What is the recommended anesthetic management for an adult female with median arcuate ligament syndrome presenting with chronic post‑prandial epigastric pain and weight loss who is undergoing surgical release of the median arcuate ligament?

Anesthetic Management of Median Arcuate Ligament Syndrome

Preoperative Anesthetic Considerations

For an adult female with MALS undergoing surgical release, general anesthesia must be adapted to accommodate significant hemodynamic fluctuations and ventilatory challenges inherent to laparoscopic celiac axis decompression, with strict postoperative pain control being critical since oral tolerance directly determines recovery success. 1

Patient Assessment and Risk Stratification

• Evaluate cardiovascular risk factors carefully as atherosclerotic disease predicts poorer surgical outcomes—patients with cardiovascular risk factors had a 67% non-response rate versus 27.3% in those without risk factors. 2

• Assess nutritional status and weight loss severity since predictors of successful outcomes include weight loss of 20 pounds or more (67% cure rate) and postprandial pain pattern (81% cure rate). 3

• Confirm diagnosis with preoperative imaging showing celiac artery compression in a "J-shaped" configuration on CTA, with dynamic worsening on expiration during angiography. 4

Intraoperative Anesthetic Management

General Anesthesia Technique

• Use general anesthesia with endotracheal intubation as the standard approach for laparoscopic MAL release, which requires pneumoperitoneum and potential for significant hemodynamic changes. 1

• Prepare for potential conversion to open surgery (10.3% conversion rate) by ensuring adequate IV access and blood product availability given proximity to major vascular structures. 2

• Anticipate mean operative time of 179 minutes (range 79-473 minutes), requiring appropriate depth of anesthesia and muscle relaxation throughout. 5

Hemodynamic Management

• Monitor for hemodynamic instability during ligament release and celiac axis manipulation, as vital vascular structures including the aorta, celiac trunk, and superior mesenteric artery are at risk of injury. 1

• Maintain adequate perfusion pressure to ensure mesenteric blood flow, particularly during periods of surgical manipulation of the celiac axis. 1

• Have vasopressors immediately available for rapid treatment of hypotension during critical dissection phases around major vessels. 1

Ventilatory Management

• Adjust ventilatory parameters for pneumoperitoneum by increasing minute ventilation to compensate for increased intra-abdominal pressure and reduced functional residual capacity. 1

• Use pressure-controlled ventilation to minimize peak airway pressures while maintaining adequate tidal volumes during laparoscopic insufflation. 1

Postoperative Pain Management

Multimodal Analgesia Strategy

Establish strict pain control immediately postoperatively as oral tolerance is the key factor determining recovery success in these chronically malnourished patients. 1

• Initiate IV opioid patient-controlled analgesia (PCA) in the immediate postoperative period for baseline pain control. 1

• Add scheduled IV acetaminophen (1000 mg every 6 hours) to reduce opioid requirements and facilitate earlier oral intake. 1

• Consider scheduled IV ketorolac (15-30 mg every 6 hours for maximum 5 days) if no contraindications exist, as conventional NSAIDs reduce pain scores and supplemental analgesic use. 3

Transition to Oral Intake

• Prioritize early oral tolerance by aggressively managing nausea and pain, as these patients have chronic postprandial symptoms and fear of eating. 1, 6

• Transition to oral analgesics (combination oxycodone/acetaminophen or tramadol) as soon as oral intake is tolerated, typically within 24-48 hours. 1

• Avoid prolonged NPO status as these patients are often significantly malnourished preoperatively with mean weight loss being a predictor of surgical candidacy. 3

Critical Perioperative Pitfalls

Vascular Injury Risk

• Maintain close communication with the surgical team as the celiac trunk, superior mesenteric artery, and aorta are directly in the surgical field with potential for catastrophic hemorrhage. 1

• Have massive transfusion protocol readily available given the 10.3% conversion rate to open surgery, often due to vascular complications. 2

Postoperative Complications

• Monitor for urinary retention which occurred as a documented complication in male patients, requiring bladder scanning and potential catheterization. 6

• Assess for celiac axis patency postoperatively as 2 of 12 patients (17%) developed celiac occlusion despite surgical release, though most remained asymptomatic. 5

• Recognize that symptom relief occurs in 84.6% of patients but is not dependent on postoperative celiac artery patency—5 patients with residual stenosis and 1 with occlusion had complete symptom resolution, suggesting neurogenic rather than purely vascular etiology. 2

Special Considerations

Patient Selection Impact

• Understand that MALS symptoms are likely neurogenic (celiac plexus irritation) rather than purely vascular, as postoperative symptom relief occurs independent of restored celiac flow. 2

• Consider preoperative celiac plexus block with local anesthetic in atypical presentations—4 of 5 patients who responded to diagnostic block also had postoperative symptom relief. 2

Endovascular Intervention

• Do not plan for routine postoperative stenting as endovascular intervention alone without surgical release is contraindicated due to persistent extrinsic compression. 3

• Reserve stenting only for residual stenosis >30% after surgical release, though one patient who received postoperative stenting remained symptomatic. 3, 2