Laparoscopic retrieval of a large gastric trichobezoar

A 16-year-old female with a background of trichotillomania presented with epigastric pain and nausea. An abdominal X-ray revealed a distended stomach with a speckled gas pattern, concerning for a bezoar, without obstruction (Figure 1). Gastroscopy demonstrated a large trichobezoar with a superficial gastric ulcer (Forrest class III). Given its size and density, chemical dissolution and endoscopic extraction were unsuitable.

View Figure 1–3.

The patient proceeded to theatre for laparoscopic-assisted removal. An anterior gastrostomy was made laparoscopically. Given the size of the specimen, a small midline laparotomy incision with Alexis O wound protector (Figure 2) was used to extract the large trichobezoar (Figure 3). The gastrotomy was closed with interrupted sutures using 2-0 Maxon. The postoperative course was uneventful. Follow-up gastroscopy at 8 weeks confirmed healing of the gastric ulcer.

Trichobezoars are rare gastric foreign bodies composed of ingested hair, occurring predominantly in young females with trichotillomania and trichotillophagia.^1,2 In some cases, there is post-pyloric extension (Rapunzel syndrome), with reported complications including obstruction, perforation and, less commonly, pancreatitis.^2,3 Because endoscopic removal is rarely successful unless the trichobezoar is small, surgical intervention remains the definitive treatment.¹

Computed tomography (CT) is useful for evaluating large trichobezoars and suspected Rapunzel syndrome. In addition to confirming the diagnosis, CT defines extension and identifies associated complications, such as perforation, obstruction and intussusception, thereby guiding management and operative planning.^2,4 Gastric mucosal ulceration due to pressure-induced ischaemia is a recognised complication of trichobezoars,^1,2 and was present in this patient.

Complete removal of the trichobezoar should be ensured by running the bowel to the ileocaecal valve, as retained fragments or satellite bezoars have been reported to migrate and precipitate distal obstruction requiring reoperation.^1,5 For large trichobezoars, conventional laparotomy remains the most reported and reliable method for en bloc removal¹ and permits systematic inspection for satellites.⁶

Pure laparoscopy offers the advantage of smaller incisions, shorter hospital admissions and reduced complications.⁷ However, for large trichobezoars, it often necessitates intragastric fragmentation with piecemeal extraction, which increases the risk of spillage and distal fragment migration with obstruction.¹

In selected patients, a laparoscopic-assisted approach may represent a pragmatic compromise by isolating the gastrotomy to the mini-laparotomy incision and utilising a wound protector to facilitate extraction of the trichobezoar and closure of the gastrotomy.⁸ This minimises intraperitoneal contamination while limiting incision length, with small series reporting uneventful recovery and favourable cosmetic results.^6,9 However, when post-pyloric extension is present (Rapunzel syndrome), most series strongly favour conventional laparotomy for complete removal.^1,10

This case demonstrates that safe en bloc removal of large trichobezoars can be achieved via a laparoscopic-assisted mini-laparotomy with wound protection, offering a practical operative strategy for surgeons faced with this rare presentation.