Chauhan AR
Adnexal
torsion is seen in approximately 2 -3 % of adolescents and young
women in the reproductive age, though prepubertal and postmenopausal
cases have also been reported. Ovarian
torsion is defined as partial or complete rotation of the ovarian
pedicle to such a degree as to occlude or compromise its vascular and
lymphatic drainage. “Twisted
ovarian cyst” presents as a medical emergency and may imply torsion
of the ovary or adnexa; less commonly, paraovarian torsion or
isolated torsion of only fallopian tube may be encountered.
Classic
clinical features include sudden onset lower abdominal pain (right
sided more common as the colon on the left is protective and does not
give enough room for torsion to occur), nausea and vomiting. The pain
may sometimes be colicky or episodic when the torsion is intermittent
or partial. The commonest differential diagnosis is ectopic
pregnancy; tubo- ovarian mass due to PID, acute appendicitis and
renal colic should also be kept in mind. Ultrasonography is the
diagnostic modality of choice, where commonly an enlarged ovary or
ovarian cyst, and free fluid in the pelvis are seen. The “whirlpool
sign” (twisted vascular pedicle) if seen, has a high sensitivity
for diagnosing torsion. Though Doppler may reveal the absence of
blood flow in the ovarian pedicle with high specificity, Doppler USG
is not a sensitive modality and has not been found to improve the
diagnostic accuracy. In fact, many surgically proven cases of torsion
show the presence of blood flow on Doppler. CT
scan and MRI should be reserved for those patients where the
diagnosis is in doubt. Misdiagnosis and diagnostic delay can lead to
the loss of the ovary, fallopian tube or both; prompt diagnosis is
essential to reduce the risk of complications and increase the
chances of ovarian conservation.
Ovarian
masses associated with torsion are usually benign. A
long utero- ovarian ligament rather than the size of the cyst
determines whether torsion will occur. Torsion of the ovarian
vascular pedicle results in venous congestion, hemorrhage, ischemia
and eventually necrosis, believed to cause loss of ovarian function.
It was for this reason that historically all torsed adnexae which
appeared necrotic were surgically removed; emergency laparotomy with
salpingo- oophorectomy was the standard treatment.
Laparoscopy
has taken over from laparotomy in the last three decades and
laparoscopic detorsion of the twisted adnexae with ovarian
preservation is now the recommended surgical treatment, even in the
presence of complete vascular occlusion or hemoperitoneum. Numerous
studies in literature have evaluated laparotomy or laparoscopy with
ovarian preservation with favorable results. Even
if the ovary is dark, ischemic or necrotic in appearance, many
authors emphasize that detorsion is the only
surgery which should be performed; this is relatively easy and safe
to do. As the tissue is extremely edematous and friable, care should
be exercised; gentle handling and non –traumatic instruments should
be used. The return of color after detorsion, and normal blood flow
may not resume immediately but this should not discourage the
surgeon. Surgeons usually excise necrotic tissue but the temptation
to bivalve the ovary or perform cystectomy should be avoided as it
can cause hemorrhage and undue removal of ovarian tissue as there is
usually no clear plane of cleavage, eventually leading to
oophorectomy. Though there are risks of sepsis (due to liberation of
toxins), peritonitis and emboli, these are largely theoretical and
have not been reported.
Oophoropexy,
the surgical fixation or suspension of the ovary, is also easily
performed via the laparoscope. It has previously been performed to
prevent repeat ovarian torsion, and on the contra-lateral normal
ovary to prevent torsion, but its efficacy is debatable and hence is
not recommended. Current
evidence has shown that ovarian function is preserved in as many as
88 - 100% of cases. Obviously, better outcomes are achieved if the
surgical intervention occurs within 36 hours, with some reports
suggesting that the best results are achieved when the time
of onset of torsion to surgery is 8 hours. Many
studies have analyzed subsequent ovarian follicular development, and
shown restoration of ovarian function in > 80% of these ovaries.
Laparotomy
performed for unrelated causes has also shown macroscopically normal
ovaries. In patients undergoing IVF treatment, oocytes have been
retrieved from the previously detorsed ovaries and successfully
fertilized. Hence
preservation of ovarian function and fertility should be paramount
and cases of twisted adnexae should be treated laparoscopically with
detorsion and ovarian conservation. The
September issue of our journal carries a case report on ovarian conservation in a case of adnexal torsion, which should interest and help the readers.