Minilaparotomy Removal of Giant Gastric Trichobezoar in a Female Teenager

Alexander M. Shulutko, MD, PhD, DrHab; Vadim G. Agadzhanov, MD, PhD; Airazat M. Kazaryan, MD, PhD


September 23, 2008

While small gastric trichobezoars may be removed via gastroscopy, large trichobezoars require surgical removal by gastrotomy through abdominal incision. We present a case of a successful minilaparotomy removal of a giant (2500-g) gastric trichobezoar in a 15-year-old girl with marginal psychological disturbances.

This is a case of a 15-year-old girl who was admitted to the surgical department with complaints epigastric pain, nausea, and weight loss. We did not observe any electrolyte abnormalities, and the rest of the blood values were normal. The patient did not appear cachectic but was generally thin. She did not have a fever.

The patient had no other somatic complaints. Plain radiographs of the thorax and abdomen did not reveal any abnormalities. The upper edge of the trichobezoar was noted during outpatient endoscopy. The size of the mass precluded endoscopic removal. Thus, the patient was referred for surgical consultation.

A minilaparotomy approach was chosen (with assistance of a special surgical tool kit of the series "Mini-assistant," Liga - 7, Ekaterinburg, Russia) in light of the importance of a good cosmetic outcome for a young girl. We used a modification of the minilaparotomy technique[1,2,3,4] first reported by Prudkov and colleagues.[3,4] A 5-cm skin incision was made in the projection of the body of stomach (Figure 1). After gastrotomy (Figure 2), the bezoar (40 х 30 х 20 сm3 and 2.5 kg) was removed (Figures 3 and 4). The gastric mucosa had moderate erosive and ulcerous lesions. Surgical time was 60 minutes; blood loss was less than 50 mL.

Skin incision.


Trichobezoar removal.

Removed specimen.

During the postoperative period, the patient received antiulcer medication. She developed moderate postoperative diarrhea corresponding to disbacteriosis triggered by a rapid change in gastrointestinal flora. She received Linex capsules (consisting of 1.2 х 107 bacteria Lactobacillus acidophilus, Bifidobacterium infantis, Streptococcus faecium, 3 times/d for 3 wk) to treat the diarrhea.

Through a conversation with the patient's parents, it was discovered that she was an excellent student and led a normal, healthy lifestyle. However, she had developed a habit of playing with and swallowing her hair. The parents were not sufficiently attentive to this unusual behavior.

As part of her treatment, the patient received a short haircut that minimized the opportunity to play with and swallow her hair. She also received a course of psychotherapeutic treatment. A follow-up endoscopy in 6 months did not reveal any abnormalities. The patient was followed up at 35 months and has not exhibited any evidence of mental or physical difficulties; she has also gained 20 kg.

Trichobezoars are concretions of swallowed hair in the digestive tract. This condition is more common in women, especially adolescent girls.[5,6,7] Trichobezoars are associated with trichophagia (compulsive eating of hair) as a result of pica -- an eating disorder manifested by an appetite for nonnutritive substances and often associated with mental retardation -- and coexistent psychiatric disturbances.[6] The insidious development of the trichophytobezoar accounts for the delayed presentation and large size at the time of diagnosis.

Although the prevalence of bezoars in humans is low, they may be associated with a high risk for mortality, mainly through gastrointestinal bleeding, obstruction, and perforation.[8,9,10,11,12,13]

While medical approaches are useful for the treatment of phytobezoars (eg, therapy using gastric motility-promoting agents and enzymes), trichobezoars require either endoscopic or surgical removal.[14,15] The endoscopic approach has been most commonly used[16,17] since first being described by McKechnie in 1972.[18] Nevertheless, treatment failure or large bezoars require surgical treatment.

In the past, surgical removal by gastrotomy through abdominal incision was the treatment of choice.[8,9,10,11,12,13,19,20,21,22] However, development of minimally invasive surgical techniques has made it possible to remove trichobezoars without large abdominal incisions. Laparoscopic and minilaparotomy approaches are widely recognized minimally invasive operations, with laparoscopy being the preferred procedure because of its decreased invasiveness.[23]

Laparoscopic treatment of bezoars was first reported by Nirasawa and coworkers in 1998.[24] A few surgeons subsequently reported laparoscopic removal of bezoars through use of slightly different techniques.[25,26] Laparoscopy is associated with less postoperative pain, faster recovery, reduced rate of wound complications, and very good cosmetic results.

In cases of giant trichobezoars, the laparoscopic approach could be problematic. We believe that minilaparotomy is a better option than traditional laparotomy in such cases, especially for young girls because of the improved cosmetic results.

Minilaparotomy could also be an alternative to laparoscopy in cases of moderately large trichobezoars in hospitals with moderate experience in advanced laparoscopic surgery.

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