Median Arcuate Ligament Syndrome (MALS) poses diagnostic challenges due to its diverse symptomatology, including abdominal pain and postprandial distress. This presentation delves into a pragmatic approach for managing MALS, emphasizing a balance between symptomatic relief and anatomical correction. When non-operative measures fall short, surgical decompression is indicated for alleviation of symptoms and restoration of blood flow, with consideration of coeliac plexus ablation. This presentation underscores the importance of recognising and managing complications inherent to MALS interventions, including potential vascular injury and thrombosis. The risk of recurrence or persistent symptoms post-treatment underscores the importance of long-term follow-up care and patient counselling. This session contributes to refining clinical practices, navigating the evolving landscape of MALS management. By embracing a multidisciplinary approach, we optimise patient outcomes. We highlight the necessity for continued research to enhance our understanding and treatment algorithms for this complex vascular syndrome.