The emerging role of robotics in plastic and reconstructive surgery: a systematic review and meta-analysis.

The role of robotics has grown exponentially. There is an active interest amongst practitioners in the transferability of the potential benefits into plastic and reconstructive surgery; however, many plastic surgeons report lack of widespread implementation, training, or clinical exposure. We report the current evidence base, and surgical opportunities, alongside key barriers, and limitations to overcome, to develop the use of robotics within the field. This systematic review of PubMed, Medline, and Embase has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PROSPERO (ID: CRD42024524237). Preclinical, educational, and clinical articles were included, within the scope of plastic and reconstructive surgery. 2, 181, articles were screened; 176 articles met the inclusion criteria across lymph node dissection, flap and microsurgery, vaginoplasty, craniofacial reconstruction, abdominal wall reconstruction and transoral robotic surgery (TOR). A number of benefits have been reported including technical advantages such as better visualisation, improved precision and accuracy, and tremor reduction. Patient benefits include lower rate of complications and quicker recovery; however, there is a longer operative duration in some categories. Cost presents a significant barrier to implementation. Robotic surgery presents an exciting opportunity to improve patient outcomes and surgical ease of use, with feasibility for many subspecialities demonstrated in this review. However, further higher quality comparative research with careful case selection, which is adequately powered, as well as the inclusion of cost-analysis, is necessary to fully understand the true benefit for patient care, and justification for resource utilisation.

Correlation between oral and oropharyngeal resection subsites and impact of reconstruction on speech and swallowing function in head and neck cancer patients: A systematic review.

This review aims to provide a correlation between oral and oropharyngeal subsites and type of reconstruction used in the management of head and neck cancer patients. A literature search of PubMed, Embase and Web of Science was conducted. All study types describing long-term speech and swallow outcomes of adults following head and neck oncological reconstruction, which used a subsite classification, were included. Risk of bias was assessed using the Robbins-1 tool. A total of 2270 patients were found in 26 studies. The number of subsites/studies ranged from 2 to 18. Subsites were predominantly divided on an anatomical basis. Other classifications included functionally grouped subsites. Seven articles considered combinations, unilateral and bilateral defects. Base of tongue, FOM, and defects crossing the midline are negatively correlated with post-operative speech and swallow. Lateral distributions were associated with superior outcomes. The University of Washington Quality of Life Questionnaire (UW-QOL) was the most prevalent tool for speech and swallow assessment. Other factors that significantly affect speech and swallow outcomes include adjuvant therapy, size, type of reconstruction (free flap compared to pedicled or local). The role of neoadjuvant therapy remains unknown. A consistent and formalised approach including risk stratification for multiple contributing factors would be useful in clinical pre- and post-operative management.

Exploring Anti-Fibrotic Effects of Adipose-Derived Stem Cells: Transcriptome Analysis upon Fibrotic, Inflammatory, and Hypoxic Conditioning.

Autologous fat transfers show promise in treating fibrotic skin diseases, reversing scarring and stiffness, and improving quality of life. Adipose-derived stem cells (ADSCs) within these grafts are believed to be crucial for this effect, particularly their secreted factors, though the specific mechanisms remain unclear. This study investigates transcriptomic changes in ADSCs after in vitro fibrotic, inflammatory, and hypoxic conditioning. High-throughput gene expression assays were conducted on ADSCs exposed to IL1-ß, TGF-ß1, and hypoxia and in media with fetal bovine serum (FBS). Flow cytometry characterized the ADSCs. RNA-Seq analysis revealed distinct gene expression patterns between the conditions. FBS upregulated pathways were related to the cell cycle, replication, wound healing, and ossification. IL1-ß induced immunomodulatory pathways, including granulocyte chemotaxis and cytokine production. TGF-ß1 treatment upregulated wound healing and muscle tissue development pathways. Hypoxia led to the downregulation of mitochondria and cellular activity.

Exploring the mechanisms behind autologous lipotransfer for radiation-induced fibrosis: A systematic review.

AIM: Radiation-induced fibrosis is a recognised consequence of radiotherapy, especially after multiple and prolonged dosing regimens. There is no definitive treatment for late-stage radiation-induced fibrosis, although the use of autologous fat transfer has shown promise. However, the exact mechanisms by which this improves radiation-induced fibrosis remain poorly understood. We aim to explore existing literature on the effects of autologous fat transfer on both in-vitro and in-vivo radiation-induced fibrosis models, and to collate potential mechanisms of action. METHOD: PubMed, Cochrane reviews and Scopus electronic databases from inception to May 2023 were searched. Our search strategy combined both free-text terms with Boolean operators, derived from synonyms of adipose tissue and radiation-induced fibrosis. RESULTS: The search strategy produced 2909 articles. Of these, 90 underwent full-text review for eligibility, yielding 31 for final analysis. Nine conducted in-vitro experiments utilising a co-culture model, whilst 25 conducted in-vivo experiments. Interventions under autologous fat transfer included adipose-derived stem cells, stromal vascular function, whole fat and microfat. Notable findings include downregulation of fibroblast proliferation, collagen deposition, epithelial cell apoptosis, and proinflammatory processes. Autologous fat transfer suppressed hypoxia and pro-inflammatory interferon-γ signalling pathways, and tissue treated with adipose-derived stem cells stained strongly for anti-inflammatory M2 macrophages. Although largely proangiogenic initially, studies show varying effects on vascularisation. There is early evidence that adipose-derived stem cell subgroups may have different functional properties. CONCLUSION: Autologous fat transfer functions through pro-angiogenic, anti-fibrotic, immunomodulatory, and extracellular matrix remodelling properties. By characterising these mechanisms, relevant drug targets can be identified and used to further improve clinical outcomes in radiation-induced fibrosis. Further research should focus on adipose-derived stem cell sub-populations and augmentation techniques such as cell-assisted lipotransfer.

A comparison of commercially available synthetic skin substitutes for surgical simulation training.

Objective: Simulation training provides an important opportunity to accelerate surgical skills acquisition whilst safeguarding patients. This study compares the suitability of different synthetic skin substitutes for use in surgical simulation training. Design: Data was collected for eight commercially available synthetic skin substitutes and included cost, delivery time, subjective assessment of fidelity by surgeons and trainees, and objective comparison with the biomechanics of human skin was made through cutometry and durometry measurements. Cutometry and durometry data was collected from three healthy adults from the forearm, forehead and back, with measurements being repeated in triplicate. Subjective assessment of skin pad quality was collected using an 8-criteria questionnaire, graded using a 5-point Likert scale for fidelity to normal skin. Results: The questionnaire assessment was completed by 30 trainees and practitioners. Overall, felt pads received the poorest outcomes in all criteria; cutometry and durometry results demonstrate poor similarity to skin, and felt received the lowest scores in the questionnaire, although the cheapest. Foam dressings were similar in both cutometric and durometric properties to skin of the face, back and arm. Clinical outcomes of foam dressings were similar to the most expensive commercial skin pad. Conclusions: Bilaminar foam-based dressings provide a low cost, high fidelity non-biological simulation of skin for surgical training, which is non-inferior to more expensive specifically designed products. Many products designed to act as skin substitutes for surgical simulation fail to adequately replicate the anatomical and mechanical properties of skin.

Single-Cell Analysis of ADSC Interactions with Fibroblasts and Endothelial Cells in Scleroderma Skin.

Adipose-derived stem cells (ADSCs) as part of autologous fat grafting have anti-fibrotic and anti-inflammatory effects, but the exact mechanisms of action remain unknown. By simulating the interaction of ADSCs with fibroblasts and endothelial cells (EC) from scleroderma (SSc) skin in silico, we aim to unravel these mechanisms. Publicly available single-cell RNA sequencing data from the stromal vascular fraction of 3 lean patients and biopsies from the skin of 10 control and 12 patients with SSc were obtained from the GEO and analysed using R and Seurat. Differentially expressed genes were used to compare the fibroblast and EC transcriptome between controls and SSc. GO and KEGG functional enrichment was performed. Ligand-receptor interactions of ADSCs with fibroblasts and ECs were explored with LIANA. Pro-inflammatory and extracellular matrix (ECM) interacting fibroblasts were identified in SSc. Arterial, capillary, venous and lymphatic ECs showed a pro-fibrotic and pro-inflammatory transcriptome. Most interactions with both cell types were based on ECM proteins. Differential interactions identified included NTN1, VEGFD, MMP2, FGF2, and FNDC5. The ADSC secretome may disrupt vascular and perivascular inflammation hubs in scleroderma by promoting angiogenesis and especially lymphangiogenesis. Key phenomena observed after fat grafting remain unexplained, including modulation of fibroblast behaviour.

The intraoperative use of augmented and mixed reality technology to improve surgical outcomes: A systematic review.

BACKGROUND: This systematic review aims to critically appraise the intraoperative use of augmented and mixed reality technology to improve surgical outcomes. METHOD: A literature search of PubMed, Scopus, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov and WHO ICTRP was performed in accordance with Cochrane Handbook for Systematic Reviews of Interventions. RESULTS: This review included 94 studies on 2473 patients, comprising 78 studies on augmented reality and 16 on mixed reality. This technology has seen broad intraoperative application. Augmented and mixed reality can reduce operative duration, blood loss, and the duration of inpatient care. Current evidence shows that they achieve this most in percutaneous surgery. CONCLUSIONS: Augmented and mixed reality technology improve surgical outcomes by increasing navigational speed and reducing navigational error intraoperatively. However, they have technical limitations which are the subject of ongoing research. Further studies are necessary to define how this technology is best applied intraoperatively. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020205892.

Update on Noma: systematic review on classification, outcomes and follow-up of patients undergoing reconstructive surgery after Noma disease.

INTRODUCTION: Noma is a significant yet neglected disease which affects some of the least developed countries in the world. The long-term benefit and safety of Noma surgical reconstructive missions have recently been under scrutiny due to a perceived lack of measurable outcomes and appropriate follow-up. This study analyses and reports on classifications, outcome measurement tools and follow-up for reconstructive surgery after Noma disease. METHODS: This systematic review was undertaken following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The three medical databases Medline, EMBASE and Web of Sciences were searched, articles published between 1 January 1983 and 15 April 2020 were included. All primary evidence on reconstructive surgery following Noma disease, reporting data on outcome after surgery, follow-up time and complications were included. Extracted data were aggregated to generate overall and population corrected mean outcomes and complication rates. RESULTS: Out of 1393 identified records, 31 studies including 1110 Noma patients were analysed. NOITULP and Montandon/WHO were the most commonly used classification systems. Mouth opening (MO) and complication rates were the two most often reported outcomes. Overall mean complication rate was 44%, reported by 24 studies. Postoperative MO was reported by eight publications, of which, five reported long-term outcomes (>12 months). Mean MO improved by 20 mm when compared with mean population weighted preoperative MO (7 mm). At long-term follow-up, MO decreased to 20 mm. CONCLUSIONS: Studies reporting on neglected diseases in developing countries often lack methodological rigour. Surgeons should be mindful during patient examination by using a classification system that allows to compare preoperative versus postoperative state of disease. Short-term mission surgery is a vital part of healthcare delivery to underdeveloped and poor regions. Future missions should aim at sustainable partnerships with local healthcare providers to ensure postoperative care and long-term patient-oriented follow-up. A shift towards a diagonal treatment delivery approach, whereby local surgeons and healthcare staff are educated and empowered, should be actively promoted. PROSPERO REGISTRATION NUMBER: CRD42020181931.

Bennett's Fracture Repair-Which Method Results in the Best Functional Outcome? A Retrospective Cohort Analysis and Systematic Literature Review of Patient-Reported Functional Outcomes.

Surgical fixation of Bennett's fracture of the thumb is critical to prevent functional impairment; however, there is no consensus on the optimal fixation method. We performed an 11-year retrospective cohort analysis and a systematic literature review to determine long-term patient-reported outcomes following Bennett's fracture fixation. Retrospective cohort analysis identified 49 patients treated with Kirschner (K)-wire fixation, 85% returned to unrestricted movement during hand therapy. Forty-seven patients (96%) completed the disabilities of the arm, shoulder, and hand (DASH) questionnaires at a mean of 5.55 years from injury, with a mean score of 7.75. Systematic literature review identified 14 studies with a cumulative 541 patients. Fixation included open or percutaneous methods utilizing K-wires, tension band wiring, lag screws, T-Plates, external fixation, and arthroscopic screw fixation. Functional outcomes reported included DASH, quickDASH (qDASH), and visual analogue scores. Superficial wound infection occurred in 4 to 8% of percutaneous K-wire fixation. Open reduction internal fixation (ORIF) methods were associated with a 4 to 20% rate of reintervention and 5 to 28% rate of persistent paresthesia. Closed reduction with percutaneous K-wire fixation should be the first choice surgical method, given excellent, long-term functional outcomes, and low risk of complications. ORIF should be utilized where closed reduction is not achievable; however, the current evidence does not support one method of ORIF above another.

Regenerative medicine for skeletal muscle loss: a review of current tissue engineering approaches.

Skeletal muscle is capable of regeneration following minor damage, more significant volumetric muscle loss (VML) however results in permanent functional impairment. Current multimodal treatment methodologies yield variable functional recovery, with reconstructive surgical approaches restricted by limited donor tissue and significant donor morbidity. Tissue-engineered skeletal muscle constructs promise the potential to revolutionise the treatment of VML through the regeneration of functional skeletal muscle. Herein, we review the current status of tissue engineering approaches to VML; firstly the design of biocompatible tissue scaffolds, including recent developments with electroconductive materials. Secondly, we review the progenitor cell populations used to seed scaffolds and their relative merits. Thirdly we review in vitro methods of scaffold functional maturation including the use of three-dimensional bioprinting and bioreactors. Finally, we discuss the technical, regulatory and ethical barriers to clinical translation of this technology. Despite significant advances in areas, such as electroactive scaffolds and three-dimensional bioprinting, along with several promising in vivo studies, there remain multiple technical hurdles before translation into clinically impactful therapies can be achieved. Novel strategies for graft vascularisation, and in vitro functional maturation will be of particular importance in order to develop tissue-engineered constructs capable of significant clinical impact.

A systematic review and meta-analysis on the effect of neoadjuvant chemotherapy on complications following immediate breast reconstruction.

BACKGROUND: The impact of neoadjuvant chemotherapy (NACT) on surgical outcomes following immediate breast reconstruction (IBR) remains unclear. While it is generally considered safe practice to perform an IBR post NACT, reported complication rates in published data are highly variable with the majority of studies including fewer than 50 patients in the NACT and IBR arm. To evaluate this further, we conducted a systematic review and meta-analysis on the effect of NACT on autologous and implant based immediate breast reconstructions. We aimed to assess for differences in the post-operative course following IBR between patients who received NACT with those who did not. METHODS: PubMed, EMBASE, and Cochrane Library were searched from 1995 to Sept 2, 2020 to identify articles that assessed the impact of NACT on IBR. All included studies assessed outcomes following IBR. Only studies comparing reconstructed patients receiving NACT to a control group of women who did not receive NACT were included. Unadjusted relative risk of outcomes between patients who received or did not receive NACT were synthesized using a fixed-effect meta-analysis. The evidence was assessed using the Newcastle Ottawa Scale scores and GRADE. Primary effect measures were risk ratios (RRs) with 95% confidence intervals. RESULTS: A total 17 studies comprising 3249 patients were included in the meta-analyses. Overall, NACT did not increase the risk of complications after immediate breast reconstructions (risk ratio [RR]: 0.91, 95% CI 0.74 to 1.11, p = 0.34). There was a moderate, but not significant, increase in flap loss following NACT compared with controls (RR: 1.23, 95% CI 0.70 to 2.18, p = 0.47; I2 = 0%). Most notably, there was a statistically significant increase in implant/expander loss after NACT (RR: 1.54, 95% CI 1.04 to 2.29, p = 0.03; I2 = 34%). NACT was not shown to significantly increase the incidence of hematomas, seromas or wound complications, or result in a significant delay to commencing adjuvant therapy (RR: 1.59, 95% CI 0.66 to 3.87, p = 0.30). CONCLUSION: Immediate breast reconstruction after NACT is a safe procedure with an acceptable post-operative complication profile. It may result in a slight increase in implant loss rates, but it does not delay commencing adjuvant therapy.

Biological versus non-biological dressings in the management of split-thickness skin-graft donor sites: a systematic review and meta-analysis.

OBJECTIVE: There are currently no definitive guidelines regarding the management of split-thickness skin-graft (STSG) donor sites. The literature reports biological and non-biological dressings as the two main groups; however, there is no conclusive evidence regarding the ideal type. A systematic review and meta-analysis of existing clinical trials was performed to compare biological and non-biological dressings in managing STSG donor sites. METHOD: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards was used to conduct this study. Electronic databases including MEDLINE, Embase, CINAHL and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched by two authors (SR and BL). Data analysis was performed with RevMan 5.3. RESULTS: In total, 10 studies, consisting of eight randomised controlled trials and two observational assessments, were identified. Wound healing time was faster with biological dressings compared to non-biological dressings (mean difference -5.44 days; p<0.05). A higher epithelialisation rate was also noted for biological dressings. There was no difference in the infection rate between the two study groups (odds ratio [OR] 0.39; 95% confidence interval [CI] 0.15-1.04) or wound exudation (OR 0.31; 95% CI 0.01-8.28). The pain level experienced during dressing changes in both groups was reported to be similar. CONCLUSION: The rate of epithelialisation and wound healing is greater for STSG donor sites when treated with biological dressings, but they offer no difference in terms of reducing pain, limiting infection or exudation.

A Methodological Assessment of Diabetic Foot Syndrome Clinical Practice Guidelines.

OBJECTIVE: Diabetic foot syndrome (DFS) contributes to significant morbidity in diabetic patients. Diagnostic and therapeutic approaches to DFS may be summarised in clinical practice guidelines (CPGs) to aid clinical practice but may only benefit patients if the CPG is of high quality. This study determines the methodological quality of DFS CPGs using a validated assessment tool to identify CPGs adequate for use in clinical practice. METHODS: Medline, EMBASE, and CPG databases were searched to 31 May 2019. Reference lists were also searched. Full text English evidence based DFS CPGs were included. CPGs based on expert consensus, guideline summaries, or those only available if purchased were excluded. Four reviewers independently assessed methodological quality using the Appraisal of Guidelines for Research and Evaluation II instrument. An overall guideline assessment scaled score of ≥80% was considered to be of adequate quality to recommend use. RESULTS: Sixteen CPGs were identified. Good inter-reviewer reliability (ICC 0.985, 95% CI 0.980-0.989) was achieved. Poor scores were noted in domains 2 (stakeholder involvement), 5 (applicability), and 6 (editorial independence). Significant methodological heterogeneity was observed in all domains with the most noted in domain 6 (mean scaled score 43.2 ± 32.1%). Four CPGs achieved overall assessment scores of ≥80%. CONCLUSION: Four CPGs were considered to be adequate for clinical practice based on methodological quality. However, elements of methodological quality were still lacking, and all CPGs had areas for improvement, potentially through increased multidisciplinary team involvement and trial application of recommendations. Methodological rigour may be improved using structured approaches with validated CPG creation tools in the future. Future work should also assess recommendation accuracy using available validated assessment tools.

Long-Term Outcomes following Pediatric Peripheral Nerve Injury Repair.

Introduction Peripheral nerve injuries in children are uncommon and can be challenging to diagnose. There is a paucity of data on long-term sensorimotor and functional outcomes following surgical repair. We present a 12-year retrospective analysis of pediatric peripheral nerve repair with long-term functional outcomes. Materials and Methods We performed a retrospective analysis of pediatric patients with peripheral nerve injury requiring surgical repair. Clinical records were analyzed for procedure type, time to surgery, mechanism of injury, postoperative recovery, and complications. Results A total of 108 patients were identified and 87 patients were included. Out of 87 patients, 83 (95.4%) had partial or complete sensorimotor recovery at final follow-up and 4 did not improve. Minor complications occurred in 10.3% of patients, all resolved with conservative management. Mechanisms of injury were predominantly lacerations with sharp objects or crush injuries. Age at time of injury was inversely correlated with sensorimotor recovery, and time to surgical repair was not. Conclusion Surgical repair with long-term hand therapy results in excellent functional outcomes following pediatric peripheral nerve injury. A low threshold for exploration and repair should be used in instances of diagnostic uncertainty. Timing of surgical repair is dependent on a patient's clinical presentation; however, repair within 48 hours is sufficient for optimal sensorimotor recovery.

A Narrative Review of the Use of Neuromuscular Electrical Stimulation in Individuals With Diabetic Foot Ulceration.

This review aims to summarize the evidence reported on the use of neuromuscular electrical stimulation (NMES) in individuals with diabetic foot ulceration (DFU). A systematic search of EMBASE and MEDLINE databases was performed in February 2019, using search terms relating to the domains DFU and NMES. All primary evidence assessing outcomes of NMES in DFU were included. Of 344 references obtained from database searching, 7 met the inclusion criteria and included a total of 140 participants, 77 of whom had DFU. All included studies used prospective designs. Two studies demonstrated improvements in chronic ulcer healing with NMES use; however, in each study, only 3 of the included participants had DFU and subgroup analyses based on ulcer etiology was omitted. The remaining 5 studies were produced by the same research group and positive effects of NMES (in combination with heat therapy) on DFU healing were consistently demonstrated. They reported significantly better healing rates with NMES in DFU than in nondiabetic wounds of a similar grade (healing rate: 70.0 ± 32.3% in DFU vs 38.4 ± 22.3% in nondiabetic ulcers [P < .01]). These studies did not provide data assessing the isolated effects of NMES without concomitant heat exposure. Data on device tolerability and compliance were lacking. The existing data support a potential role for NMES in individuals with DFU; however, the identified studies inadequately controlled for confounding and were underpowered. Given the significant morbidity and mortality associated with DFU, higher quality evidence is needed to assess the adjunctive role for NMES in this group.

Cyanoacrylate glue embolisation for varicose veins - A novel complication.

BACKGROUND: Non-thermal non-tumescent methods for varicose vein treatment have rapidly gained popularity in recent years due to clinical efficacy comparable to other endovenous methods, but with a superior safety and tolerability profile. Cyanoacrylate is an adhesive that rapidly polymerises during endovenous treatment to cause rapid occlusion of veins and initiate vein fibrosis. METHOD: Cyanoacrylate glue treatment is known to cause complications such as phlebitis, cellulitis and deep vein thrombosis in rare instances. We present the first reported case of cyanoacrylate extravasation with chronic foreign body reaction in a patient nine months after initial treatment. RESULTS: We discuss the aetiology of this complication, its treatment, patient outcome and its significance to both clinicians and patients. CONCLUSION: Cyanoacrylate glue embolisation can, in rare instances, lead to extravasation and chronic foreign body reaction, necessitating surgical intervention. The relative novelty of cyanoacrylate glue embolisation in the treatment of varicose veins requires clinicians to monitor for rare complications during its use in clinical practice. Patients should be aware of the rare risk of glue extravasation and foreign body reaction for fully informed consent prior to treatment.

Median arcuate ligament syndrome.

BACKGROUND: Median arcuate ligament syndrome (MALS) describes the clinical presentation associated with direct compression of the celiac artery by the median arcuate ligament. The poorly understood pathophysiologic mechanism, variable symptom severity, and unpredictable response to treatment make MALS a controversial diagnosis. METHODS: This review summarizes the literature pertaining to the pathophysiologic mechanism, presentation, diagnosis, and management of MALS. A suggested diagnostic workup and treatment algorithm are presented. RESULTS: Individuals with MALS present with signs and symptoms of foregut ischemia, including exercise-induced or postprandial epigastric pain, nausea, vomiting, and weight loss. Consideration of MALS in patients' diagnostic workup is typically delayed. Currently, no group consensus agreement as to the diagnostic criteria for MALS exists; duplex ultrasound, angiography, and gastric exercise tonometry are used in different combinations and with varying diagnostic values throughout the literature. Surgical management involves decompression of the median arcuate ligament's constriction of the celiac artery; robotic, laparoscopic, endoscopic retroperitoneal, and open surgical intervention can provide effective symptom relief, but long-term follow-up data (>5 years) are lacking. Patients treated nonoperatively appear to have worse outcomes. CONCLUSIONS: MALS is an important clinical entity with significant impact on affected individuals. Presenting symptoms, patient demographics, and radiologic signs are generally consistent, as is the short-to medium-term (<5 years) response to surgical intervention. Future prospective studies should directly compare long-term symptomatic and quality of life outcomes after nonoperative management with outcomes after open, laparoscopic, endoscopic retroperitoneal, and robotic celiac artery decompression to enable the development of evidence-based guidelines for the management of MALS.