The origin of bezoar is either from the Arabic term “badzehr” or possibly the Persian word “padzahr”, both meaning to expel poison, or antidote. These words were described a greenish, hard concretion found in the animal stomach, which was formerly considered a useful medication, sometimes with magical properties. In the mid-1890s, Quain, an Irish surgeon and anatomist at the University of London, reported a mass in the stomach, found on autopsy, which he called a “bezoar” [19, 20].
Our 6 year retrospective review showed that surgical treatment for gastrointestinal bezoars is rare. As regard trichobezoar, we have reported our experience of five adolescent patients (three gastric, one both gastric and colon and one ileum) who were treated for trichobezoar. Gorter et al. , reported four cases of gastric bezoars were identified over an 18 year period and Fallon et al.  identified seven cases that occurred over an 8 year period. However, we should suspect of gastrointestinal bezoars as the etiology of abdominal cramps, vomiting, and loss of weight or abdominal mass despite of its rarity.  We found epigastric mass in two patients in addition to a mass in the left hypochondrium in one case, and this finding in patients with the above mentioned symptoms should raise the suspicion of gastrointestinal bezoar. In girls, history of trichotillomania and trichophagia, can lead to the correct diagnosis and workup. Additionally, mental retardation is another medical condition that should raise the suspicion of gastrointestinal bezoars.
Various imaging modalities have proved to be sensitive in demonstrating gastrointestinal bezoars and their complications especially of the gastric ones. Therefore, we recommend starting with plain films, and performing more advanced imaging only if the above are equivocal.
Endoscopy is rare to be successful in removal of gastric bezoars, while reports of unsuccessful endoscopic attempts are more common [24–25]. Moreover, attempted endoscopic fragmentation might lead to complications such as gastric and esophageal perforations [26, 27] and distal “embolization” of fragments causing bowel obstruction .
Our attemptof endoscopic retrieval failed, whereas in the series reported by Gorter, endoscopy was attempted in two of four cases and failed in both . Therefore, failure of endoscopy should prompt surgical intervention. Moreover, surgical intervention may be suitable in cases where the trichobezoar is strongly suspected, especially with large and extended trichobezoars or in cases where gastric perforation is suspected.
Surgical removal is generally accomplished via laparotomy then gastrotomy or enterotomy with removal of the bezoar . Rapunzel syndrome, defined as extension of the bezoar beyond the pylorus , it can generally be removed through the gastrotomy only. However, one should be aware of possible small bowel obstruction due to fragmentation of the bezoar. Therefore, extracting the bezoar through the gastrostomy should be done very carefully.
Gastrotomy and colotomy in our series were performed via laparotomy, with one case of enterotomy was done laparoscopically assisted. In the literature, laparoscopic removal of bezoars is controversial. In 1998, the laparoscopic trial of a gastric trichobezoar removal was described , and then more cases were also illustrated especially in adults and adolescents. Cintolo and team  mentioned success of laparoscopical removal a large gastric trichobezoar from a 4 year old girl, during which fragmentation of the bezoar was done allowing removal through the 12 mm port site. In 2010, Gorter and colleagues  found only six case reports of the laparoscopic removal of gastric bezoars since the initial trial in 1998, two cases failed and conversion was done. Till now, the open approach is still the best choice due to the difficult removal of a large bezoar and the risk of spillage in laparoscopy. Recently reported, however, was the successful laparoscopy-assisted removal of gastric trichobezoars in five patients. The technique involves temporary gastrocutaneopexy, with or without the use of Alexis wound protector. [32, 33]
The outcome expected after surgical removal via laparotomy then gastrotomy or enterotomy, as found in our series as well as in the literature, is excellent. In our series we did not encounter any complications except one case had port site infection. The reported rate of postoperative complications in the literature according to the review by Gorter et al.  was also very low – 8 of 100 patients, with mostly minor complications (minor wound infections in three, pneumonia in two, postoperative ileus in two, and fecal leakage into the wound in one). In the case study reported by Fallon and co-authors , the rate of postoperative complications was also similar – 1 case (14%) of wound infection .