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 ¤ Case report
 ¤ Discussion
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UNUSUAL CASE
Year : 2014  |  Volume : 10  |  Issue : 3  |  Page : 154-156
 

Complete laparoscopic removal of a gastric trichobezoar


Department of Paediatric Surgery, Apollo Hospitals, Bangalore, Karnataka, India

Date of Submission29-Oct-2013
Date of Acceptance22-Jan-2014
Date of Web Publication20-Jun-2014

Correspondence Address:
Anand Alladi
Department of Paediatric Surgery, Apollo Hospitals, 154/11, Bannerghatta Road, Bangalore - 560 076, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-9941.134880

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 ¤ Abstract 

Trichobezoars are seen usually in adolescent girls and laparotomy is required to remove them, though recently laparoscopic assisted and laparoscopic removal have been reported in adults and older children.
We report this 4-year-old boy who underwent complete laparoscopic removal of a gastric trichobezoar, both for its rarity in such young boys and also because he is the youngest reported patient to undergo complete laparoscopic removal of a gastric trichobezoar.


Keywords: Gastric, laparoscopy, trichobezoar, youngest


How to cite this article:
Vepakomma D, Alladi A. Complete laparoscopic removal of a gastric trichobezoar. J Min Access Surg 2014;10:154-6

How to cite this URL:
Vepakomma D, Alladi A. Complete laparoscopic removal of a gastric trichobezoar. J Min Access Surg [serial online] 2014 [cited 2019 Nov 14];10:154-6. Available from: http://www.journalofmas.com/text.asp?2014/10/3/154/134880



 ¤ Introduction Top


Trichobezoar is a mass of swallowed hair forming a concretion in the gastrointestinal tract, usually seen in adolescent girls, with a history of psychological disorder. [1] Gastric trichobezoars attain a large size before becoming symptomatic, are generally not amenable to endoscopic removal and are often removed surgically. Laparotomy, mini laparotomy and laparoscopic-assisted removal have been routinely practiced. Laparoscopic removal of gastric trichobezoars has been reported, but the concern with this technique is the difficulty in complete removal of the large bezoar without spillage of hairs in the peritoneal cavity. [1] Most of the reports are laparoscopic assisted, utilizing an extended incision to facilitate direct removal from the peritoneal cavity. There have also been reports of removing the bezoar piecemeal through one of the port sites, but only in adolescents and older children. [2] Boys account for 10% of all patients and most are children above 6 years. [3]


 ¤ Case report Top


A 4-year-old boy was incidentally detected to have a mass abdomen by his paediatrician when he was being evaluated for a respiratory infection. There were no symptoms pertaining to the mass. On examination he had a 15 cm × 10 cm firm to hard mass in the epigastrium and left hypochondrium. Ultrasound of the abdomen showed a solid mass occupying the entire stomach, possibly a trichobezoar. This was followed by CECT to confirm the diagnosis. Retrospective history was then elicited. This was a Sikh (a community in which the male members also leave their hair long) child who had moved to a new city 1 1/2 years previously and had problems settling down at the new preschool. Parents noticed that he would pull out and chew his hair. They said the problem resolved spontaneously after 6 months when they and the teachers along with child psychologist helped the child adapt to the new environment.

He was admitted for laparoscopic removal of the trichobezoar. Under general anaesthesia, a diagnostic endoscopy was first performed. A 5-12 mm trocar was placed through the umbilicus which was used initially for a 10 mm zero degree telescope and later for the endostapler and endobag. Three 5-mm ports, one each in the epigastrium, right hypochondrium and left lumbar regions, were placed. A pneumoperitoneum of 14 mmHg was maintained. A long anterior wall gastrotomy was made using the Harmonic scalpel ® . The bezoar was delivered by initially manoeuvring the upper pole out by holding the edges of the gastrotomy [Figure 1] with graspers and then the whole bezoar pushed out of the stomach. The bezoar was gently placed in the left sub-phrenic space. The 10 mm telescope was replaced by a 5-mm scope through the epigastric port. A linear endostapler was passed through the umbilical port and the gastrotomy closed. An endobag then replaced the stapler into which the bezoar was manipulated [Figure 2]. The mouth of the endobag was brought out through the umbilical port and the bezoar removed piecemeal till the whole bag could be delivered. This was achieved without any spillage. The procedure took 2 hours 10 minutes. Feeding was started on post-operative day 4. The child had an uneventful recovery and was discharged on post-op day 7 [Figure 3].
Figure 1: Picture showing trichobezoar being delivered out of stomach

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Figure 2: Picture showing bezoar guided into endobag

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Figure 3: Picture showing scars of Laparoscopy port incisions

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 ¤ Discussion Top


Gastric trichobezoars are almost exclusively seen in adolescent girls with some underlying psychiatric illness leading to trichotillomania (pulling out hair) and trichophagia (ingestion of hair). [3] However, our patient though a very young boy, had the same background of trichophagia secondary to psychological trauma. Trichobezoars usually present with pain abdomen, vomiting, failure to thrive or obstruction. Rarely it can present as an asymptomatic mass like in our patient, or with complications. [3],[4] Endoscopic removal of small masses has been reported but surgical intervention is usually required. In a recent review of literature [Table 1] out of 109 children reported so far only 8 patients had attempted laparoscopic removal. Of these only 3 were removed completely by laparoscopy alone without extension of the port site incisions. [1],[5] Our patient is the youngest reported to date. The limiting factor is the size and fear of spillage and peritoneal contamination. In laparoscopic removal of trichobezoar in another 4 year old, two5-mm working ports were placed in the right upper quadrant and left mid abdomen. A fourth incision was made in the left inguinal skin crease through which a 12-mm trocar was initially placed and later used as the extraction site varying from our approach slightly. [5] In another case report of a 17-year-old girl, the technical variation was the performance of a gastrotomy by inserting a blunt trochar into the stomach, inflating a gastric balloon, and pulling the balloon against the stomach wall, creating a 10-mm intragastric port. Carbon dioxide was then pumped into the stomach to create 4 mmHg pressure. Using the working scope, the hair was removed in pieces. [6] Others have reported removing the bezoar through a separate suprapubic incision. [7]
Table 1: Comparing other techniques

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Complete laparoscopic removal of trichobezoar is safe and possible in young children. Even in very young children, an underlying psychological stress factor can exist and needs to be simultaneously addressed in addition to the surgical management.[8]

 
 ¤ References Top

1.Gorter RR, Kneepkens CM, Mattens CJ, Aronson DC, Heij HA. Management of trichobezoar: Case report and literature review. Pediatr Surg Int 2010;26:457-63.  Back to cited text no. 1
    
2.Hernández-Peredo-Rezk G, Escárcega-Fujigaki P, Campillo-Ojeda ZV, Sánchez-Martínez ME, Rodríguez-Santibáñez MA, Angel-Aguilar AD, et al. Trichobezoar can be treated laparoscopically. J Laparoendosc Adv Surg Tech A 2009;19:111-3.   Back to cited text no. 2
    
3.Shami SB, Jararaa AA, Hamade A, Ammori BJ. Laparoscopic removal of a huge gastric trichobezoar in a patient with trichotillomania. Surg Laparosc Endosc Percutan Tech 2007;17:197-200.   Back to cited text no. 3
    
4.Gonuguntla V, Joshi DD. Rapunzel syndrome: A comprehensive review of an unusual case of trichobezoar. Clin Med Res 2009;7:99-102.   Back to cited text no. 4
    
5.Cintolo J, Telem DA, Divino CM, Chin EH, Midulla P. Laparoscopic removal of a large gastric trichobezoar in a 4-year-old girl. JSLS 2009;13:608-11.   Back to cited text no. 5
    
6.Dorn HF, Gillick JL, Stringel G. Laparoscopic intragastric removal of giant trichobezoar. JSLS 2010;14:259-62.  Back to cited text no. 6
    
7.Nirasawa Y, Mori T, Ito Y, Tanaka H, Seki N, Atomi Y. Laparoscopic removal of a large gastric trichobezoar. J Pediatr Surg 1998;33:663-5.  Back to cited text no. 7
    
8.Pimpalwar A. Use of laparoscopic approach for removal of large gastric trichobezoar in children. Available from: http://www.sages.org [Last accessed on 2014 February 22].  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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