Outcomes in laparoscopic versus robotic-assisted surgery for median arcuate ligament syndrome: a systematic review and meta-analysis

Clinical Snapshot

Key Findings

• P Value: p = 0.0003

• Effect Size: RMALR associated with significantly longer time to symptom recurrence: mean 9.04 months longer than LMALR

• Primary Outcome: Time to symptom recurrence following MAL release

• Nnt Or Sensitivity: No NNT reported. No statistically significant differences detected between RMALR and LMALR for conversion to open surgery, resolution of pain, postoperative complications, or length of hospital admission. Recurrence rates were not significantly different between groups; only time to recurrence differed.

• Confidence Interval: 95% CI: 4.18 to 13.89 months

Clinical Application

Both LMALR and RMALR are technically feasible in experienced centres. Robotic platforms (e.g., da Vinci system) require significant capital investment, dedicated theatre infrastructure, and surgeon credentialling, limiting availability to major tertiary hospitals. Laparoscopic MAL release is more widely accessible. The marginal benefit of robotic surgery — a longer symptom-free interval — must be weighed against substantially higher procedural costs and limited platform availability. MALS is a rare diagnosis in Australian practice, managed in specialist vascular surgery or upper GI surgery units at major tertiary centres. There is no specific PBS item number for robotic surgical procedures in this context, and robotic surgery costs are largely borne by hospitals or patients. The TGA has approved robotic surgical systems for use in Australia, but access remains concentrated in metropolitan teaching hospitals. RACGP and ANZSVS guidelines do not currently provide specific recommendations on surgical approach for MALS. Australian clinicians should note that the evidence base is insufficient to justify preferential use of robotic over laparoscopic approaches on clinical grounds alone. Referral pathways for MALS in Australia typically involve vascular surgery, gastroenterology, and interventional radiology multidisciplinary teams. Adult patients with confirmed MALS being considered for minimally invasive surgical release. Applicable primarily in tertiary vascular or upper gastrointestinal surgical centres with access to both laparoscopic and robotic platforms and appropriate diagnostic workup (CT angiography, duplex ultrasound, coeliac axis pressure gradient measurement).

Abstract

Median Arcuate Ligament Syndrome (MALS) is a rare condition caused by external compression of the coeliac artery by the median arcuate ligament (MAL), leading to postprandial abdominal pain, nausea, vomiting, and weight loss. This study aims to compare outcomes of robotic (RMALR) and laparoscopic (LMALR) MAL release. A systematic search of PubMed/MEDLINE, Scopus, and Embase databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to compare perioperative and postoperative outcomes of LMALR versus RMALR. Comparative studies including adult patients undergoing either approach were included. Outcomes assessed were conversion to open surgery, resolution of pain, length of admission, postoperative complications, symptom recurrence and time to recurrence. Five retrospective comparative studies comprising 158 patients were included. No differences were found between laparoscopic and robotic approaches in conversion to open, resolution of pain, postoperative complications, length of admission, or overall time to recurrence. However, RMALR showed a significantly longer time to symptom recurrence (9.04 months, 95% CI 4.18-13.89; p = 0.0003). Both LMALR and RMALR are safe and effective for MALS, with comparable perioperative and postoperative outcomes. The longer symptom-free interval after robotic surgery may reflect greater precision in dissection around the coeliac axis. However, further prospective studies with standardised follow-up are needed to validate these findings.

References

1. 1.Arabi, Z., Geropoulos, G., Jayawardena, P., Karim, S., Reza, L., Colucci, N., & Patel, V. (2026). Outcomes in laparoscopic versus robotic-assisted surgery for median arcuate ligament syndrome: a systematic review and meta-analysis. Journal of Robotic Surgery. https://doi.org/10.1016/j.jvs.2022.10.022