Page 58 - World Journal of Laparoscopic Surgery

Role of Laparoscopy in Gastric Trichobezoar

Figs. 2A and B: Trichobezoar specimen retrieved through umbilical port

The postoperative course was uneventful. She was started on most important less risk of wound infection. It has the benefit of
liquid diet on the first postoperative day and was discharged on confirming any spillage and irrigation of the peritoneal cavity to
3
third postoperative day after psychiatric consultation. avoid any intra-abdominal complications. 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
dIscussIon trichobezoar without any spillage and peritoneal contamination
Conventionally laparotomy has been used for the removal of gastric inside the endobag needs hands of experienced and skilled
7
trichobezoar. Endoscopy has also been tried for removal but it has laparoscopic surgeon. If not performed carefully, it can make the
its own disadvantages like it is a time taking procedure, requiring procedure messy with significant intra-abdominal contamination.
multiple sessions and has a high failure rate. Since the advent of The operative time, in my view, mainly depends on the size
laparoscopy, few reports have been published in the literature of the bezoar, the size of the patient, and the operating skills
about its use in gastric trichobezoar removal, the first being by of the surgeon. The duration of the procedure using complete
Nirwasa et al. in 1998. 2 laparoscopic removal varied from 2.10 hours to 3.5 hours except
The ideal approach is still not clear. The main challenge in in a case in which intragastric ports were used which took
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removal of gastric trichobezoar is the usual large size of the bezoar about 6 hours. Our procedure took about 2.30 hours. The most
and the associated risk of peritoneal and wound contamination. important factor which increases the duration of the procedure
To overcome this, laparoscopic techniques have been modified is the fragmentation and removal of bezoar. Most of the bezoars
by various surgeons especially the technique of extraction. A including ours were more than 10 cm in size.
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detailed search of the literature was done to understand the various Kanetaka et al. described a two-channel method technique
laparoscopic techniques used in retrieving the gastric trichobezoar. which combined gastroscopy along with laparoscopy to remove
We reviewed the published pediatric and adolescent cases of a bezoar of about 100 gm. The technique involved gastroscopic
gastric trichobezoar till 18 years of age in which laparoscopic or retrieval after the trichobezoar was fragmented by an intragastric
laparoscopic-assisted procedures were performed. The youngest laparoscope. Although minimal invasive does not seem to be a
child was 4-year-old who had undergone complete removal of large feasible option for large bezoars as it requires multiple passages
trichobezoar weighing 192 gm through a 12 mm port. 3 of endoscope in the stomach.
A total of 23 reported cases performed by 20 surgeons Laparoscopic-assisted removal of trichobezoar has been
2,5
were reviewed. Three procedures that were used for retrieving reported in eight cases. The trichobezoar after placing inside
trichobezoar were (1) complete laparoscopic removal without the endobag was retrieved either by extending the port incision or
3,4
extending the port incision, (2) laparoscopic-assisted removal by making a separate 3 to 5 cm incision in suprapubic (Pffenesteil
2,5
/laparoscopic-assisted mini-laparotomy, and (3) laparoscopic- incison)/left subcoastal/hypochondrium incision or midline incision.
assisted gastrocutaneopexy. 1,6 The most important benefit of this procedure is that it reduces the
Laparoscopic removal mainly involves the three-or four-port operative time. By increasing the length of the incision, extraction
placements. The step used were (a) gastrotomy with or without stay of the specimen especially the large ones becomes relatively easy.
sutures, (b) mobilizing the bezoar within the stomach, (c) placing Although it defeats the purpose of minimal access surgery. Wound
the bezoar inside the endobag, (d) closure of gastrostomy by infection risk can be minimized with the use of endobag or a wound
endostaplers or suturing, and (e) retrieval of the mouth of endobag protector. Although the duration of surgery was not mentioned in
through large 10 or 12 mm port and then removing the specimen most of the cases, we presume it to be relatively less as compared
piecemeal or after fragmenting it with the scissors. to the complete laparoscopic procedure.
Laparoscopy as compared to laparotomy definitely has the Another reported procedure is laparoscopic-assisted
1,6
advantages of less postoperative pain, better cosmesis, and gastrocutaneopexy used in nine cases of gastric trichobezoar.

World Journal of Laparoscopic Surgery, Volume 14 Issue 1 (January–April 2021) 59