Dr Varsha V S, , Dr Naveen Viswanath, Dr Pramod ,DrC Jayakumar
AIMS, Kochi
Eleven year old girl presented with severe abdominal pain of 1day duration and 2 episodes vomiting after referral from a near hospital. No h/o of fever, vomiting or loose stool. Child at ER had severe abdominal pain with normal vitals She was fully conscious, oriented. Systemic examination done showed severe tender abdomen mainly in the right iliac fossa
Labs TC: 15.24K/uL, N/L : 86%/8% Hb: 12.7g/dl, platelet count: 3.83Lac,
CRP was negative and PT INR was normal. USG abdomen severe RIF tenderness and showed well defined large cyst measuring 6.5 cm x 6cm noted in the midline.
A hypoechoic bulky mass measuring 3.1cm x 3.5cm noted in the right adnexa likely to represent right ovary with suspicious loss of internal vascularity.
Left ovary cyst not visualised separately.
Diagnosis of Torsion of ovarian cyst was made
she was taken for emergency laproscopic oopheropexy. Right ovarian cystectomy was done (as right ovary was not still black in colour- hot dog in bun pexy done). Operative diagnosis of Torsion para ovarian cyst and torsion ovary was made. HPE of the specimen showed serous cystadenoma with features of partial torsion. Post operative period was uneventful. At discharge she was afebrile and vitals were stable.
Ovarian torsion is a process that occurs when the ovary twists over the ligaments that support it in the adnexa. The fallopian tube often twists with the ovary and is then referred to as adnexal torsion. The ovary is supported multiple structures in the pelvis. Ligaments suspended are the infundibulopelvic ligament (suspensory ligament) and tubo ovarian ligament. This ligament also contains the main ovarian vessels. Twisting of these ligaments can lead to venous congestion, edema, compression of arteries, and eventually loss of blood supply to the ovary. This can cause a constellation of symptoms, including severe pain when blood supply is compromised. This is a true surgical emergency that can lead to necrosis, loss of ovary, and infertility if not identified promptly.
The main risk factor for ovarian torsion is an ovarian mass that is 5 cm in diameter or larger.
Ovarian torsion in pubertal age group is rare. Commonly present with abdominal pain or pelvic pain.
Pain can be sharp, dull, constant, or intermittent.
Pain may radiate to the abdomen, back, or flank with nausea
Fever may be present if the ovary is necrotic. Vaginal bleeding or discharge, if torsion involves a tubo-ovarian abscess.
Infants with torsion present with feeding intolerance or inconsolability.
Abdominal tenderness focally in the lower abdomen, pelvic area, or diffusely is usual. One-third have no abdominal tenderness. It can present as a mass also.
Guarding, rigidity, or rebound tenderness suggests necrosis of the ovary.
Every patient should also have a pelvic exam to better evaluate for masses, discharge, and cervical motion tenderness.
Laboratory testing should include a complete blood count, complete metabolic panel. The imaging study of choice is ultrasound with doppler.
Both a transvaginal and pelvic ultrasound should be done. The most sensitive findings on ultrasound are ovarian edema, abnormal ovarian blood flow and relative enlargement of the ovary.
There may also be free fluid or the whirlpool sign, which is thought to be due to the twisting of the vascular pedicle in cross-section.
Blood flow should be assessed as compared to the contralateral ovary. The ovary may also not be torsed at the time of ultrasound, which is why ultrasound alone cannot rule out ovarian torsion. CT and MRI are not generally used to diagnose ovarian torsion but are commonly done to rule out other abdominal pathology such as acute appendicitis.
The treatment of ovarian torsion is surgical detorsion. Surgery with adnexal sparing is the management of choice. A dark, enlarged ovary with hemorrhagic lesions may have compromised blood flow but is often salvageable.
After detorsion, ovaries were found to be functional in greater than 90% of patients who underwent detorsion. This was assessed the appearance of the adnexa on ultrasound, including follicular development on the ovaries. Rarely, if the ovary appears necrotic and gelatinous beyond possible salvage, the choice would be salpingo-oophorectomy and associated cystectomy if a benign cyst is present. Differentials
Ectopic pregnancy,
Ruptured ovarian cyst,
Tubo-ovarian abscess,
Appendicitis,
Pyelonephritis,
Diverticulitis
Pelvic inflammatory disease.
Ovarian torsion is not usually life-threatening, but it is organ threatening if not promptly diagnosed early
Complication of ovarian torsion
Inability to salvage the ovary and the need for salpingo-oophorectomy.
This may affect fertility. Other complications of torsion include abnormal pelvic anatomy that may contribute to infertility, such as adhesions, or atrophied ovaries.
Surgical complications are infection or venous thromboembolism. The risk of post-operative infection is increased when necrotic tissue is already present.
Hotdog in bun” technique is a new method on the block. In this method, the round ligament and utero ovarian ligaments act as the “bun”, while the fallopian tube serves as the “hotdog”. The fallopian tube is cushioned in between the two ligaments. A lateral mattress suture is passed from the round ligament, the clear space of the mesosalphinx and the utero-ovarian ligament. This decreases the mobility of the long ligament pedicles while avoiding excessive crushing of the tube. In cases where the round ligament or uteroovarian ligament is excessively long, a plication of the same can be done as an adjunct procedure. However, there is no long term data to know the outcome of these measures.