Hemangiomas of the GI tract are uncommon, and account for only 0.05% of all intestinal neoplasms and 7 to 10% of all benign tumors of the small bowel. Ninety percent of hemangiomas are clinically evident, and present with symptoms, such as, acute or chronic GI hemorrhage, anemia, or obstruction, and rarely with platelet sequestration [4
]. Other potentially serious complications of hemangiomas of the GI tract, such as, intussusception, small bowel obstruction, perforation, malabsorption, and bleeding from other sites of involvement, may also occur [5
Bleeding is one of the symptoms associated with a small bowel neoplasm, and is usually occult and requires an extensive GI evaluation before a diagnosis is obtained. However, the diagnosis and localization of small bowel tumors remains a clinical challenge, because of the inaccessibility of this region to conventional diagnostic modalities. CT is frequently used as a front line tool for the evaluation of abdominal symptoms, especially in critically ill patients. CT scans show transluminal thickening of the wall of involved bowel loops with non-homogenous and persistent lesion contrast enhancement [5
]. Double contrast studies demonstrate a nodular defect, which may change in configuration after compression or distension, which suggests a soft, possibly vascular tumor. The detection of this pathologic finding by double contrast study depends on the size of lesion and on the presence of active intestinal peristalsis [4
Livengood and associates [6
] described the feasibility of the angiographic localization of hemangioma of the small bowel. They performed angiography with methylene blue, which allowed lesions to be identified from an extraluminal vantage point. This method avoids the guesswork involved in transillumination and palpation for tumor localization during laparoscopy. In our case, we performed EGD, colonoscopy, an abdominal CT scan, and a double contrast study to indentify the bleeding focus, and with the exception of abdominal CT, these modalities did not indenty the problematic lesion.
We performed a single incisional laparoscopic exploration to localize and treat the jejunal tumor. Laparoscopic small bowel resection is an established technique and is performed by exteriorizing the diseased bowel segment and using traditional resection and anastomotic techniques [6
]. Recently, multiple attempts have been made to reduce parietal trauma and visible scar formation even after laparoscopic surgery, and patient satisfaction has become a rapidly evolving issue, particularly in terms of single incisional laparoscopic surgery [3
]. This issue reflects the importance of cosmesis and body image trauma associated with surgical procedures, and many surgeons have devised "scarless" surgical procedures using standard laparoscopic instruments. In the described case, standard laparoscopic instruments were used during the procedure.
Bleeding that originates from the small bowel presents challenges in terms of diagnosis, localization, and treatment. However, single incisional laparoscopic exploration may be helpful for localization and treatment purposes. In addition to its superior cosmetic results, a single incisional laparoscopic approach causes less morbidity by minimizing skin incisions. However, some bleeding lesions in the small bowel may be manifestations of a malignant process, and thus, it is essential that the surgeon has multiport laparoscopic skills, because these are vital for safe and effective single incisional laparoscopic surgery.