Laparoscopic management of Giant gastric Trichobezoar: Rapunzel syndrome.

Luciano Poggi, MD1, Felix Camacho, MD2, Omar Ibarra, MD2, Gerardo Arredondo, MD2, Margarita Villanueva, MD2, Luis Poggi, MD2. 1Oklahoma University Hospital, 2Clinica Anglo Americana

INTRODUCTION: Rapunzel syndrome is defined as a gastric trichobezoar with a tail that extends distally into the small intestine. It is a rare syndrome associated with psychiatric disease. We report a case of a giant gastric trichobezoar managed laparoscopically.

DESCRIPTION: We present the case of a 14 year-old female with a one-year history of colic abdominal pain that worsened 2 weeks prior to admission who was evaluated at our emergency department. On physical examination a palpable mass in the epigastric area that extended to the periumbilical area was noted. Abdomen was not significantly tender to palpation. Preoperative evaluation included a laboratory workup and CT scan. A large intraluminal mass visualized in the stomach compatible with a bezoar was reported. Laparoscopic approach was attempted. Initially a 4 trochars were placed (standard foregut surgery). Due to the size of the stomach, three more trochars had to be placed, including a suprapubic trochar used for scoping which later incision was used to remove trichobezoar. In order to avoid contamination a specimen bag was introduced in the abdominal cavity and placed around the stomach. Gastric incision was performed along the greater curvature of the stomach with electrocuatery. The thin gastric wall was retracted and peeled off from the bezoar. Slowly the bezoar was introduced into the bag and the long tail was pulled from the duodenum. Once the bezoar was inside the bag, the specimen was retrieved using a Pfannenstiel incision.

CONCLUSION:

Trichobezoar is an atypical cause of gastric outlet obstruction. It needs to be suspected in patients with psychiatric disorders. A large trichobezoar (Rapunzel syndrome) can be managed laparoscopically with minimal contamination. A Pfannenstiel incision is a good option to remove a large the specimen, with good cosmetic results.

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