Chapter 11.4 Management of Adnexal Torsion. Operative Technique

 Chapter 11.4 Management of Adnexal Torsion

GENERAL PRINCIPLES

Definition

■ Adnexal torsion is defined as twisting of the ovary and/or tube around usually the utero-ovarian ligament and in case of the ovary the infundibulopelvic ligament (Fig. 11.4.1). It is responsible for 2.7% of all gynecologic emergencies. This number is likely an underestimate given that some patients fail to undergo surgery and thus a definitive diagnosis is not made. Patients typically present with sudden-onset lower abdominal pain that may be continuous or intermittent. The exact cause of adnexal torsion is not known. However, not uncommonly an adnexal mass such as an ovarian cyst, a hydrosalpinx, or a paraovarian cyst is present. In some instances, it is believed that an unusually long utero-ovarian ligament may lend itself to torsion. This diagnosis is usually made in reproductive-aged women, although it is not uncommon in premenarchal girls.

■ As a result of the twisting about the gonadal vessels, venous flow is first compromised and thus the ovary becomes edematous. Once arterial flow is compromised, the ovary and tube will experience ischemia and possible necrosis.

■ The classic signs of ovarian torsion are acute abdominal/pelvic pain accompanied by an adnexal mass and signs of peritoneal irritation. Other symptoms may include nausea and fever, although the latter may occur much later.

■ The right side is most frequently affected by torsion possibly secondary to the fact that the sigmoid traverses to the left and reduces space for torsion to occur.

Differential Diagnosis

■ The preoperative accuracy of adnexal torsion is at best 44% as noted in a study by Cohen,1 where by only 29 out of 66 patients who underwent laparoscopy for presumed diagnosis of torsion in fact had adnexal torsion.

Other causes of lower abdominal pain must be considered in the differential diagnosis. These include:

■ Ruptured ovarian cyst

■ Appendicitis■ Pelvic inflammatory disease

■ Ectopic pregnancy

■ Colitis

■ Pyelonephritis

■ Nephrolithiasis

■ Degeneration of a fibroid

Figure 11.4.1. Ovary and tube twisted upon the utero-ovarian ligament.

Anatomic Considerations

■ In most cases of torsion an ovarian tumor is present. Cysts less than 5 cm are less likely to lead to torsion than larger cysts.

■ In conditions where pelvic adhesions are likely, such as endometriosis and past pelvic inflammatory disease, there is less of a likelihood of torsion. However, hydrosalpingies may lead to an isolated twisting of the fallopian tube.

■ Benign ovarian cysts are more likely to lead to ovarian torsion than malignant lesions, since malignant lesions can invade adjacent tissues thereby prohibiting movement and torsion.

■ During early pregnancy as the uterus is growing the corpus luteum may twist upon itself.

■ Ovarian torsion has also been described in patients with congenital anomalies such as elongated utero-ovarian ligament or abnormally located ovary due to müllerian agenesis.

■ Patients undergoing ovarian stimulation are at increased risk for ovarian torsion secondary to the enlarged size of the ovaries. The diagnosis in this case is extremely difficult given the multicystic appearance of the ovaries bilaterally.

IMAGING AND OTHER DIAGNOSTICS

■ Pelvic ultrasound is usually the first imaging tool utilized to assist with this diagnosis (Fig. 11.4.2).

Figure 11.4.2. Transvaginal ultrasound image of torsed ovary.

Figure 11.4.3. Swollen large right ovary.

■ A transvaginal approach will provide better visualization of the ovarian vessels compared to the transabdominal approach.

■ Indirect findings can include an enlarged ovarian/adnexal mass, multiple cystic structures in the periphery of the enlarged ovary, thickening of interfollicular tissue, and some fluid in the cul-de-sac or adjacent to the enlarged adnexa. The location of the ovary may also be abnormal. It may be located anterior to the uterus or on the contralateral side.■ The only direct ultrasound sign of torsion is the “whirlpool sign.”2

■ Doppler flow studies are routinely used to demonstrate flow in the ovaries. Doppler studies can miss torsion in 60% of cases but its positive predictive value is 100%. Thus while establishing the existence of flow to the ovaries may be reassuring; the clinical picture should direct the course of action. Lack of flow may be a late symptom of torsion, when not only venous but arterial flow is compromised.

■ Given that the patient commonly presents to the emergency room with such symptoms the CT scan may be the first imaging study performed. Findings will include enlarged adnexa, fallopian tube thickening, ascites, and uterine deviation to the twisted side.

■ MR findings on T2-weighted images include swollen ovarian stroma (the hyperintensity of the ovarian stroma is similar to that of water) (Fig. 11.4.3).

PREOPERATIVE PLANNING

■ These cases are considered an emergency and should be performed as soon as possible.

Figure 11.4.4. Twisted pedicle of large swollen ovary.

■ The decision to proceed with surgery is based primarily on the clinical picture and suspicion of torsion.

■ A discussion must occur with patient and family regarding their desire to preserve fertility. The younger the patient is the more important it is to address this issue.

■ If a patient has had a prior history of torsion, there should be a discussion regarding possible need for oophoropexy.

■ In a postmenopausal woman it is reasonable to discuss performing an oophorectomy. Only 2% of torsion cases are secondary to malignancy. However, this possibility does need to be addressed with the patient.

SURGICAL MANAGEMENT

■ Once the diagnosis of ovarian torsion is entertained, surgery must be performed in an emergent manner. The purpose of surgery is to determine the exact cause of the symptoms and rule in or out the diagnosis of torsion. If torsion is identified, the goal is to untwist the adnexa. There is no evidence to suggest that the number of thromboembolic events increases in patients undergoing detorison of their adnexa.

Positioning

■ In preparation for laparoscopy, the patient is placed in the dorsolithotomy position. The younger child and adolescent may be placed in the supine position.

APPROACH

■ The typical approach to such patients is via laparoscopy. Once the diagnosis is confirmed, then one proceeds with detorsion and assessment of cause of torsion.

■ However, laparotomy may be indicated if the mass is quite large or if there is concern for malignancy or spillage of cyst material (Fig. 11.4.4).Procedures and Techniques (Video 11.4)

Detorsion

■ Upon laparoscopic entry into the abdomen, the pelvis is assessed. The normal anatomy of the pelvis is noted as well as the area of concern. The direction in which the adnexa has twisted and number of times it has twisted is noted as is the size and color of the adnexa. In rare instances, the vessels supplying blood to the gonad have completely auto-amputated. But in the majority of cases the ovary can be easily untwisted (Tech Figs. 11.4.1 and 11.4.2).

Tech Figure 11.4.1. Laparoscopic view of torsed right ovary.

Tech Figure 11.4.2. Laparoscopic view of torsed left ovary after ovarian stimulation with gonadotropins.

■ Using the two lower ports, blunt-tipped graspers are placed on either side of the mass and twisted in a reverse direction of the torsion. Usually the torsion is loose and gonad is easily placed back into normal position (Tech Fig. 11.4.3).

Tech Figure 11.4.3. Detorsed right ovary.

Assess for cause of torsion

■ While waiting for the adnexa to reperfuse after detorsion, the affected adnexa are carefully examined for causes of torsion. Most commonly, an ovarian mass or cyst or paratubal cyst is noted that will need to be removed. Not uncommonly, the organ will appear so dark and swollen that it is difficult to clearly see a distinct mass or cyst. In such cases after untwisting the adnexa the procedure can be terminated and the patient followed carefully with follow-up ultrasound to assess the size and composition of the adnexa in the next couple of weeks. If a cyst is in fact seen, a planned operative laparoscopy and cystectomy can be performed.

■ In the majority of cases, the adnexa will reperfuse dramatically and the color of the tissue will become pink.

Cystectomy/cyst aspiration

■ If a distinct cyst is noted, the ovarian capsule on the cyst is cut using low-wattage current. The ovarian cortex is gently grasped and the cyst wall underneath is undermined and dissected away from the cortex. As the base of the cyst is approached, care must be taken regarding blood supply and small vesselscoagulated. This can clearly be more difficult to assess the larger the size of the cyst. The goal is to remove the cyst wall intact and in its entirety without spill. An endocatch bag can be placed through one of the ports and the cyst is decompressed on the top of the bag and the cyst wall then removed from the abdomen. At times, a mini-laparotomy may be necessary to remove the cyst especially if bone fragments exist from a dermoid.

■ In cases of large paratubal cysts, care must be taken to identify the course of the fallopian tube which in many instances is splayed very thin on the cyst and can easily be missed. Once again, an area away from the tube on the cyst is identified and the leaf of the broad ligament is grasped after incision is made, and the underlying cyst is dissected away. These cysts are typically clear and easily dissected and decompressed.

■ In some instances, a larger looking ovary is noted secondary to polycystic ovarian syndrome or stimulation via gonadotropins. In these instances, only detorsion occurs and an assessment for possible oophoropexy.

Oophoropexy

■ There is no consensus regarding the preferred technique or the timing of an oophoropexy.

■ In the majority of cases, a nonabsorbable suture is recommended for use.

■ In cases where the utero-ovarian ligament appears elongated, the proximal portion of the utero-ovarian ligament may be attached or plicated to its most distal portion via 2-0 nonabsorbable suture. This leads to shortening of this ligament thereby giving less mobility to the gonad. This is likely the preferred technique given that the anatomy of the pelvis is least distorted with this method. The relationship between the tube and ovary remains intact (Tech Fig. 11.4.4A,B).

■ In some cases where the anatomy of the ligaments appears very normal but the size of the ovary is likely to remain large as in PCO-like ovaries, the mesoovarium may be attached to the pelvic sidewall taking care to avoid the large pelvic vessels. This may again be performed with 2-0 nonabsorbable suture. There is some concern that the fallopian tube function may be compromised (Tech Fig. 11.4.5).

■ In the pediatric literature, suturing the ovary to the posterior aspect of the uterine wall has been described.

Tech Figure 11.4.4. A and B: Stich is applied to the proximal and distal portions of the utero-ovarian ligament and then inched down and tied. This results in shortening of the ligament.

Tech Figure 11.4.5. Stich is placed in the meso-ovarium and then stitched to the peritoneum of the sidewall.

PEARLS AND PITFALLS

Give time for the ovary to reperfuse. 

There is always some part of the ovary that can be salvaged.

POSTOPERATIVE CARE

■ The immediate postoperative care is similar to a diagnostic laparoscopy. Typically when the patient awakens, the original pain from torsion is no longer present. They will need to be monitored for appropriate bowel and bladder function.

■ Recurrence of pain and fever may indicate that the gonad has undergone necrosis. This is in fact a very rare occurrence.

OUTCOMES

■ Ovarian function is preserved in 88% to 100% of patients that undergo detorsion of their adnexa.3 Ovarian follicular development has been noted on ultrasound in such patients. In addition, ovaries have noted to look normal in a subsequent surgical procedure.

■ In cases where cystectomies were done successfully at the time of the detorsion, the pathology was consistent with functional cyst in 58% of cases. In which case an argument can be made not to proceed with any intervention at the time of detorsion.

■ Thus patients who have experienced torsion secondary to probable ovarian cyst may do well on combined oral contraceptive pills to prevent recurrence of a cyst.

COMPLICATIONS

■ A very low probability of postoperative infection secondary to persistence of necrotic tissue has been reported.

■ Loss of gonadal function may theoretically occur in cases of undiagnosed torsion.