Surgery for median arcuate ligament syndrome (MALS) carries substantial risk, particularly when performed laparoscopically or robotically. The celiac artery and nerve plexus lie within a tight, “high stakes” region of the body, which allows little to no room for error during surgery. Thorough knowledge and assessment of all the key structures involved in the surgical procedure are paramount to avoid intraoperative complications such as bleeding and provide the best outcomes in terms of safety and symptom relief. The aim of this chapter is to describe both normal and variant anatomy of the main structures encountered during surgery for MALS.