Median arcuate ligament (MAL) can significantly affect outcomes in pancreaticoduodenectomy (PD) patients.

• MAL stenosis occurred in 1.3% (115/8676), with hemodynamically significant cases in 0.7% (59 patients).
• Preoperative stenting was performed in 14%, while 83% underwent intraoperative division; 14% of divisions required vascular reconstruction due to failure.

MAL management doesn’t worsen overall outcomes but demands early detection and tailored surgical approaches.

• Overall morbidity was 25%, with 4.3% mortality, including deaths from hepatic ischemia linked to MAL.