Role of Laparoscopy in Gastric Trichobezoar: A Case Report and Review of Laparoscopic Techniques in Pediatric and Adolescents

DISCUSSION

Conventionally laparotomy has been used for the removal of gastric trichobezoar. Endoscopy has also been tried for removal but it has its own disadvantages like it is a time taking procedure, requiring multiple sessions and has a high failure rate. Since the advent of laparoscopy, few reports have been published in the literature about its use in gastric trichobezoar removal, the first being by Nirwasa et al. in 1998.²

The ideal approach is still not clear. The main challenge in removal of gastric trichobezoar is the usual large size of the bezoar and the associated risk of peritoneal and wound contamination. To overcome this, laparoscopic techniques have been modified by various surgeons especially the technique of extraction. A detailed search of the literature was done to understand the various laparoscopic techniques used in retrieving the gastric trichobezoar.

We reviewed the published pediatric and adolescent cases of gastric trichobezoar till 18 years of age in which laparoscopic or laparoscopic-assisted procedures were performed. The youngest child was 4-year-old who had undergone complete removal of large trichobezoar weighing 192 gm through a 12 mm port.³

A total of 23 reported cases performed by 20 surgeons were reviewed. Three procedures that were used for retrieving trichobezoar were (1) complete laparoscopic removal without extending the port incision,³,⁴ (2) laparoscopic-assisted removal /laparoscopic-assisted mini-laparotomy,²,⁵ and (3) laparoscopic- assisted gastrocutaneopexy.¹,⁶

Laparoscopic removal mainly involves the three-or four-port placements. The step used were (a) gastrotomy with or without stay sutures, (b) mobilizing the bezoar within the stomach, (c) placing the bezoar inside the endobag, (d) closure of gastrostomy by endostaplers or suturing, and (e) retrieval of the mouth of endobag through large 10 or 12 mm port and then removing the specimen piecemeal or after fragmenting it with the scissors.

Laparoscopy as compared to laparotomy definitely has the advantages of less postoperative pain, better cosmesis, and most important less risk of wound infection. It has the benefit of confirming any spillage and irrigation of the peritoneal cavity to avoid any intra-abdominal complications.³ But then it has its own disadvantages like it is a technically difficult procedure especially in a young child with limited abdominal space. The placement of trichobezoar without any spillage and peritoneal contamination inside the endobag needs hands of experienced and skilled laparoscopic surgeon.⁷ If not performed carefully, it can make the procedure messy with significant intra-abdominal contamination.

The operative time, in my view, mainly depends on the size of the bezoar, the size of the patient, and the operating skills of the surgeon. The duration of the procedure using complete laparoscopic removal varied from 2.10 hours to 3.5 hours except in a case in which intragastric ports were used which took about 6 hours.⁸ Our procedure took about 2.30 hours. The most important factor which increases the duration of the procedure is the fragmentation and removal of bezoar. Most of the bezoars including ours were more than 10 cm in size.

Kanetaka et al.⁹ described a two-channel method technique which combined gastroscopy along with laparoscopy to remove a bezoar of about 100 gm. The technique involved gastroscopic retrieval after the trichobezoar was fragmented by an intragastric laparoscope. Although minimal invasive does not seem to be a feasible option for large bezoars as it requires multiple passages of endoscope in the stomach.

Laparoscopic-assisted removal of trichobezoar has been reported in eight cases.²,⁵ The trichobezoar after placing inside the endobag was retrieved either by extending the port incision or by making a separate 3 to 5 cm incision in suprapubic (Pffenesteil incison)/left subcoastal/hypochondrium incision or midline incision. The most important benefit of this procedure is that it reduces the operative time. By increasing the length of the incision, extraction of the specimen especially the large ones becomes relatively easy. Although it defeats the purpose of minimal access surgery. Wound infection risk can be minimized with the use of endobag or a wound protector. Although the duration of surgery was not mentioned in most of the cases, we presume it to be relatively less as compared to the complete laparoscopic procedure.

Another reported procedure is laparoscopic-assisted gastrocutaneopexy used in nine cases of gastric trichobezoar.¹,⁶ This procedure involves the placement of infraumbilical port with an extended skin incision. The anterior wall of the stomach is fixed to the skin on the perimeter of the wound to prevent the spillage of contents into the peritoneal cavity. Anterior gastrotomy is made and trichobezoar is pulled out piecemeal or in fragments without causing any contamination. The gastrotomy is then closed in two layers after releasing the seromuscular attachment to the abdominal wall.¹

Javed et al.¹ who used this technique in three cases with an incision of 4 to 5 cm reported excellent outcomes with average duration of the procedure being 45 minutes. Similar technique was used by Iftikhar et al.⁶ in two cases in which a small umbilical incision of 1.5 cm was used to remove a bezoar of size more than 10 cm. Although the size of the incision was similar or even less than what has been used in laparoscopic-assisted procedures, a temporary gastrostomy minimizes the contamination and also reduces the duration of the procedure. Tudor et al.¹⁰ recommended running suture while fixing the stomach to the anterior abdominal wall along with the use of the Alexis device which provides extra protection and also prevents trauma to the gastric mucosa. This technique definitely seems to be promising as it requires no laparoscopic handling of bezoar and so the risk of peritoneal and wound contamination is minimal. The duration of surgery is less and so it is useful in cases of large bezoar.