A case report on laparoscopic retrieval of a massive gastric trichobezoar causing partial gastric outlet obstruction in a paediatric patient

Honey George1, Shalini HS2, Vijayakumari. D3

1Nursing In charge, Kauvery Hospital, Electronic City, Bengaluru

2Chief Nursing Officer, Kauvery Hospital, Electronic City, Bengaluru

3Nurse Educator, Kauvery Hospital, Electronic City, Bengaluru

Abstract

Trichobezoar, a mass composed of ingested hair, is a rare form of bezoar typically found in the stomach. It is strongly associated with trichophagia, an impulse control disorder. When the mass is large enough to extend from the stomach through the pylorus and into the duodenum, it is known as Rapunzel Syndrome. Clinical presentation often involves chronic, non-specific abdominal pain and signs of gastric outlet obstruction. Management requires definitive removal, traditionally via open gastrotomy. This report details the successful management of a massive gastric trichobezoar in an 11-year-old girl using a minimally invasive laparoscopic approach, facilitating rapid recovery and simultaneous psychiatric intervention for the underlying behavioural disorder.

Key words: Trichobezoar; Rapunzel Syndrome; Laparoscopic

Case Presentation

An 11-year-old female patient presented on 04 November 2025 with acute symptoms of abdominal pain and vomiting persisting for one week. The history of the presenting illness was notable for on-and-off episodes of abdominal pain and vomiting dating back approximately 10 years. Similar gastrointestinal complaints had been reported over the preceding two to three years.

Crucially, the patient had a documented history of eating hair follicles and clothes since childhood, consistent with pica and trichophagia. One week prior to admission (26 October 2025), an endoscopic retrieval attempt was made but was unsuccessful in removing the gastric obstruction.

On arrival, the patient was conscious and oriented. Vitals were stable, with a pulse rate of 99/min, blood pressure of 87/60 mmHg, respiratory rate of 18/min, and oxygen saturation (SpO2) of 99% on room air. Clinical examination revealed bilateral normal vesicular breath sounds, S1/S2 heart sounds, and a soft abdomen with no tenderness or distension. The patient weighed 24.4 kg.

Trichobezoar

Investigations

Pre-operative investigations included a failed endoscopic removal attempt on 26 October 2025, which confirmed the presence of a large amount of hair causing gastric outlet obstruction. The pre-operative diagnosis was Gastric Bezoar (Trichobezoar).

Initial routine laboratory results were not fully detailed in the admission summary. However, on Postoperative Day 2 (POD-2), blood work showed: Sodium (Na) 134, Potassium (K) 3.8, Chloride (Cl) 104, Urea 32, Creatinine 0.4. The Total Leukocyte Count (TLC) was 19.7 k and Haemoglobin (Hb) was 11.7.

Pre-operative Nursing Care

Pre-operative nursing care focused on stabilizing the patient, preparing her for anaesthesia, and minimizing risks associated with gastric outlet obstruction. Nursing assessment included continuous monitoring of vital signs, hydration status, and pain. The patient was kept Nil Per Oral (NPO) to prevent aspiration, and intravenous access was established for maintenance fluids and correction of electrolytes as needed. Pre-operative preparation involved verifying parental consent, checking for allergies, and ensuring compliance with anaesthesia fasting guidelines. The nursing team administered prophylactic antibiotics as instructed and monitored temperature to detect early infection. Given the paediatric age group, nurses provided psychological support through age-appropriate communication and reassurance to reduce anxiety for both the child and her parents. These interventions ensured the patient was optimally stabilized for the planned laparoscopic procedure.

Management

Given the size and extent of the mass, and the failure of endoscopic removal, definitive surgical management was indicated. The procedure was performed on 04 November 2025 under General Anaesthesia (GA).

Procedure: Laparoscopic Gastrostomy and Retrieval of the Trichobezoar

Intraoperative findings confirmed the diagnosis, revealing a massive trichobezoar occupying the entire stomach and extending into the duodenum, resulting in partial gastric outlet obstruction.

The surgical approach utilized standard laparoscopic access, including a 10mm infraumbilical port and an 8.5mm right hypochondrium (RH) port. A gastrostomy was executed on the anterior gastric wall using a monopolar hook. The surgical team successfully retrieved the entire trichobezoar out of the stomach. To minimize fascial disruption during specimen removal, the mass was extracted through a 5mm supra-pubic Pfannenstiel incision. Following retrieval, the gastrostomy site was closed in two layers (sutures using MAXON 2-0 and Prolene 2-0). The abdomen was subjected to Normal Saline (NS) wash before closure.

Postoperative Course

The patient was initially kept Nil Per Oral (NPO) and commenced on intravenous maintenance fluids (DNS/NS/RL) and empirical intravenous antibiotics (Inj. Ceftriaxone, along with other supportive medications like Inj. Pantoprazole and Inj. Emeset).

The patient maintained a generally stable and uncomplicated postoperative course.

  • POD 1/2 (05/11/2025 & 06/11/2025): The patient was comfortable and hemodynamically stable, reporting reduced pain. Oral intake was initiated with clear liquids (water, tea, milk) and tolerated well, progressing subsequently to a soft diet.
  • POD 3 onwards (07/11/2025): The surgical retrieval site (Pfannenstiel incision) was explored and dressings were changed. The patient remained comfortable, afebrile, and stable, continuing to tolerate oral feeds with no wound discharge.

Given the established history of trichophagia and sleep disturbance, a multidisciplinary approach was initiated. The patient was reported to be comfortable but was noted to be unable to cooperate fully for a detailed Mental Status Examination (MSE). Treatment with T. Clonotril 0.25mg was advised for sleep disturbance, and the need for a detailed psychiatric evaluation post-discharge was emphasized to manage the underlying behavioural condition.

Post-operative Nursing Care

Post-operative nursing care was directed at supporting recovery, preventing complications, and facilitating early return to normal function. The nursing team monitored airway, breathing, and circulation closely in the immediate post-anaesthesia period, with regular checks of heart rate, respiratory rate, blood pressure, and oxygen saturation. Pain was assessed using paediatric pain scales, and analgesics were administered as prescribed. Strict fluid balance monitoring was maintained during the NPO period, transitioning to oral intake as tolerated. Port sites and the Pfannenstiel incision were inspected for bleeding, discharge, or signs of infection, and dressing changes were performed under aseptic precautions. The patient was observed for gastrointestinal recovery, including the return of bowel sounds and tolerance to oral feeds. Nurses encouraged early mobilization to reduce postoperative morbidity. Given the underlying behavioural history of trichophagia, the nursing team also supported psychiatric recommendations, monitored sleep patterns, and reinforced the importance of ongoing psychiatric follow-up with the caregivers.

Outcome and Follow-Up

The patient was discharged on 10 November 2025, six days post-procedure, in a stable condition. Discharge advice included a soft diet and oral medications (including Syp. Gudcef, Syp. Metrogyl, and Tab. lanzol) for a short course. Follow-up was scheduled in the General Surgery and Paediatrician Outpatient Departments (OPD) on 12 November 2025. Critical long-term follow-up included the mandated detailed psychiatric evaluation to prevent recurrence of trichobezoar.

Discussion

Trichobezoars are uncommon entities in paediatric surgery, typically presenting with non-specific gastrointestinal symptoms. The definitive challenge in managing these large masses is removal while minimizing surgical morbidity. Given that the patient’s trichobezoar occupied the entire gastric lumen and caused partial duodenal obstruction, standard non-surgical endoscopy failed.

This case successfully demonstrates the feasibility of laparoscopic gastrostomy and retrieval for massive gastric bezoars. By utilizing a small supra-pubic Pfannenstiel incision solely for specimen extraction, the morbidity associated with traditional midline open gastrotomy was avoided, contributing to the patient’s rapid return to oral intake and stable discharge within six days.

This minimally invasive technique is particularly valuable in paediatric patients where cosmetic outcome and reduced recovery time are paramount. This case reports increasingly support laparoscopy as a safe alternative to open surgery when performed by experienced and skilled paediatric surgeon. This case adds to the growing evidence that even large bezoars can be reliably removed laparoscopically.

Furthermore, the integration of psychiatric consultation immediately post-operatively underscores the necessity of a multidisciplinary approach. Failure to address the underlying psychological condition of trichophagia carries a high risk of recurrence.

Conclusion

Laparoscopic gastrostomy and retrieval are a safe and effective minimally invasive surgical option for the management of massive gastric trichobezoars, particularly after failed endoscopic attempts, allowing for swift resolution of gastric outlet obstruction. It provides Excellent post operative outcomes and should be considered a first line surgical intervention in appropriately selected cases. A comprehensive treatment plan for paediatric trichobezoar patients must integrate surgical removal with mandatory long-term psychiatric follow-up to address the root behavioural disorder and mitigate recurrence risk.

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