Median Arcuate Ligament Release (MALS Surgery)

Median arcuate ligament syndrome (MALS) — also called celiac artery compression syndrome, Dunbar syndrome, or Harjola-Marable syndrome — is caused by a band of the diaphragm, the median arcuate ligament, pressing on the celiac artery and the dense web of nerves around it (the celiac plexus) at the top of the abdomen (Kim et al., JAMA Surgery, 2016; Goodall et al., Journal of Vascular Surgery, 2020). In most people this ligament sits harmlessly above the artery; in people with MALS, a high celiac origin or low-lying ligament lets the band compress the vessel and irritate the nerves — compression that characteristically worsens on expiration, when the celiac artery rides up against the fixed ligament (Cernigliaro et al., Abdominal Radiology, 2021; Koshy et al., Abdominal Radiology, 2024). The result is a triad of compression, chronic nerve injury, and pain, and because the celiac axis supplies the stomach and upper intestine, eating triggers the pain (Park et al., Vascular Medicine, 2025).

MALS is uncommon and predominantly affects young, otherwise healthy, often thin women between roughly 20 and 50 years of age, with women affected three to four times as often as men (Cernigliaro et al., Abdominal Radiology, 2021; Koshy et al., Abdominal Radiology, 2024). It is a genuine diagnosis of exclusion — its symptoms overlap with far more common disorders, and imaging "compression" can appear in people with no symptoms at all — which is why it is so often missed and why it belongs in the hands of a program that evaluates it routinely (Kim et al., JAMA Surgery, 2016; Brenner et al., Clinical Gastroenterology and Hepatology, 2023). The definitive treatment is surgical decompression — median arcuate ligament release — performed minimally invasively in this practice; patients managed nonoperatively generally do worse (Goodall et al., Journal of Vascular Surgery, 2020).

The pain of MALS arises through two overlapping mechanisms, and MALR is designed to address both. The first is vascular — chronic external compression narrows the celiac artery and limits foregut blood flow, producing a "mesenteric angina" driven up by the demand of digestion (Kim et al., JAMA Surgery, 2016). The second, increasingly emphasized, is neuropathic — constant compression and irritation of the overlying celiac ganglion and sympathetic pain fibers generate pain and reflex vasoconstriction independent of true ischemia (Kim et al., JAMA Surgery, 2016; Park et al., Vascular Medicine, 2025).

Release relieves both: it divides the median arcuate ligament where it drapes over and tethers the celiac artery, and clears the dense ganglionic/neural tissue off the vessel. This restores the artery's natural caliber and flow and interrupts the irritated nerve fibers responsible for the pain — which is exactly why a favorable response to a preoperative celiac plexus block (temporarily numbing those nerves) strongly predicts a better surgical outcome (DeCarlo et al., Journal of Vascular Surgery, 2023; Shnayder-Adams et al., Journal of Vascular and Interventional Radiology, 2024).

• Definitive treatment for a disabling condition — decompression directly addresses the cause, whereas nonoperative management is associated with worse outcomes (Goodall et al., Journal of Vascular Surgery, 2020).
• High rates of symptom relief — roughly 83–89% of appropriately selected patients report partial or complete resolution after release (Pather et al., Journal of Vascular Surgery, 2021; Boaz et al., Surgery, 2026).
• Minimally invasive, with far lower morbidity — laparoscopic/robotic release produces far less ileus (2.0% vs 17.5%) and a much shorter stay (~1.7 vs ~4.6 days) than open surgery, while delivering comparable long-term relief (Alsabbagh et al., Journal of Vascular Surgery, 2026; DeCarlo et al., Journal of Vascular Surgery, 2023).
• Restored ability to eat and regain weight — relieving meal-triggered pain lets patients eat normally again and recover the weight lost to food avoidance (Park et al., Vascular Medicine, 2025).
• Quality of life returns to normal — patients who become symptom-free report health-related quality of life on par with the general population, and about 87% say they would choose the operation again (Pather et al., Journal of Vascular Surgery, 2021).

The ideal candidate has the classic MALS clinical picture plus objective evidence of celiac compression, after other causes are excluded (Kim et al., JAMA Surgery, 2016; Goodall et al., Journal of Vascular Surgery, 2020). Favorable features include:

• Characteristic symptoms — chronic postprandial (and/or exercise-induced) epigastric pain, nausea, vomiting, fear of eating, and unintentional weight loss, sometimes with an epigastric bruit and relief in the knee-to-chest position (Koshy et al., Abdominal Radiology, 2024; Park et al., Vascular Medicine, 2025).
• Imaging confirmation — focal celiac narrowing with the "hook sign" and post-stenotic dilation on expiratory-phase CT/MR angiography, and elevated celiac velocities on dynamic duplex ultrasound (Brenner et al., Clinical Gastroenterology and Hepatology, 2023; Cernigliaro et al., Abdominal Radiology, 2021).
• A positive celiac plexus block — the single best predictor of surgical success (~96% favorable outcome in responders) (Shnayder-Adams et al., Journal of Vascular and Interventional Radiology, 2024; DeCarlo et al., Journal of Vascular Surgery, 2023).
• Thorough exclusion of other foregut pathology — more preoperative GI studies correlate with lower treatment failure (DeCarlo et al., Journal of Vascular Surgery, 2023).

Factors associated with higher failure risk — warranting more cautious counseling — include gastroparesis, dysphagia/odynophagia, multiple pain locations, no relief from a plexus block, abdominal malignancy, and higher BMI (DeCarlo et al., Journal of Vascular Surgery, 2023; Alsabbagh et al., Journal of Vascular Surgery, 2026).

MALR can be performed open, laparoscopically, or robotically; minimally invasive technique is standard in this practice (Kim et al., JAMA Surgery, 2016; DeCarlo et al., Journal of Vascular Surgery, 2023). Under general anesthesia, the lesser omentum is opened to expose the aorta above the celiac origin. The surgeon dissects down onto the celiac artery and systematically divides the median arcuate ligament fibers draping across it, continuing cephalad until the artery is fully freed and the supraceliac aorta is visible. The surrounding celiac ganglion and neural tissue are skeletonized to decompress the plexus and address the neuropathic component (Kim et al., JAMA Surgery, 2016; Ito et al., Langenbeck's Archives of Surgery, 2021). Adequacy of decompression is confirmed by direct inspection.

If a persistent fixed, scarred stenosis remains after decompression, adjunctive balloon angioplasty (and, rarely, open vascular reconstruction) may be added; stenting without ligament release is specifically discouraged because ongoing external compression leads to stent fracture, migration, and failure (Kim et al., JAMA Surgery, 2016; Koshy et al., Abdominal Radiology, 2024). Conversion from minimally invasive to open surgery is uncommon — about 4–5%, usually for bleeding (Boaz et al., Surgery, 2026; Belluzzi et al., Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2023).

MALR can be performed with low mortality (no deaths in major modern series) and an acceptable complication profile, though risk is meaningfully higher with the open approach (Pather et al., Journal of Vascular Surgery, 2021; DeCarlo et al., Journal of Vascular Surgery, 2023). Potential risks include:

• Bleeding/vascular injury — injury to the celiac artery or aorta is the most feared intraoperative complication and the leading reason for conversion to open surgery (Pather et al., Journal of Vascular Surgery, 2021; Boaz et al., Surgery, 2026).
• Postoperative ileus — far more common after open release (~17.5%) than minimally invasive release (~2%) (Alsabbagh et al., Journal of Vascular Surgery, 2026).
• Perioperative complications overall — roughly 19% across a large cohort (open ~30%, robotic ~18.5%, laparoscopic ~9%), including cardiac, respiratory, wound complications, and readmissions (DeCarlo et al., Journal of Vascular Surgery, 2023).
• Treatment failure and symptom recurrence — the most important risk to counsel about (detailed under Long-Term Expectations) (DeCarlo et al., Journal of Vascular Surgery, 2023; Boaz et al., Surgery, 2026).
• General surgical/anesthetic risks — infection, pancreatitis, venous thromboembolism.

Because the operation is done through small incisions, recovery is relatively quick. Most patients stay in the hospital about 1 to 2 days after laparoscopic or robotic release, versus 2 to 3 days (or longer) after open surgery (Park et al., Vascular Medicine, 2025; Alsabbagh et al., Journal of Vascular Surgery, 2026). Diet is advanced as bowel function returns, and many patients notice improvement in meal-related pain early, with further gains over the following weeks; light activity resumes within days. Structured follow-up — including repeat duplex ultrasound to document restored celiac flow — is recommended at about one and three months, because that early window is when most recurrences surface (Boaz et al., Surgery, 2026). A central goal of recovery is restoring nutrition and regaining lost weight, often with dietitian support.

Most appropriately selected patients do well, but durability is imperfect and is discussed frankly with every patient. A long-term single-center series (8-year mean follow-up) found 83% initial improvement, 17% treatment failure, and recurrence in 18% of initial successes — an estimated 5-year freedom from symptoms of about 67% (Pather et al., Journal of Vascular Surgery, 2021). A large international, multi-institutional cohort found full relief in 58.8%, partial relief in 24.4%, and no benefit in 16.8%, with 1- and 3-year freedom from treatment failure of 63.8% and 51.9% (DeCarlo et al., Journal of Vascular Surgery, 2023). A recent minimally invasive series reported 88.7% initial improvement, with recurrences often appearing within the first three months and frequently without a radiographic correlate (Boaz et al., Surgery, 2026). Despite this, satisfaction is high — about 87% of long-term respondents, including those who recurred, would undergo the operation again (Pather et al., Journal of Vascular Surgery, 2021). The key message: careful selection and honest counseling about failure and recurrence are what produce lasting relief.

More in General and Minimally Invasive Surgery

Related procedures: Major Surgical Oncology and Complex Benign Tumor Surgery, Robotic Surgery, Laparoscopic Cholecystectomy, Hernia Repair, Inguinal Hernia Repair, Appendectomy. For an overview of all options, see Minimally Invasive Surgery.

Conditions treated: Median Arcuate Ligament Syndrome (MALS).

Expected symptom and functional improvements

The primary measurable gains after MALR are in pain, nausea, and eating tolerance, with corresponding improvement in quality of life. Successful release significantly reduces the elevated expiratory celiac velocities that define the disease, confirming the compression has been relieved (Butz et al., Langenbeck's Archives of Surgery, 2024). Open release has shown a trend toward greater improvement in pain (~84% vs 72%) and nausea (~90% vs 79%) than laparoscopic release, though at the cost of higher morbidity — which is why approach is individualized (Alsabbagh et al., Journal of Vascular Surgery, 2026). Patients who become symptom-free report health-related quality of life (physical and mental domains) returning to the general-population average, a marked contrast with the impaired scores seen in those with persistent symptoms (Pather et al., Journal of Vascular Surgery, 2021).

Symptom-recurrence prevention strategy

Because recurrence is the central long-term challenge, prevention begins with patient selection and complete decompression, not postoperative measures. The evidence supports: (1) a thorough, exclusion-based preoperative workup — more diagnostic GI studies correlate with lower failure (DeCarlo et al., Journal of Vascular Surgery, 2023); (2) a celiac plexus block to confirm the neuropathic contribution and select responders (Shnayder-Adams et al., Journal of Vascular and Interventional Radiology, 2024); (3) complete division of both the ligament and the celiac neural tissue, with intraoperative confirmation of restored flow (Kim et al., JAMA Surgery, 2016; Ito et al., Langenbeck's Archives of Surgery, 2021); and (4) structured early surveillance (duplex at ~1 and 3 months) to detect the recurrences that typically appear within the first three months, with angioplasty considered for a persistent fixed stenosis (Boaz et al., Surgery, 2026).

Median arcuate ligament syndrome is rare, frequently misdiagnosed, and demands a surgeon experienced in advanced minimally invasive dissection around the aorta and celiac axis — structures where bleeding is the principal danger, which is why it is explicitly recommended that MALR be performed by surgeons focused on this disease (Park et al., Vascular Medicine, 2025). Dr. Nestor de la Cruz-Muñoz, MD, FACS, DABOM is one of the first surgeons in Florida, if not the first, to perform median arcuate ligament release minimally invasively, and his MALS release video was among the first on that procedure in WebSurg, the international surgical video library. He has continued to refine and present the operative technique to surgical audiences. His practice functions as a regional referral center for MALS: patients and physicians refer here specifically because this diagnosis requires the concentrated experience that comes only from evaluating and operating on it routinely. He emphasizes the rigorous, exclusion-based workup the evidence shows improves outcomes (dedicated CT/MR angiography, dynamic duplex ultrasound, and celiac plexus block), pairs it with a minimally invasive release to minimize morbidity and speed recovery, provides structured postoperative surveillance to catch early recurrence, and counsels patients candidly about expected benefit, treatment failure, and all available options (DeCarlo et al., Journal of Vascular Surgery, 2023; Boaz et al., Surgery, 2026; Shnayder-Adams et al., Journal of Vascular and Interventional Radiology, 2024).

For median arcuate ligament release, Dr. de la Cruz-Muñoz draws on over 25 years in practice and over 15,000 minimally invasive procedures, a body of work that includes complex foregut, hernia, gallbladder and abdominal operations along with bariatric surgery.

For patients with persistent or recurrent symptoms after an initial release, options are individualized and may include:

• Repeat imaging and duplex ultrasound to distinguish true residual/recurrent celiac compression from an alternative diagnosis (Boaz et al., Surgery, 2026).
• Endovascular angioplasty for a persistent fixed stenosis after adequate ligament division (stenting alone is discouraged under ongoing external compression due to poor durability) (Kim et al., JAMA Surgery, 2016; Koshy et al., Abdominal Radiology, 2024).
• Open revision or vascular reconstruction in selected cases of incomplete decompression or fixed disease (Kim et al., JAMA Surgery, 2016).
• Multidisciplinary reassessment (GI motility, pain management, evaluation for associated conditions such as Ehlers-Danlos/hypermobility or POTS) when symptoms persist despite a technically successful release (Park et al., Vascular Medicine, 2025).

MALR for symptomatic MALS is generally covered as a medically necessary treatment for a documented disease, in contrast to elective weight-loss procedures. Payers typically expect documentation establishing the diagnosis of exclusion: characteristic symptoms, objective imaging of celiac compression (CT/MR angiography and/or dynamic duplex ultrasound), exclusion of other foregut pathology, and often a celiac plexus block supporting the diagnosis (Kim et al., JAMA Surgery, 2016; DeCarlo et al., Journal of Vascular Surgery, 2023). Specific coverage, documentation, and any pre-authorization requirements should be confirmed with each individual plan.

• Complete diagnostic workup — CT/MR angiography (inspiratory and expiratory phases) and dynamic duplex ultrasound confirming celiac compression (Brenner et al., Clinical Gastroenterology and Hepatology, 2023; Koshy et al., Abdominal Radiology, 2024).
• Exclusion of alternative foregut pathology — upper endoscopy, RUQ ultrasound, and relevant GI studies (Brenner et al., Clinical Gastroenterology and Hepatology, 2023).
• Celiac plexus block to support the diagnosis and gauge likely response (Shnayder-Adams et al., Journal of Vascular and Interventional Radiology, 2024; DeCarlo et al., Journal of Vascular Surgery, 2023).
• Nutritional assessment and optimization in patients significantly underweight from food avoidance (Park et al., Vascular Medicine, 2025).
• Standard pre-anesthesia evaluation and fasting per the care team.

Many MALS patients arrive malnourished and deconditioned after months of restricted eating, so the post-surgical goal is rebuilding lean body mass and restoring healthy nutrition, not losing weight. As pain resolves and eating normalizes, patients are supported with a gradual return to a balanced, protein-adequate diet to rebuild muscle lost during the illness, often with dietitian involvement. Combining adequate protein intake with a progressive return to activity and resistance (strength) training helps restore the lean muscle and functional capacity eroded by prolonged undernutrition (Park et al., Vascular Medicine, 2025).

Weight Restoration

MALS itself produces significant involuntary weight loss from meal-triggered pain and food avoidance, with patients commonly losing 10–20 pounds over months before diagnosis (Park et al., Vascular Medicine, 2025; Butz et al., Langenbeck's Archives of Surgery, 2024). When surgery successfully relieves postprandial pain, most patients are able to eat normally again and regain the weight they lost to a healthy baseline (Park et al., Vascular Medicine, 2025). Failure to regain weight, or ongoing weight loss after surgery, should prompt evaluation for treatment failure, recurrence, or an alternative/overlapping diagnosis such as a motility disorder (DeCarlo et al., Journal of Vascular Surgery, 2023).

With minimally invasive release there are no large incisions and most patients resume light activity within days; open release requires a longer, more graduated return (Alsabbagh et al., Journal of Vascular Surgery, 2026). Walking is encouraged early. A progressive return to aerobic activity and resistance (strength) training is reintroduced as tolerated, with the specific goal of rebuilding the muscle mass and conditioning lost during the illness rather than weight reduction.

MALS is frequently misdiagnosed, and many patients come from far away for a definitive evaluation. Please send CT angiography or duplex ultrasound results and prior workups for review. Most patients need about one week in Miami for surgery and early recovery.