Author Information
Parulekar SV.
(Professor and Head of Department of Obstetrics and GynecologySeth
G.S. Medical
College and K.E.M
Hospital , Mumbai , India
Abstract
Determination of viability of ovarian tissue in a case of a
torsion of an ovarian cyst is important in a young woman. If the ovarian tissue
is not viable, an oophorectomy is performed. But if it is viable, the ovary is
conserved by performing an ovarian cystectomy. Viability of ovarian tissue is
determined by Doppler studies preoperatively. The final diagnosis is made
intraoperatively using a new simple test described here.
Introduction
Torsion of an ovarian cyst is its twisting on its ligamentous supports. It
can result in a compromise of its blood supply. It is the fifth most common
gynecologic emergency requiring operative treatment.[1] Though it
can occur at any age, it is most common during the reproductive age, about
15-20% cases occurring during pregnancy.[2] Depending on the degree
and duration of the torsion, the blood supply of the ovary may get compromised
more or less. The diagnosis is essentially clinical. The diagnostic features
are sharp, localized right or left lower abdominal pain and tenderness, a
palpable abdominopelvic tender mass, peritoneal signs, sometimes nausea,
vomiting and pyrexia.[3,4] Initially, the twists in the vascular
pedicle compromise venous and lymphatic outflow. However, arterial inflow is
sustained because arteries have thicker and muscular walls. The resultant diffuse
ovarian edema and enlargement lead to pressure on the ovary, arterial
thrombosis, ovarian ischemia and infarction. In such cases, the ovary has to be
removed along with the ovarian cyst. If torsion is left untreated, the cyst may
rupture. But if the ovarian cyst is
benign, and the blood supply of the ovary is maintained, an ovarian cystectomy
can be performed, and the ovarian function can be preserved. This is important
in young girls and women, for preservation of both the menstrual and
reproductive functions. Ovarian circulation can be assessed preoperatively by
color Doppler studies. However, even if the blood flow is found to be
interrupted, it is always advisable to assess ovarian circulation
intraoperatively, and if it is found to be present after removal of the
torsion, ovarian cystectomy and reconstruction should be performed. A simple
method is described to determine ovarian circulation and viability.
Method
In case there is no blood flow in the ovarian pedicle on a
Doppler study, or if a Doppler study is not available, the ovarian circulation
is checked during a laparotomy. If the ovarian vessels are found to be
thrombosed and the ovarian mass, usually with the fallopian tube, is found to
be blue-black and necrotic, the ovary is considered to be infracted and not
salvageable. In such cases an oophorectomy is done. But if the ovarian vessels
do not appear to be thrombosed and the ovarian mass appears relatively healthy,
the torsion in the pedicle is removed by untwisting. Then an incision is made
in the capsule of the ovarian cyst and the ovarian cyst is dissected out of the
capsule, leaving behind the capsule and ovarian stroma. If the cur edges of the
capsule and the exposed ovarian stroma ooze blood or actually bleed, ovarian
blood supply is considered to be intact and the ovary is considered to be
salvageable. Then it is reconstructed by closure of its cavity with a series of
horizontal mattress sutures of No. 3-0 monofilament nylon, and cut edges of the
capsule are sutured with a continuous stitch of No. 5-0 monofilament nylon.
Discussion
In presence of clinical features of torsion of ovarian mass,
presence of multiple peripheral cysts in the enlarged ovary is helpful in
diagnosing ovarian torsion. On gray-scale USG a twisted vascular pedicle is seen
as an echogenic round or beaked mass with multiple concentric, hypoechoic,
targetlike stripes.[6] During color Doppler sonography of the
twisted vascular pedicle, visualization of circular or coiled vessels is the
whirlpool sign. The most frequent finding is either decrease or absence of
venous flow. An absence of arterial flow is the classic color Doppler
sonographic finding in ovarian torsion. But it appears later than occlusion of
venous flow. Viable twisted ovaries show the presence of central venous flow.[5]
Ovaries without flow in the vascular pedicle during color Doppler USG are
necrotic or infarcted at surgery. But if the occlusion is recent, it might be
reversible on untwisting the pedicle. Such ovaries can be conserved. The value
of the simple intraoperative sign described lies in saving such ovaries, which
will be removed if one relied solely on color Doppler study. Untwisting of the
pedicle of an ovarian mass which had undergone torsion was not recommended in
the past for fear of thromboembolism. However untwisting has been to be safe in
a number of studies, even when the appearance of the ovaries was necrotic.[6,7,8]
In such cases, another operation can be performed after 4-6 weeks, when the
edema and hemorrhage have resolved.[6]
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Citation