Laparoscopic management of superior mesenteric artery syndrome.

Superior mesenteric artery syndrome (SMAS) is a rare clinical condition that should be considered in patients with long-standing abdominal complaints where endoscopic and conventional roentgenographical findings are often negative. It has been claimed that SMAS is caused by intermittent obstruction of the horizontal portion of the duodenum between the superior mesenteric artery and the spine and the aorta. The main target of this presentation is to present our experience in the laparoscopic management of 4 cases of documented SMAS after failure of medical treatment. The laparoscopic severing of the ligament of Treitz is a feasible and safe technique. It could bring about total relief of symptoms in three out of the four patients. The operative time rapidly decreased with the acquaintance of the field. The visualization (exposure) is quite satisfactory. the technique offers added precision and accuracy to the dissection manoeuvres. Recovery was uneventful and rapid with minimal needs for postoperative analgesia. We recommend the use of mini-endoshear (pediatric). Phases of dissection from the mesocolon and retro-pancreatically are presented. We stress the finding of the drainage of the inferior mesenteric vein into the superior mesenteric vein instead of the splenic vein. This could put the inferior mesenteric vein (looking as a fibrous band) in jeopardy. Also it reduces the area of access to the retropancreatic dissection. We raise the possibility of an etiological role of this anatomical variation to the duodenal compression and call upon the study of such a possibility. The importance to attain the proper retropancreatic space has been shown by the possibility of dissecting between the uncinate process and the rest of the pancreas. The psychological impact of a minimal invasive approach together with symptoms relief was quite rewarding.