迫综合征

Laparoscopic treatment of middle arch ligament syndrome

目的:探讨中弓韧带压迫综合征(middle arch ligament syndrome,MALS)的诊治。方法:回顾性分析2023年5月苏州大学附属第四医院(苏州市独墅湖医院)收治的1例MALS患者的临床资料。患者女,60岁,因"间断性腹部隐痛1年,突发上腹部剧痛16 h"入院。体格检查未发现阳性体征,血常规示中性粒细胞百分比稍高,余血液检验结果未见明显异常。心脏及腹腔脏器检查结果未显示特异性异常,胸腹大血管计算机断层扫描血管造影(computed tomography angiography,CTA)示:腹腔动脉起始处管腔重度狭窄,狭窄率为85%。于2023年5月全麻下行腹腔镜下中弓韧带松解术及腹腔神经节切除术。观察患者手术情况及术后症状缓解情况。结果:通过五孔腹腔镜切开肝胃韧带并顺行探查至腹腔动脉,切开后腹膜后见中弓韧带压迫腹腔动脉,切断中弓韧带并剥离腹腔动脉周围神经节。术后患者恢复良好,症状较术前明显缓解,术后4 d复查胸腹大血管CTA示腹腔动脉狭窄较前明显好转,遂出院。术后20 d门诊复诊,症状完全缓解,随访至投稿日期,未观察到腹腔动脉再狭窄或症状复发。结论:MALS是一种罕见综合征,目前主要依赖于排除性诊断,大血管CTA可较好地显示腹腔动脉受压情况。腹腔镜下中弓韧带松解术及腹腔神经节切除术为治疗MALS的主流,根据动脉形态及病情转归,选择血管内治疗或血管重建以根本消除腹腔动脉狭窄。

Objective To investigate the diagnosis and management of middle arch ligament syndrome(MALS).Methods We retrospectively analyzed the clinical data of a patient with MALS admitted to The Fourth Affiliated Hospital of Soochow University(Suzhou Dushu Lake Hospital)in May 2023.The patient was a 60-year-old woman who was admitted to the hospital with"intermittent vague abdominal pain for 1 year and sudden severe pain in the upper abdomen for 16 hours".No positive signs were found on physical examination,and the routine blood test showed a slightly high percentage of neutrophils,while the rest of the blood test results showed no obvious abnormality.Examination of the heart and abdominal organs showed no specific abnormality,and computed tomography angiography(CTA)of thoracic and abdominal vessels showed severe stenosis of the lumen at the beginning of the celiac artery,with a stenosis rate of 85%.Laparoscopic middle arch ligament release and celiac ganglionectomy were performed in May 2023 under general anesthesia.The patient was observed for surgery and postoperative symptom relief.ResultsFive-hole laparoscopy was used to incise the hepatogastric ligament and explore the peritoneal artery,and after incision of the retroperitoneum,the mid-arch ligament was seen to compress the peritoneal artery,so the mid-arch ligament was cut off and the periportal ganglion of the peritoneal artery was peeled off.After surgery,the patient recovered well,and the symptoms were significantly relieved compared with the preoperative period.CTA of the thoracic and abdominal vessels was repeated 4 d after surgery,which showed that the stenosis of the celiac artery had significantly improved compared with the previous period,and the patient was discharged from the hospital.The patient was discharged from the hospital.At the 20-d postoperative outpatient follow-up,the symptoms were completely relieved,and no restenosis of the celiac artery or recurrence of symptoms was observed until the date of manuscript submission.Conclusion MALS is a rare syndrome that currently relies on a diagnosis of exclusion,and large-vessel CTA provides a better indication of compression of the celiac artery.Laparoscopic middle arch ligament release and abdominal ganglionectomy are the mainstay of treatment for MALS,and endovascular treatmenot r revascularization is chosen to fundamentally eliminate the stenosis of the celiac artery according to arterial morphology and disease regression.