HOW I DO IT DIFFERENTLY
|Year : 2013 | Volume
| Issue : 1 | Page : 42-44
A modified minimally invasive technique for the surgical management of large trichobezoars
Amit Javed, Anil K Agarwal
Department of GI Surgery, GB Pant Hospital & MAM College, New Delhi, India
|Date of Submission||08-Jan-2012|
|Date of Acceptance||05-Apr-2012|
|Date of Web Publication||14-Feb-2013|
Anil K Agarwal
Department of GI Surgery, GB Pant Hospital & MAM College, New Delhi
Source of Support: None, Conflict of Interest: None
Background: Trichobezoar which were traditionally managed by open surgical retrieval are now often managed by minimally invasive surgical approach. Removal of a large trichobezoar by laparoscopy, however, needs an incision (usually 4-5 cm in size) for specimen removal and has the risk of intra-peritoneal spillage of hair and inspissated secretions. Materials and Methods : The present paper describes a modified laparoscopy-assisted technique with temporary gastrocutaneopexy for the effective removal of a large trichobezoar using a camera port and a 4-5 cm incision (which is similar to that needed for specimen removal during laparoscopy). Results: Three patients with large trichobezoar were managed with the described technique. The average duration of surgery was 45 (30-60) min and the intraoperative blood loss was minimal. There was no peritoneal spillage and the trichobezoar could be retrieved through a 4-5 cm incision in all patients. All had an uneventful recovery and at a median followup of 6 months had excellent cosmetic and functional results. Conclusion: The described technique is a minimally invasive alternative for trichobezoar removal. There is no risk of peritoneal contamination and the technical ease and short operative time in addition to an incision limited to size required for the specimen removal, makes it an attractive option.
Keywords: Limited incision, trichobezoar, bezoar, laparoscopy, trichotillomania, rapunzel syndrome, gastric, hair ball
|How to cite this article:|
Javed A, Agarwal AK. A modified minimally invasive technique for the surgical management of large trichobezoars. J Min Access Surg 2013;9:42-4
| ¤ Introduction|| |
Trichobezoars are retained conglomeration of swallowed hairs seen most commonly in adolescent girls (90%). Many of these patients have underlying psychiatric problems and insidious onset of this condition leads to a delayed presentation. The majority of small trichobezoars are managed by endoscopic removal; however, the larger ones are best removed surgically. Conventionally these have been managed via open surgery, however, over the past decade there have been increasing reports of laparoscopic removal. The laparoscopic technique especially for the larger trichobezoars is time consuming and may result in contamination of the peritoneal cavity and the wound with hair and inspissated secretions making it a rather 'messy' affair. In addition, a 4-5 cm incision is required for the final removal of the large specimen. The present paper describes a modified laparoscopy-assisted technique with temporary gastrocutaneopexy for the effective removal of a large trichobezoar using a camera port and a 4-5 cm incision (which is similar to that needed for specimen removal during laparoscopy). There is no spillage of hair or secretions in the peritoneum and technical ease, reduced post-operative morbidity and excellent cosmetic results are additional benefits.
| ¤ Materials and Methods|| |
Patients with large trichobezoars who are not candidates of endoscopic removal are suitable for this procedure. Preoperative evaluation is done with an upper gastrointestinal endoscopy (UGIE), with or without barium meal and contrast enhanced computerised tomography (CT) scan of the abdomen. A thorough psychiatric and psychological assessment is important both prior to and after surgery.
The surgery is performed under general anaesthesia. The patient is supine and a camera is introduced through an infraumblical port and a transverse skin incision of 4-5 cm is sited in the epigastric area just over the most prominent part under its guidance. In those wherein the trichobezoar is palpable the incision may be sited directly over it [Figure 1], alternatively, the stomach may be distended by insufflating air via the nasogastric tube or an endoscope [like a percutaneous endoscopic gastrostostomy (PEG) procedure] to make it palpable and the incision sited. The skin and the abdominal wall are incised and the peritoneum opened. The anterior wall of the stomach is identified and fixed to the skin on the perimeter of the wound with seromuscular sutures [Figure 2]. This prevents the spillage of contents into the peritoneal cavity. An anterior gastrotomy is then made along the line of abdominal incision. The cast like trichobezoar is visualised, grasped and pulled out [Figure 3]a and b. The stomach is inspected from inside by inserting the laparoscope to ensure complete removal of the trichobezoar. Hemostasis is ensured and the anterior gastrotomy is then closed in two layers after releasing the seromuscular attachment to the abdominal wall. Anterior abdominal wall is closed and subcuticular sutures are applied to the skin.
|Figure 1: Incision marked at the site of bulge due to the underlying trichobezoar|
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|Figure 2: The anterior wall of the stomach is fixed to the skin on the perimeter of the wound with seromuscular sutures to prevent the spillage of contents into the peritoneal cavity|
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|Figure 3: (a) The cast like trichobezoar is visualised and is grasped using a sponge holding forceps and pulled out. (b) Retrieved trichobezoars|
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| ¤ Results|| |
Three patients with large trichobezoars were managed over a period of 1 year with the described technique. All were young girls aged 9, 14 and 15 years, respectively, and were admitted with complaints of abdominal pain. Two of the three girls denied trichophagia and even the parents were not aware of any such habit. One patient had short hairs with visible hair loss. All three patients had mobile lump in epigastrium and were diagnosed as trichobezoar on the basis of endoscopy/CT scan/barium study. The average duration of surgery was 45 min (30, 45 and 60, min respectively) and the intra-operative blood loss was minimal. There was no peritoneal spillage and the trichobezoar could be retrieved through a 4-5 cm incision in all patients. All three patients had uneventful post-operative recovery with no surgical site infection, good cosmetic scar [Figure 4] and were discharged by the 3 rd post-operative day. At a median follow-up of 6 months all patients are doing well and have excellent cosmetic and functional results.
| ¤ Discussion|| |
Trichotillomania, the irresistible desire to pull out one's own hair, was first described in 1889 by Hallopeau, and the first case of a trichobezoar was reported a century earlier by Baudamant in 1779.  By necessity, trichotillomania (compulsive urge to pull out one's own hair) and trichophagia (swallowing of hairs) are the leading events for formation of a trichobezoar and these are most commonly seen in young females. Stomach is the most common site of trichobezoar formation. The reason why the hair gets collected in the stomach is not fully understood and the process may be initiated by the entrapment of hair in the gastric rugal folds.  Due to its indigestibility, resilience and slippery nature, it becomes entrapped within the mucosal folds where it gets enmeshed, and acquires more hairs and thus a larger size. The large trichobezoars form a cast of the stomach as they grow and the mucus covering the bezoar gives it a glistening shiny surface. Decomposition and fermentation of fats in the interstices gives it a putrid smell. 
The patient who is usually a young female with an underlying psychiatric illness presents with pain in the abdomen, a lump or gastric outlet obstruction (due to a trichobezoar obstructing the pyloric outlet). The diagnosis is established via an endoscopy, upper gastrointestinal contrast study or a CT scan. In view of its large size, endoscopic retrieval is often inadequate and surgery is required for most of the cases. Traditionally the trichobezoars were removed by formal laparotomies with big abdominal incisions. With the advent of laparoscopy and its application in various surgeries, there have been reports of its use in trichobezoar removal.  Although laparoscopy results in decreased post-operative pain, early recovery and better cosmesis, spillage of hair and gastric juice during retrieval may lead to intra-abdominal and wound infection especially for large trichobezoars. In addition, a 4-5 cm laparotomy is usually required to retrieve the large specimen. In an attempt to decrease the risk of intra-peritoneal spillage and wound infection and to obviate the need for incision to deliver the trichobezoar, Dorn et al. reported a single case of laparoscopic intra-gastric removal of a trichobezoar. In this technique, three trocars were placed inside the lumen of stomach by distending the stomach by carbon dioxide and the trichobezoar was fragmented and removed piecemeal. This procedure lasted for 6 hours. Even though the intra-peritoneal spillage and risk of wound infection were decreased, need to place multiple trocars into the stomach and prolonged duration of surgery negates the benefits obtained. This patient was started orally only on 4 th post-operative day and thus the hospital stay was prolonged. The present technique incorporates the benefits of minimal invasive surgical approach, while avoiding the risk of intra-peritoneal spillage and wound infection. Incision of 4-5 cm which is used in our technique is equivalent to what is required for specimen removal after a laparoscopic procedure. ,,,, By fixing the stomach using seromuscular sutures to the perimeter of the incision any contamination of the peritoneal cavity and incision is avoided. All three of our patients were discharged on 3 rd post-operative day which is similar to or less than various laparoscopic reports. ,, The average duration of surgery in our cases was 45 min, which was significantly less than various reported laparoscopic procedures. Cosmetic results in our patients were excellent and similar to those that are achieved following laparoscopy. We thus feel that this technique is a better procedure as compared with conventional laparotomy or laparoscopy.
| ¤ References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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