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Laparoscopic-assisted removal of gastric trichobezoar

Article in Journal of Pediatric Surgery Case Reports · May 2019

DOI: 10.1016/j.epsc.2019.101243

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 Journal of Pediatric Surgery Case Reports 47 (2019) 101243

Contents lists available at ScienceDirect

Journal of Pediatric Surgery Case Reports

journal homepage: www.elsevier.com/locate/epsc

Laparoscopic-assisted removal of gastric trichobezoar by a Novel Technique T

a,∗ b a a a
Iftikhar A. Jan , Ikram Shaalan , Zahid L. Saqi , Mona Al Shehi , Mokhtar A. Hassan
a
Department of Pediatric Surgery, Mafraq Hospital, United Arab Emirates
b
Department of General Pediatrics, Mafraq Hospital, United Arab Emirates

A B S T R A C T

Trichobezoar are mass of hair in the digestive tract caused by ingestion of hairs (trichophagia) mostly as a result of psychiatric disorders. The management of
Trichobezoar includes psychiatric treatment to stop trichophagia and removal of trichobezoar for the GIT.
Several techniques have been used for removal of Trichobezoar from the gut including endoscopy, laparotomy and laparoscopy. Laparoscopic retrieval is asso-
ciated with minimal trauma and early recovery. The conventional laparoscopic removal of whole mass of hairs using endobag is associated with contamination of
abdominal cavity, larger scars and possible infection. We suggest a simple laparoscopic assisted technique of Trichobezoar removal. In this technique two ports are
used one umbilical port and one right abdomen port. The stomach is visualized with the right port used as camera port. Using umbilical port stomach is grasped in an
avascular area and pulled out through the umbilicus. The umbilical incision is about 1.5 cm. The stomach is opened along the greater curvature away from the
marginal vessels and temporary sutured to umbilical wound. Two langenbeck retractors are used to open the wound A strong grasper is then used to remove the hairs
from the stomach piecemeally undirect vision. Any residual hairs are removed by direct visualization of the stomach lumen by the laparoscope. It is possible to
retrieve the whole mass by this technique leaving minimal scarring and early recovery.
We are reporting this technique in two patient with excellent recovery and minimal scarring.

1. Introduction 2. Cases report

Trichobezoar are mass of hairs in the stomach and may extend to A 10 years old previously healthy girl presented to the pediatric
the small intestine (Rapunzel Syndrome). Most trichobezoars are re- surgery clinic with complain of abdominal pain and distention for 4
ported in females and are often associated with psychiatric issues [1]. months. Mother noticed that her child is losing her scalp hairs and
Presence of trichobezoars can cause complications including gastric developed a habit of pulling hairs (trichotillomania). Child living with
perforation, peritonitis, protein-losing enteropathy, steatorrhea, ob- her divorced mother with complicated family issues. Moreover, she was
structive jaundice and appendicitis [1]. Psychiatric treatment is re- facing verbal abuse form her colleagues at school with a history of
quired before surgical removal of trichobezoars. changing her school twice recently. On examination, she had abdom-
Surgical management of trichobezoars depend on the type and size inal distention with a palpable firm mass in the epigastrium. Hair loss
of Bezoar and available facilities. Various methods have been used for was obvious in the right temporal area. All other examinations were
removal of trichobezoars including endoscopy, laparoscopy and lapar- normal. Initial lab investigations were normal. US & CT abdomen
otomy [2,3]. Non-operative techniques have also been tried with me- showed distended stomach and duodenum and a large echogenic mass
chanical electrohydraulic and chemical dissolution with less success with acoustic shadow in mid abdomen suggestive of 12 × 10 cm gastric
[4]. Trichobezoar.
The conventional laparoscopic removal of whole mass of hairs is The second child was 5 years old with a similar history and a
associated with contamination of abdominal cavity, larger scars and 15 × 12 trichobezoar in stomach (Fig. 1). The children were initially
possible infection. We shall present a novel technique of retrieval of referred for Psychological assessment and management. Then Laparo-
trichobezoars in two cases through a laparoscopic assisted temporary scopic assisted retrieval of Trichobezoar was planned.
umbilical gastric fixation and piecemeal removal of Trichobezoar. We
call it “Iftikhar Jan” Technique of Trichobezoars Removal. By this 3. Technique
technique, the contamination of the abdominal cavity is avoided and
large Trichobezoar can be retrieved with minimal scarring 4,5. Under GA the children was placed in supine position. In the first
child we used a supraumbilical incision and in second we used infra

∗
Corresponding author.
E-mail address: iftikarjan@gmail.com (I.A. Jan).

https://doi.org/10.1016/j.epsc.2019.101243
Received 13 May 2019; Received in revised form 27 May 2019; Accepted 28 May 2019
Available online 29 May 2019
2213-5766/ © 2019 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
I.A. Jan, et al. Journal of Pediatric Surgery Case Reports 47 (2019) 101243

Fig. 1. CT Abdomen showing a large trichobezoar.

Fig. 3. Grasping the stomach through Umbilical wound.

Fig. 4. Creation of temporary umbilical gastrostomy.

Fig. 2. Incisions for two ports (in red). Trichobezoar outlined by interrupted
lines. (For interpretation of the references to colour in this figure legend, the
reader is referred to the Web version of this article.) abdomen and wound closure by polyglycolate sutures (Fig. 6). In the
post op period, one child developed some superficial wound infection
but healed spontaneously. Feeding was started on the 2nd postop days
umbilical incision and a 5 mm port inserted (Fig. 2). Another 5 mm port
and both children remained well and were later discharged in stable
was inserted on right side of the abdomen. The camera was then moved
condition. At 6 months follow up both children were well with no signs
to the right side port. Stomach was grasped using umbilical port
of recurrence.
(Fig. 3). The umbilical incision was extended to about 1.5 cm, Stomach
was opened along the greater curvature away from the marginal vessels
between two stay sutures and then sutured securely to the margins of 4. Discussion
umbilical wound (Fig. 4). The camera was passed through the tem-
porary gastrostomy and Trichobezoar location was confirmed. Two Trichobezoars forms a large entangled mass of hairs in the stomach
small Lagenbeck retractors were used to make space for removal of and intestine usually secondary to psychological condition. Psychiatric
trichobezoars in pieces. Using Kocher's forceps the mass of hair was treatment is a must before removal of trichobezoars to prevent recur-
broken and piecemealy removed (Fig. 5). Badly entangled hairs needed rence. The standard surgical procedure for removal of trichobezoar is
cutting with the scissors. It took about 90 min to remove the whole laparotomy, opening of stomach and removing the mass of
mass of hairs. Any residual hairs were removed with direct visualization Trichobezoar. It however requires a large surgical incision, a big
of the stomach with the camera through the temporary gastrostomy. opening in stomach, increased risk of complications, long hospital stay
The stomach was washed, Gastrostomy closed, reduced back in the and a bad scar on the abdomen. In 1998, the first laparoscopic assisted

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I.A. Jan, et al. Journal of Pediatric Surgery Case Reports 47 (2019) 101243

Fig. 5. Retrieval of trichobezoars in pieces through temporary umbilical gas- Fig. 7. Cosmetic appearance after Surgery.
trostomy.

endoscope are present. Endoscopic removal of trichobezoars has been

removal of gastric bezoar was reported by Nirasawa [5]. He removed successful in few cases with small size trichobezoars however it is a
the mass after laparoscopic mobilization & through a suprapubic la- useful technique for phytobezoars with high success rate [8].
parotomy. Many successful laparoscopic cases were reported after that Various innovative techniques have been described for laparoscopic
[6,7]. The advantages of laparoscopic assisted removal of trichobezoars removal of trichobezoars. The classical approach is laparoscopy using
are less postoperative complication, reduced hospital stay and excellent several ports, opening the stomach, retrieval of trichobezoars using an
cosmetic results. On the other hand, long operation time, risk of spillage endobag through a large abdominal or umbilical incision. The risk of
and contamination are the major disadvantage of using laparoscopy peritoneal contamination and complexity of the procedures make it a
[7,8]. For that reason endoscopic removal of gastric bezoars have also less favorable approach. Other techniques have also been successful in
been attempted and is successful in small bezoars especially phytobe- individual cases. Tormod Lund et al. described as small midline upper
zoars [2,3]. The issue with endoscopic removal is that the mass has to abdominal laparotomy aided by an Alexis wound retractor, break up
be broken and then removed by multiple passes of endoscope some- and remove the trichobezoar [9]. The procedure however left a midline
times up to 25 times through the esophagus. There is no scar on ab- scar on the abdomen. Tudor ECC & Clark MC published a similar
domen but potential complications of multiple times passage of technique [10]. Javed A & Amit AK reported a similar technique by

Fig. 6. Removed mass of entangled hairs.

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I.A. Jan, et al. Journal of Pediatric Surgery Case Reports 47 (2019) 101243

fixing the stomach to a midline laparotomy and thus avoided the ab- 5. Conclusion
dominal contamination [11]. There were other similar approaches.
Jason DF et reported a cases where they opened the stomach using an Laparoscopic assisted removal of trichobezoars by “Iftikhar Jan”
umbilical approach and secured with external sutures for avoiding technique is a safe and feasible procedure for removal of large tricho-
contamination of the abdominal cavity [12]. bezoars with minimal complications and can be performed in pediatric
We have removed trichobezoar with a novel technique which helps patients safely with excellent outcome.
in complete isolation of the peritoneal cavity, complete removal of
trichobezar, small gastric incision, minimal risk of other bowel injury, Declaration
minimal scarring and early recovery. To remove the trichobezoar we
used two 5 mm ports only. One umbilical 5 mm port and one right None.
abdominal port. The camera was swapped to the right abdominal port
and umbilical incision was enlarged to 1.5 cm. The stomach was de- References
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