正中弓状靱帯圧迫症候群に対して腹腔鏡下正中弓状靱帯切離を行った1例—術中ICG蛍光造影と術前後4D flow MRIの有用性

A case of median arcuate ligament syndrome managed by laparoscopic surgery : The utility of intraoperative ICG fluorography and perioperative 4D flow MRI

◆要旨：患者は44歳，男性．突然の腹痛を主訴に近医を受診した．CTにて膵鉤部周囲血腫と正中弓状靱帯圧迫症候群（MALS）に伴う後上膵十二指腸動脈解離を認めた．前医でコイル塞栓止血術を施行され，MALSに対する腹腔鏡下手術を施行した．上腹部5ポートによる手術操作にて，左胃動脈を根部に向かって剝離し，肥厚した正中弓状靱帯（MAL）を同定した．MALを切離して腹腔動脈の根部を広く露出した．術中ICG蛍光造影にて，腹腔動脈根部の順行性血流を確認した．術後問題なく経過し，4D flow MRIにて腹腔動脈系血流の是正が確認された．従来，開腹でのMAL切離が行われていたが，近年では腹腔鏡下手術の有用性が報告されつつある．

　A 44 year-old male visited the affiliated hospital because of sudden epigastralgia. Abdominal enhanced CT showed a large hematoma around the uncinate process of the pancreas and celiac compression by median arcuate ligament （MAL）. Since angiography revealed the posterior superior pancreaticoduodenal artery （PSPDA） dissociation, he underwent coil embolization. Since the regurgitated common hepatic artery flow sustained after embolization, he was introduced to our hospital for the purpose of MAL section. Under laparoscopic surgery with 5 ports, the omental cavity was opened and MAL was identified after skeletonization of the diaphragmatic crura and the left gastric artery. These compressing fibers were divided until the aortoceliac artery bifurcation was clearly visualized. After the hemi-circumference of the root of the celiac artery had been dissected, the ligament compression was released. Intraoperative ICG fluorography showed anterograde blood flow from the root of the celiac artery. Postoperative course was uneventful. Perioperative hemodynamic evaluation using 4D flow MRI elucidated the normalization of blood flow from the celiac artery to the common hepatic artery. Laparoscopic MAL section was safely performed and was a good option for patients with MALS.