MALS Surgery: Open, Laparoscopic, Robotic, Celiac Plexus Neurolysis, and Long-Term Outcomes

There is no single universally standardized operation for Median Arcuate Ligament Syndrome (MALS). Nearly all operations aim to remove the external compression at the origin of the celiac artery, but surgeons differ in the operative approach, how completely they skeletonize the celiac artery, whether they remove or divide celiac plexus and ganglion tissue, and whether they reconstruct or stent the artery when narrowing persists.

What every MALS operation is trying to accomplish

The median arcuate ligament and nearby fibrous tissue cross over the origin of the celiac artery. A basic release divides those fibers and exposes the celiac origin. The operation may also include circumferential dissection around the celiac artery, division of dense fibrotic tissue, and some degree of celiac plexus neurolysis or ganglionectomy. The exact extent of dissection varies by surgeon.

1. Open median arcuate ligament release

Open surgery is performed through an abdominal incision and gives the surgeon direct access to the aorta, celiac origin, surrounding ganglion tissue, and the celiac artery itself. It historically allowed the most extensive decompression, neurolysis, and arterial reconstruction during the same operation.

Potential benefits include wide exposure, tactile feedback, direct control if the celiac artery or aorta is injured, and the ability to perform patch angioplasty, bypass, reimplantation, or another arterial reconstruction when needed. The tradeoff is a larger incision, more postoperative pain, slower recovery, longer hospitalization, and the general risks associated with a laparotomy.

In a 2010 UCLA comparison of open and laparoscopic celiac ganglionectomy, median hospitalization was 7.0 days after open surgery versus 2.3 days after laparoscopic surgery. Immediate symptom relief occurred in 83% of the open group, but 50% still reported persistent pain at the last follow-up. The study was very small, so these percentages should not be generalized as modern open-surgery failure rates.

2. Laparoscopic median arcuate ligament release

Laparoscopic release uses several small incisions and long instruments. Compared with open surgery, it usually offers shorter hospitalization, less incisional pain, and faster return to activity. It also avoids a full laparotomy.

The main technical challenge is that the celiac origin sits immediately next to major arteries. Laparoscopic instruments have less freedom of movement than robotic or open instruments, and bleeding from the celiac artery, aorta, splenic artery, or nearby branches can require conversion to open surgery. Incomplete release or incomplete removal of dense neural/fibrous tissue is another concern.

Long-term results vary widely by center. One small 2018 series of six laparoscopic patients reported no complications and all six remained symptom-free at a median follow-up of about nine years. Other larger studies report substantially more recurrence and persistent symptoms, emphasizing how much patient selection and operative technique matter.

3. Robotic median arcuate ligament release

Robotic release follows the same basic anatomical goal as laparoscopy but gives the surgeon articulated instruments, tremor filtration, and a magnified three-dimensional view. Those features can make circumferential dissection around the celiac artery and celiac plexus technically easier, particularly for surgeons performing a wide neurolysis.

Robotic surgery is not automatically a more complete operation. Results depend on the surgeon's technique, experience, and how much ligament, fibrous tissue, and neural tissue are actually removed. Robotic surgery can also take longer, costs more, and still carries the same fundamental risk of vascular injury.

A 2026 systematic review and meta-analysis included five retrospective comparative studies with 158 adults. It found no statistically significant difference between laparoscopic and robotic surgery in conversion to open surgery, postoperative complications, hospital stay, pain resolution, or overall symptom recurrence. Time to recurrence was longer in the robotic group, but the evidence was rated low or very low quality because the studies were small and retrospective.

A separate 2026 single-center study of 38 patients reported much higher complete symptom resolution after robotic surgery than laparoscopy at both one month and six months. However, the robotic operations in that study included a deliberate circumferential celiac ganglion neurolysis, whereas that was not consistently documented in the laparoscopic group. The authors themselves argued that the difference may have reflected the extent of nerve and vessel dissection more than the robot itself.

The major debate: leave the celiac ganglion/plexus or remove it?

This is one of the most important differences between MALS surgeons. The celiac plexus is a dense network of sympathetic nerves around the celiac artery. Some surgeons believe MALS is partly a neurogenic pain syndrome and therefore perform an extensive celiac plexus neurolysis or celiac ganglionectomy along with the ligament release. Others believe the key treatment is complete mechanical decompression and prefer to minimize nerve destruction.

Why some surgeons favor wide neurolysis or ganglionectomy

Supporters of wide neurolysis point to several observations: symptoms do not always correlate with the amount of residual celiac artery stenosis; some patients improve after celiac plexus blocks; and series using complete circumferential dissection and ganglion removal have reported strong symptom improvement. The neurogenic theory proposes that compressed, stretched, or chronically irritated celiac ganglion fibers may contribute substantially to pain.

In the 2026 robotic-versus-laparoscopic single-center study, the robotic technique intentionally removed ganglion tissue for at least 2 cm from the celiac bifurcation and circumferentially exposed the celiac artery to its aortic origin. That group had better short-term symptom resolution despite having higher postoperative celiac velocities, which the authors interpreted as support for a neurogenic component.

Why some surgeons do not perform an extensive ganglionectomy

Other surgeons point out that there is no randomized trial proving that removing more celiac plexus tissue improves long-term outcomes. Complete neurolysis requires dissection immediately around major vessels, which can increase technical complexity and potentially increase bleeding or arterial injury. Sympathetic denervation can also cause temporary diarrhea and low blood pressure, and the long-term consequences of extensive neural disruption are not completely defined in MALS populations.

There are published cases and series of successful decompression without formal ganglionectomy. This is why VCA should describe the question as an active surgical controversy rather than saying that the ganglion should always be removed or should always be preserved.

Celiac plexus block before surgery

Some centers use a temporary celiac plexus block as part of patient selection, particularly when a neurogenic mechanism is suspected. A 2024 study specifically evaluated celiac plexus block as a diagnostic tool for suspected neurogenic MALS. A positive block may strengthen the case that the celiac plexus contributes to symptoms, but it is not a universally accepted requirement and does not guarantee surgical success.

What if the celiac artery is still narrowed after release?

External compression can sometimes leave behind a fixed arterial narrowing caused by chronic vessel-wall change or intimal hyperplasia. Some surgeons assess flow during or after surgery with duplex ultrasound, angiography, or occasionally intravascular ultrasound. If significant stenosis persists and remains clinically important, additional treatment may be considered.

Arterial reconstruction

Open arterial options reported in the literature include patch angioplasty, celiac artery reimplantation, bypass, or reconstruction of the celiac origin. These procedures are much more invasive than ligament release alone and are generally reserved for selected patients with severe persistent fixed stenosis, arterial damage, aneurysmal disease, or failed prior treatment.

Angioplasty and celiac artery stenting

Endovascular angioplasty or stenting can treat residual intraluminal stenosis, but stenting the artery without first relieving the external ligament compression is controversial. Continued external compression can deform the vessel or stent and may contribute to persistent symptoms or treatment failure. Published vascular literature includes cases in which endovascular treatment failed and open ligament division plus arterial reconstruction was subsequently required.

In the 2010 UCLA series, three patients with recurrent symptoms after laparoscopic ganglionectomy had persistent celiac stenosis on angiography and underwent angioplasty. That experience illustrates why symptom recurrence can reflect either residual vascular narrowing, incomplete release, another pain generator, or more than one problem.

Long-term outcomes: what larger studies actually show

The best long-term numbers are more modest than many short-term surgical success claims. A Mayo Clinic study of 100 surgically treated patients found no operative mortality. Among 46 patients who completed long-term questionnaires at a mean eight years, 83% initially improved or became symptom-free and 17% had primary treatment failure. Of those who initially improved, 18% later had recurrent symptoms. Estimated freedom from symptoms at five years was 67% ± 7%.

That same study reported 21 major 30-day adverse events among the full 100-patient cohort. These included major blood loss, ileus, respiratory failure, pancreatitis, and one myocardial infarction. One laparoscopic operation was converted after an aortic injury that required repair and splenectomy. Most of the adverse events occurred in the open group, but the groups were not randomized and the open operations likely included more complex patients and reconstructions.

Importantly, 87% of long-term respondents said they would choose surgery again, including patients who later developed recurrent symptoms. Patients who remained symptom-free had quality-of-life scores comparable with the general population.

Why published MALS success rates range from roughly 40% to 90%+

Studies use very different definitions of success. Some count any early improvement; others require complete pain resolution, weight regain, freedom from medications, or durable improvement years later. Operative techniques also vary enormously. A 'MAL release' may mean cutting only the ligament, or it may mean complete skeletonization of the celiac origin plus extensive ganglion neurolysis and arterial reconstruction.

Patient populations also differ. Gastroparesis, dysautonomia, hypermobility, SMAS, Nutcracker Syndrome, chronic pain syndromes, prior abdominal surgery, malnutrition, and other conditions can all influence the outcome. A technically complete MALS operation does not necessarily treat those other problems.

Potential complications families should understand

Reported or anatomically plausible complications include bleeding; injury to the aorta, celiac artery, hepatic artery, splenic artery, or nearby branches; conversion from minimally invasive to open surgery; pancreatic injury or pancreatitis; splenic injury; pneumothorax or diaphragmatic injury; infection; ileus; blood clots; incisional hernia after open surgery; persistent or recurrent pain; residual celiac stenosis; need for angioplasty, stenting, arterial reconstruction, or repeat release; and autonomic effects such as diarrhea or low blood pressure after extensive celiac plexus neurolysis.

Questions to ask a MALS surgeon

Is the operation open, laparoscopic, or robotic? How many MALS releases has the surgeon performed? Do they completely expose the celiac origin and aorta? Do they perform a formal celiac plexus neurolysis or ganglionectomy, and why? How much ganglion tissue do they remove? How do they confirm that the release is complete? What is their conversion-to-open rate? What are their own one-year and five-year symptom recurrence rates? How often do their patients later need angioplasty, stenting, or arterial reconstruction? What is their plan if symptoms persist despite technically successful decompression?

Selected peer-reviewed research

Jimenez JC, et al. Open and laparoscopic treatment of median arcuate ligament syndrome. J Vasc Surg. 2010. Comparative open/laparoscopic ganglionectomy data. DOI: 10.1016/j.jvs.2010.05.083

Pather K, et al. Long-term symptom improvement and health-related quality of life after operative management of median arcuate ligament syndrome. J Vasc Surg. 2021. DOI: 10.1016/j.jvs.2020.10.074

De'Ath HD, et al. The Laparoscopic Management of Median Arcuate Ligament Syndrome and Its Long-Term Outcomes. J Laparoendosc Adv Surg Tech A. 2018. DOI: 10.1089/lap.2018.0204

Ali Z, et al. Outcomes in laparoscopic versus robotic-assisted surgery for median arcuate ligament syndrome: a systematic review and meta-analysis. J Robot Surg. 2026. DOI: 10.1007/s11701-026-03551-x

Fay et al. Robotic Median Arcuate Ligament Release May Offer Superior Symptom Improvement to Laparoscopic Release. Ann Vasc Surg. 2026. DOI: 10.1016/j.avsg.2025.09.033

Celiac plexus block: A diagnostic tool for neurogenic median arcuate ligament syndrome. Pain Pract. 2024. DOI: 10.1111/papr.13403

Outcome predictors in median arcuate ligament syndrome. J Vasc Surg. 2017. DOI: 10.1016/j.jvs.2016.11.040

Median arcuate ligament syndrome: Open celiac artery reconstruction and ligament division after endovascular failure. J Vasc Surg. 2007. DOI: 10.1016/j.jvs.2007.05.049

Pediatric Median Arcuate Ligament Syndrome: Surgical Outcomes and Quality of Life. J Laparoendosc Adv Surg Tech A. 2014. DOI: 10.1089/lap.2013.0438

Bottom line

The most important distinction may not be simply open versus laparoscopic versus robotic. The completeness of decompression, extent of celiac plexus dissection, the condition of the celiac artery, surgeon experience, and whether the patient's symptoms truly come from MALS may matter just as much. Current research does not support telling every patient that one technique is universally superior.

Important limitation

MALS research is dominated by retrospective series from specialized centers. There are no large randomized trials comparing open, laparoscopic, robotic, ganglion-preserving, and wide-neurolysis approaches head-to-head. Percentages from individual studies should be used to understand the range of outcomes, not to predict an individual patient's result.