MALS with Trinity

This video demonstrates a laparoscopic division of the median arcuate ligament for Mal syndrome using the Trinity 5 millimeter cool seal. A 17 year old female with a 1 year history of chronic pain was found to have celiac artery compression and angulation on a CT angio. This shows the patient's position on the table, and here are the port placements using 5 ports, 45s, and 13. The left lobe of the liver is retracted superiorly, exposing the area of the caudate, the gastropatic ligament, and the right cruise. The gastropatic ligament is then opened using the 5 millimeter cool seal device. The ability to seal and cut safely with no heat spread is key for the entirety of the procedure. Using the fine dissecting jaws. The right cruise is mobilized and visualized. Identifying the right crews and where the right and left crews come together are critical for this procedure. The common hepatic artery was then dissected out. Unusually there was a large amount of inflammation in this area and a number of enlarged inflammatory nodes. Here you can see the hepatic artery coming into view, and the trinity is used to dissect off these inflamed nodes to better visualize and expose the vessel. This is critical in identifying the celiac trunk and to prevent inadvertent injury to the hepatic artery. Because of the size of these nodes. And the way they obscured the anatomy, I elected to resect these at this point to give better visualization of the hepatic artery in the celiac trunk. Also, the fibrous tissue in this area seemed to be impinging on the hepatic artery. Here you can see a fibrous band near the superior border of the hepatic artery being divided. The left gastric artery was then dissected out and a vessel loop was placed around it for traction. It was secured in place with 5 millimeter clips to allow for easier traction. Through a 3 millimeter port in the left upper quadrant, the vessel could then be retracted. Medially Thereby helping exposing the area of the right cruise and eventually the celiac trunk and median arcuate ligament. Dissection was then carried down from the confluence of the common hepatic artery in the celiac. To gradually try to expose the celiac trunk. At this point, we encounter fibers. Of the celiac plexus. And it is necessary to divide these two fully. Uh Open up this area. You can see the nerve fibers just at the superior border of the hepatic artery, and here we are taking some of the fibrous tissue lying just above them. Again, the nerve fibers are elevated. And Celiac ganglion. It's divided To expose The appropriate area. Now, attention is turned to the right cruise as well as the celiac plexus. And these fibers are elevated off the iliac, at the celiac trunk. The fine tips of the Trinity allow for. Dissection in this area safely. Also, the fact that all the energy is between the jaws and there is absolutely no heat spread outside of the jaws allows us to dissect, seal, and divide tissues while resting on the hepatic artery, the celiac trunk, the stomach, and other structures. Here you can see how the curved jaws allow us to get a better orientation to start to divide the fibers of the right crew, exposing the median arcuate ligament. Two-hand dissection is used to expose these fibers, and dissection is continued out. The ability to dissect grass tissue and elevate planes with both hands greatly enhances the surgery. Now you can see the celiac trunk clearly visualized, and you can see the median arcuate ligament crossing over it and compressing. The trunk. Now we start the median arcuate ligament division, and again, this can be done safely, uh, right on the body of the artery. As the ligament is divided, you can see how the celiac trunk expands and fills into view, showing that there was significant compression of the structure. The ligament is divided up into the insertion of the celiac trunk on the aorta to ensure that a complete division is obtained. This surgery, again, was done with 5 ports, 4 5s and 13. The surgery lasted 90 minutes. And the patient was discharged to home with complete resolution of her symptoms the following day. The ability to apply safe energy, seal and divide, as well as dissect, greatly enhanced. The ability to perform this operation laparoscopically and safely. Here we're taking the last remnants of the ligament, uh, just to the insertion of the aorta. Here you can see complete release.