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Laparoscopic-assisted removal of gastric trichobezoar by a Novel Technique
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 a,∗
b
a
a
Iftikhar A. Jan , Ikram Shaalan , Zahid L. Saqi , Mona Al Shehi , Mokhtar A. Hassan a b
T
a
Department of Pediatric Surgery, Mafraq Hospital, United Arab Emirates 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 associated 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 the small intestine (Rapunzel Syndrome). Most trichobezoars are reported in females and are often associated with psychiatric issues [1]. Presence of trichobezoars can cause complications including gastric perforation, peritonitis, protein-losing enteropathy, steatorrhea, obstructive jaundice and appendicitis [1]. Psychiatric treatment is required before surgical removal of trichobezoars. Surgical management of trichobezoars depend on the type and size of Bezoar and available facilities. Various methods have been used for removal of trichobezoars including endoscopy, laparoscopy and laparotomy [2,3]. Non-operative techniques have also been tried with mechanical electrohydraulic and chemical dissolution with less success [4]. The conventional laparoscopic removal of whole mass of hairs is associated with contamination of abdominal cavity, larger scars and possible infection. We shall present a novel technique of retrieval of trichobezoars in two cases through a laparoscopic assisted temporary umbilical gastric fixation and piecemeal removal of Trichobezoar. We call it “Iftikhar Jan” Technique of Trichobezoars Removal. By this technique, the contamination of the abdominal cavity is avoided and large Trichobezoar can be retrieved with minimal scarring 4,5.
A 10 years old previously healthy girl presented to the pediatric surgery clinic with complain of abdominal pain and distention for 4 months. Mother noticed that her child is losing her scalp hairs and developed a habit of pulling hairs (trichotillomania). Child living with her divorced mother with complicated family issues. Moreover, she was facing verbal abuse form her colleagues at school with a history of changing her school twice recently. On examination, she had abdominal distention with a palpable firm mass in the epigastrium. Hair loss was obvious in the right temporal area. All other examinations were normal. Initial lab investigations were normal. US & CT abdomen showed distended stomach and duodenum and a large echogenic mass with acoustic shadow in mid abdomen suggestive of 12 × 10 cm gastric Trichobezoar. The second child was 5 years old with a similar history and a 15 × 12 trichobezoar in stomach (Fig. 1). The children were initially referred for Psychological assessment and management. Then Laparoscopic assisted retrieval of Trichobezoar was planned.
∗
3. Technique 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: [email protected] (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/).
Journal of Pediatric Surgery Case Reports 47 (2019) 101243
I.A. Jan, et al.
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 and both children remained well and were later discharged in stable condition. At 6 months follow up both children were well with no signs of recurrence.
umbilical incision and a 5 mm port inserted (Fig. 2). Another 5 mm port was inserted on right side of the abdomen. The camera was then moved to the right side port. Stomach was grasped using umbilical port (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 umbilical wound (Fig. 4). The camera was passed through the temporary gastrostomy and Trichobezoar location was confirmed. Two small Lagenbeck retractors were used to make space for removal of trichobezoars in pieces. Using Kocher's forceps the mass of hair was broken and piecemealy removed (Fig. 5). Badly entangled hairs needed cutting with the scissors. It took about 90 min to remove the whole mass of hairs. Any residual hairs were removed with direct visualization of the stomach with the camera through the temporary gastrostomy. The stomach was washed, Gastrostomy closed, reduced back in the
4. Discussion Trichobezoars forms a large entangled mass of hairs in the stomach and intestine usually secondary to psychological condition. Psychiatric treatment is a must before removal of trichobezoars to prevent recurrence. The standard surgical procedure for removal of trichobezoar is laparotomy, opening of stomach and removing the mass of Trichobezoar. It however requires a large surgical incision, a big opening in stomach, increased risk of complications, long hospital stay and a bad scar on the abdomen. In 1998, the first laparoscopic assisted 2
Journal of Pediatric Surgery Case Reports 47 (2019) 101243
I.A. Jan, et al.
Fig. 7. Cosmetic appearance after Surgery.
Fig. 5. Retrieval of trichobezoars in pieces through temporary umbilical gastrostomy.
endoscope are present. Endoscopic removal of trichobezoars has been successful in few cases with small size trichobezoars however it is a useful technique for phytobezoars with high success rate [8]. Various innovative techniques have been described for laparoscopic removal of trichobezoars. The classical approach is laparoscopy using several ports, opening the stomach, retrieval of trichobezoars using an endobag through a large abdominal or umbilical incision. The risk of peritoneal contamination and complexity of the procedures make it a less favorable approach. Other techniques have also been successful in individual cases. Tormod Lund et al. described as small midline upper abdominal laparotomy aided by an Alexis wound retractor, break up and remove the trichobezoar [9]. The procedure however left a midline scar on the abdomen. Tudor ECC & Clark MC published a similar technique [10]. Javed A & Amit AK reported a similar technique by
removal of gastric bezoar was reported by Nirasawa [5]. He removed the mass after laparoscopic mobilization & through a suprapubic laparotomy. Many successful laparoscopic cases were reported after that [6,7]. The advantages of laparoscopic assisted removal of trichobezoars are less postoperative complication, reduced hospital stay and excellent cosmetic results. On the other hand, long operation time, risk of spillage and contamination are the major disadvantage of using laparoscopy [7,8]. For that reason endoscopic removal of gastric bezoars have also been attempted and is successful in small bezoars especially phytobezoars [2,3]. The issue with endoscopic removal is that the mass has to be broken and then removed by multiple passes of endoscope sometimes up to 25 times through the esophagus. There is no scar on abdomen but potential complications of multiple times passage of
Fig. 6. Removed mass of entangled hairs. 3
Journal of Pediatric Surgery Case Reports 47 (2019) 101243
I.A. Jan, et al.
fixing the stomach to a midline laparotomy and thus avoided the abdominal contamination [11]. There were other similar approaches. Jason DF et reported a cases where they opened the stomach using an umbilical approach and secured with external sutures for avoiding contamination of the abdominal cavity [12]. We have removed trichobezoar with a novel technique which helps in complete isolation of the peritoneal cavity, complete removal of trichobezar, small gastric incision, minimal risk of other bowel injury, minimal scarring and early recovery. To remove the trichobezoar we used two 5 mm ports only. One umbilical 5 mm port and one right abdominal port. The camera was swapped to the right abdominal port and umbilical incision was enlarged to 1.5 cm. The stomach was delivered along the avascular plane through umbilical port, 1.5 cm gastrostomy performed and stomach and margins were sutured to port wound creating a temporary gastrostomy. Under direct vision with the camera through the temporary gastrostomy, Trichobezoar was removed piecemealy and removed completely without spillage in peritoneal cavity. Later gastrostomy was closed and umbilical port wound was closed with cosmetically invisible scar at umbilicus. Although umbilical wound in one case developed superficial infection but still after wound healing there was no obvious scar. Right camera port site was only 5 mm and healed nicely. The procedure does need patience and piecemeal removal of hairs. Smelly contents may be an issue but taking in to the consideration cosmetic and surgical out come this is a small price for an excellent outcome. Regarding the operative time it may be equal or slightly higher than the other reported techniques. The time used in our second patient was less due to more clarity of the operative technique and it will be reduced further as we get more experience in using this technique of trichobezoars removal. The approach provides a virtually scar less removal of trichobezoars and we expect with more experience the duration of surgery shall be comparable to other techniques.
5. Conclusion Laparoscopic assisted removal of trichobezoars by “Iftikhar Jan” technique is a safe and feasible procedure for removal of large trichobezoars with minimal complications and can be performed in pediatric patients safely with excellent outcome. Declaration None. References [1] Al-Osail EM, Zakary NY, Abdelhadi Y. Best management modality of trichobezoar: a case report. Int Surg Case Rep. 2018;53:458–60. [2] Benatta MA. Endoscopic retrieval of gastric trichobezoar after fragmentation with electrocautery using polypectomy snare and argon plasma coagulation in a pediatric patient. Gastroenterol Rep (Oxf). 2016 Aug;4(3):251–3. [3] Wang YG, Seitz U, Li ZL, Soehendra N, Qiao XA. Endoscopic management of huge bezoars. Endoscopy 1998 May;30(4):371–4. [4] Ogawa K, Kamimura K, Mizuno K, Shinagawa Y, et al. The combination therapy of dissolution using carbonated liquid and endoscopic procedure for bezoars: pragmatical and clinical review. Gastroenterol Res Pract 2016;2016:7456242. [5] Nirasawa Y, Mori T, Ito Y, Tanaka H, Seki N, Atomi Y. Laparoscopic removal of a large gastric trichobezoar. J Pediatr Surg 1998 Apr;33(4):663–5. [6] Ulukent SC, Ozgun YM, Şahbaz NA. A modified technique for the laparoscopic management of large gastric bezoars. Saudi Med J 2016 Sep;37(9):1022–4. [7] Vepakomma D, Alladi A. Complete laparoscopic removal of a gastric trichobezoar. J Minimal Access Surg 2014 Jul;10(3):154–6. [8] Wang YG, Seitz U, Li ZL, Soehendra N, Qiao XA. Endoscopic management of huge bezoars. Endoscopy 1998 May;30(4):371–4. [9] Lund Tormod, Wexels Fredrik, Helander Ronny. Surgical considerations of the gastric trichobezoar. A case report. J Ped Surg Case Rep 2014;2:403. [10] Tudor EC, Clark MC. Laparoscopic-assisted removal of gastric trichobezoar; a novel technique to reduce operative complications and time. J Pediatr Surg 2013 Mar;48(3):13–5. [11] Javed A, Agarwal AK. A modified minimally invasive technique for the surgical management of large trichobezoars. J Minimal Access Surg 2013 Jan;9(1):42–4. [12] Fraser JD, Leys CM, St Peter SD. Laparoscopic removal of a gastric trichobezoar in a pediatric patient. J Laparoendosc Adv Surg Tech A 2009 Dec;19(6):835–7.
4
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 a,∗
b
a
a
Iftikhar A. Jan , Ikram Shaalan , Zahid L. Saqi , Mona Al Shehi , Mokhtar A. Hassan a b
T
a
Department of Pediatric Surgery, Mafraq Hospital, United Arab Emirates 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 associated 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 the small intestine (Rapunzel Syndrome). Most trichobezoars are reported in females and are often associated with psychiatric issues [1]. Presence of trichobezoars can cause complications including gastric perforation, peritonitis, protein-losing enteropathy, steatorrhea, obstructive jaundice and appendicitis [1]. Psychiatric treatment is required before surgical removal of trichobezoars. Surgical management of trichobezoars depend on the type and size of Bezoar and available facilities. Various methods have been used for removal of trichobezoars including endoscopy, laparoscopy and laparotomy [2,3]. Non-operative techniques have also been tried with mechanical electrohydraulic and chemical dissolution with less success [4]. The conventional laparoscopic removal of whole mass of hairs is associated with contamination of abdominal cavity, larger scars and possible infection. We shall present a novel technique of retrieval of trichobezoars in two cases through a laparoscopic assisted temporary umbilical gastric fixation and piecemeal removal of Trichobezoar. We call it “Iftikhar Jan” Technique of Trichobezoars Removal. By this technique, the contamination of the abdominal cavity is avoided and large Trichobezoar can be retrieved with minimal scarring 4,5.
A 10 years old previously healthy girl presented to the pediatric surgery clinic with complain of abdominal pain and distention for 4 months. Mother noticed that her child is losing her scalp hairs and developed a habit of pulling hairs (trichotillomania). Child living with her divorced mother with complicated family issues. Moreover, she was facing verbal abuse form her colleagues at school with a history of changing her school twice recently. On examination, she had abdominal distention with a palpable firm mass in the epigastrium. Hair loss was obvious in the right temporal area. All other examinations were normal. Initial lab investigations were normal. US & CT abdomen showed distended stomach and duodenum and a large echogenic mass with acoustic shadow in mid abdomen suggestive of 12 × 10 cm gastric Trichobezoar. The second child was 5 years old with a similar history and a 15 × 12 trichobezoar in stomach (Fig. 1). The children were initially referred for Psychological assessment and management. Then Laparoscopic assisted retrieval of Trichobezoar was planned.
∗
3. Technique 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: [email protected] (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/).
Journal of Pediatric Surgery Case Reports 47 (2019) 101243
I.A. Jan, et al.
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 and both children remained well and were later discharged in stable condition. At 6 months follow up both children were well with no signs of recurrence.
umbilical incision and a 5 mm port inserted (Fig. 2). Another 5 mm port was inserted on right side of the abdomen. The camera was then moved to the right side port. Stomach was grasped using umbilical port (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 umbilical wound (Fig. 4). The camera was passed through the temporary gastrostomy and Trichobezoar location was confirmed. Two small Lagenbeck retractors were used to make space for removal of trichobezoars in pieces. Using Kocher's forceps the mass of hair was broken and piecemealy removed (Fig. 5). Badly entangled hairs needed cutting with the scissors. It took about 90 min to remove the whole mass of hairs. Any residual hairs were removed with direct visualization of the stomach with the camera through the temporary gastrostomy. The stomach was washed, Gastrostomy closed, reduced back in the
4. Discussion Trichobezoars forms a large entangled mass of hairs in the stomach and intestine usually secondary to psychological condition. Psychiatric treatment is a must before removal of trichobezoars to prevent recurrence. The standard surgical procedure for removal of trichobezoar is laparotomy, opening of stomach and removing the mass of Trichobezoar. It however requires a large surgical incision, a big opening in stomach, increased risk of complications, long hospital stay and a bad scar on the abdomen. In 1998, the first laparoscopic assisted 2
Journal of Pediatric Surgery Case Reports 47 (2019) 101243
I.A. Jan, et al.
Fig. 7. Cosmetic appearance after Surgery.
Fig. 5. Retrieval of trichobezoars in pieces through temporary umbilical gastrostomy.
endoscope are present. Endoscopic removal of trichobezoars has been successful in few cases with small size trichobezoars however it is a useful technique for phytobezoars with high success rate [8]. Various innovative techniques have been described for laparoscopic removal of trichobezoars. The classical approach is laparoscopy using several ports, opening the stomach, retrieval of trichobezoars using an endobag through a large abdominal or umbilical incision. The risk of peritoneal contamination and complexity of the procedures make it a less favorable approach. Other techniques have also been successful in individual cases. Tormod Lund et al. described as small midline upper abdominal laparotomy aided by an Alexis wound retractor, break up and remove the trichobezoar [9]. The procedure however left a midline scar on the abdomen. Tudor ECC & Clark MC published a similar technique [10]. Javed A & Amit AK reported a similar technique by
removal of gastric bezoar was reported by Nirasawa [5]. He removed the mass after laparoscopic mobilization & through a suprapubic laparotomy. Many successful laparoscopic cases were reported after that [6,7]. The advantages of laparoscopic assisted removal of trichobezoars are less postoperative complication, reduced hospital stay and excellent cosmetic results. On the other hand, long operation time, risk of spillage and contamination are the major disadvantage of using laparoscopy [7,8]. For that reason endoscopic removal of gastric bezoars have also been attempted and is successful in small bezoars especially phytobezoars [2,3]. The issue with endoscopic removal is that the mass has to be broken and then removed by multiple passes of endoscope sometimes up to 25 times through the esophagus. There is no scar on abdomen but potential complications of multiple times passage of
Fig. 6. Removed mass of entangled hairs. 3
Journal of Pediatric Surgery Case Reports 47 (2019) 101243
I.A. Jan, et al.
fixing the stomach to a midline laparotomy and thus avoided the abdominal contamination [11]. There were other similar approaches. Jason DF et reported a cases where they opened the stomach using an umbilical approach and secured with external sutures for avoiding contamination of the abdominal cavity [12]. We have removed trichobezoar with a novel technique which helps in complete isolation of the peritoneal cavity, complete removal of trichobezar, small gastric incision, minimal risk of other bowel injury, minimal scarring and early recovery. To remove the trichobezoar we used two 5 mm ports only. One umbilical 5 mm port and one right abdominal port. The camera was swapped to the right abdominal port and umbilical incision was enlarged to 1.5 cm. The stomach was delivered along the avascular plane through umbilical port, 1.5 cm gastrostomy performed and stomach and margins were sutured to port wound creating a temporary gastrostomy. Under direct vision with the camera through the temporary gastrostomy, Trichobezoar was removed piecemealy and removed completely without spillage in peritoneal cavity. Later gastrostomy was closed and umbilical port wound was closed with cosmetically invisible scar at umbilicus. Although umbilical wound in one case developed superficial infection but still after wound healing there was no obvious scar. Right camera port site was only 5 mm and healed nicely. The procedure does need patience and piecemeal removal of hairs. Smelly contents may be an issue but taking in to the consideration cosmetic and surgical out come this is a small price for an excellent outcome. Regarding the operative time it may be equal or slightly higher than the other reported techniques. The time used in our second patient was less due to more clarity of the operative technique and it will be reduced further as we get more experience in using this technique of trichobezoars removal. The approach provides a virtually scar less removal of trichobezoars and we expect with more experience the duration of surgery shall be comparable to other techniques.
5. Conclusion Laparoscopic assisted removal of trichobezoars by “Iftikhar Jan” technique is a safe and feasible procedure for removal of large trichobezoars with minimal complications and can be performed in pediatric patients safely with excellent outcome. Declaration None. References [1] Al-Osail EM, Zakary NY, Abdelhadi Y. Best management modality of trichobezoar: a case report. Int Surg Case Rep. 2018;53:458–60. [2] Benatta MA. Endoscopic retrieval of gastric trichobezoar after fragmentation with electrocautery using polypectomy snare and argon plasma coagulation in a pediatric patient. Gastroenterol Rep (Oxf). 2016 Aug;4(3):251–3. [3] Wang YG, Seitz U, Li ZL, Soehendra N, Qiao XA. Endoscopic management of huge bezoars. Endoscopy 1998 May;30(4):371–4. [4] Ogawa K, Kamimura K, Mizuno K, Shinagawa Y, et al. The combination therapy of dissolution using carbonated liquid and endoscopic procedure for bezoars: pragmatical and clinical review. Gastroenterol Res Pract 2016;2016:7456242. [5] Nirasawa Y, Mori T, Ito Y, Tanaka H, Seki N, Atomi Y. Laparoscopic removal of a large gastric trichobezoar. J Pediatr Surg 1998 Apr;33(4):663–5. [6] Ulukent SC, Ozgun YM, Şahbaz NA. A modified technique for the laparoscopic management of large gastric bezoars. Saudi Med J 2016 Sep;37(9):1022–4. [7] Vepakomma D, Alladi A. Complete laparoscopic removal of a gastric trichobezoar. J Minimal Access Surg 2014 Jul;10(3):154–6. [8] Wang YG, Seitz U, Li ZL, Soehendra N, Qiao XA. Endoscopic management of huge bezoars. Endoscopy 1998 May;30(4):371–4. [9] Lund Tormod, Wexels Fredrik, Helander Ronny. Surgical considerations of the gastric trichobezoar. A case report. J Ped Surg Case Rep 2014;2:403. [10] Tudor EC, Clark MC. Laparoscopic-assisted removal of gastric trichobezoar; a novel technique to reduce operative complications and time. J Pediatr Surg 2013 Mar;48(3):13–5. [11] Javed A, Agarwal AK. A modified minimally invasive technique for the surgical management of large trichobezoars. J Minimal Access Surg 2013 Jan;9(1):42–4. [12] Fraser JD, Leys CM, St Peter SD. Laparoscopic removal of a gastric trichobezoar in a pediatric patient. J Laparoendosc Adv Surg Tech A 2009 Dec;19(6):835–7.
4