Laparoscopic Detorsion of Twisted Ovary CASE REPORT

Laparoscopic Detorsion of Twisted Ovary
Yiu-Tai Li*, Lung-Ching Kuon, Po-Ning Lee, Tsung-Cheng Kuo
Department of Obstetrics and Gynecology, Kuo General Hospital, Tainan, Taiwan, R.O.C.
An 18-year-old female presented with a 6-day history of lower abdominal pain. Transabdominal ultrasonography revealed
a right adnexal cyst measuring 9 cm. Laparoscopic examination demonstrated a 10-cm right paratubal cyst and
a 5-cm right ovarian torsion with gangrenous discoloration. After removal of the right paratubal cyst, untwisting of
the right ovary was performed. The postoperative period was uneventful. During follow-up, ultrasonography revealed
restoration of right ovarian size with follicular growth. Arterial and venous blood flows were seen on Doppler examination.
The right ovary appeared to be completely viable through a second-look laparoscopic examination. A twisted ovary
may be completely restored with conservative management. [J Chin Med Assoc 2005;68(12):595–598]
Key Words: adnexal torsion, detorsion, laparoscopy
Ovarian torsion is a relatively infrequent gynecologic
disease. The traditional recommended treatment for
ovarian torsion is removal of the ovary without
detorsion. However, conservative therapy for preservation of ovarian function should be undertaken,
because most women with adnexal torsion are of
reproductive age.1–5 Here, we present a young female
with ovarian torsion and paratubal cyst who was
successfully managed with conservative treatment using
Case Report
An 18-year-old female presented to our institution
with nausea, vomiting and a 6-day history of worsening
abdominal pain. Her menstrual periods had been
regular after menarche. On examination, she had
involuntary guarding in the right lower quadrant. She
was afebrile, with a pulse rate of 80 beats per minute
and blood pressure of 110/70 mmHg. Transabdominal
ultrasound revealed a right adnexal cyst measuring
9 × 7 × 6 cm (Figure 1). Laboratory findings were all
within normal limits, including a CA125 of 18 U/mL,
Figure 1. Transabdominal ultrasound showing a right adnexal
cyst (C). BL = urinary bladder; UT = uterus.
*Correspondence to: Dr. Yiu-Tai Li, Department of Obstetrics and Gynecology, Kuo General Hospital, 22,
Section 2, Ming-Sheng Road, Tainan 700, Taiwan, R.O.C.
Received: January 3, 2005
Accepted: June 15, 2005
E-mail: [email protected]
J Chin Med Assoc • December 2005 • Vol 68 • No 12
©2005 Elsevier. All rights reserved.
Y.T. Li, et al
CA199 of 25 U/mL, carcinoembryonic antigen of
0.8 ng/mL, and white blood cell count of 8,000/
mm . The provisional diagnosis was a right adnexal
Under general anesthesia, pneumoperitoneum was
established with carbon dioxide insufflated through a
Veress needle inserted into the lower margin of the
umbilicus. After reaching a pressure of 15 mmHg,
a 10-mm trocar and sleeve were inserted through an
incision made at the lower margin of the umbilicus.
An operative laparoscope was introduced through the
sleeve. The uterus and left adnexa appeared normal.
A right paratubal cyst with a smooth surface measuring
10 × 9 × 7 cm was identified. However, the right ovary
was found to be twisted 3-fold around the base and
appeared black-bluish (Figures 2 and 3). The twisted
ovary measured 5 × 4 × 4 cm.
At this time, detailed explanation of the risks of
detorsion of the twisted ovary, including pulmonary
embolism, fever, and abdominal pain, was given to the
patient’s parents, and they agreed to the procedure.
After aspiration of clear watery fluid from within the
paratubal cyst, the cyst was removed smoothly. Then,
untwisting of the right ovary was performed with the
aid of a probe introduced via a second suprapubic
puncture. In an effort to prevent recurrence, ovariopexy
was performed by fixing the right ovarian ligament to
the round ligament with interrupted ‘0’ Prolene sutures.
The postoperative period was uneventful. Four days
after the operation, ultrasonography revealed a
shrinkage of the right ovary to 4 cm in diameter. She was
dismissed on the fifth postoperative day. The surgical
specimen was interpreted as a benign paratubal cyst.
The patient was followed-up every 4 weeks after
discharge from hospital. Ultrasonography revealed
resolution of right ovarian size with follicular growth
(Figure 4). Arterial and venous blood flows were seen
on Doppler examination. Four months after discharge,
Figure 2. Laparoscopic aspect of the twisted right ovary.
Figure 3. Black-bluish discoloration of the twisted right ovary.
Figure 4. Pelvic ultrasonography showing a normal-sized right
ovary with follicular growth and blood flow in the vessels.
Figure 5. Second-look laparoscopy showing a normal-sized right
J Chin Med Assoc • December 2005 • Vol 68 • No 12
Detorsion of twisted ovary
a second-look laparoscopy showed that the volume of
the right ovary was similar to that of the left ovary, with
a smooth, uniform, white surface without any adhesions. The right ovary appeared to be completely viable (Figure 5). Clinical follow-up at 9 months using
ultrasonographic examination revealed no recurrence
of the torsion.
At present, the standard option to treat twisted ischemic
adnexa is adnexectomy without untwisting. The risks
of thromboembolism were thought to be so high that
oophorectomy was recommended for all patients
regardless of age. The fear of unwinding the pedicles
of ovarian torsion is based on the assumption that
thrombus in the ovarian vein would be released into
the systemic circulation by this procedure. However,
Wagaman and Williams,6 in a literature review, found
no cases of pulmonary embolism occurring from a
thrombosed vein. Furthermore, Oelsner et al7 reported
that 102 adnexal torsion patients routinely underwent detorsion without oophorectomy or salpingooophorectomy, regardless of the ischemic appearance
of the adnexa. They used either laparoscopy or
laparotomy to complete the operations. No patient in
their study had clinical signs of thromboembolism
postoperatively. Recovery of normal ovarian size and
function, as shown by follicular development, was
93.3% and 90.6% in the laparoscopy and laparotomy
groups, respectively. Moreover, McGovern et al 8
performed a literature review of 309 patients with
adnexal torsion who were treated by detorsion and
672 patients who were treated by adnexectomy without
detorsion. The incidence of pulmonary embolism
after adnexal torsion was 0.2%, and they found that
this incidence was not increased with detorsion (p =
0.47). Pulmonary embolism actually did not occur in
patients in the detorsion group.
We believe that laparoscopic detorsion should be
the first choice treatment in the management of ovarian
torsion, regardless of the color or number of twists of
the ovary. In this patient, as the detorsion procedure
was decided during operation, preoperative Doppler
dynamic flow study was not performed. However,
even if Doppler dynamic flow study had shown vascular occlusion, we would still have recommended
the untwisting procedure. In our opinion, even
gangrenous-appearing adnexa should not be removed
because it is impossible to predict the chances of the
ovary reviving after detorsion. The presumptive
diagnosis in the present case was a simple ovarian cyst,
J Chin Med Assoc • December 2005 • Vol 68 • No 12
and ovarian torsion was finally diagnosed after
identifying 3-fold rotation of the ovary. Even though
the twisted ovary was dark bluish and edematous after a symptom duration of 6 days, we treated it by
detorsion without extirpative surgery. There was no
postoperative fever, and the patient’s injured ovary
was preserved.
In the study reported by Oelsner et al,7 5 of the 102
(4.9%) patients had retorsion in the same adnexa. In
order to prevent retorsion, several methods of
oophoropexy have been described, including fixing
the utero-ovarian ligament to the round ligament, the
ovary to the pelvic wall, the ovary to the uterus and
shortening the utero-ovarian ligament. 9–12 In our
present case, the ovary was plicated by fixing the uteroovarian ligament to the round ligament with permanent
sutures. The patient was still well at the time of writing.
Torsion of otherwise normal tubes and ovaries
seems to appear most frequently in children and young
adults. In such patients, the ideal management is
conservative treatment. Conservative treatment may
restore the blood supply to the ischemic adnexa and,
thus, preserve a viable tube or ovary. Sometimes,
sequential torsion of the adnexa occurs in a young girl
many years after treatment. Such patients would lose
their endocrine function if adnexectomy was repeatedly
used as the treatment option.6
Our successful treatment of this patient has indicated
that, although twisted adnexa may appear to be ischemic
or hemorrhagic, it can safely be revived by detorsion
with preservation of function. The ability to retain
viability even after prolonged ischemia was proved by
the excellent results in a severely damaged ovary, and
demonstrated that complete arterial obstruction is not
commonly encountered, and blood perfusion can still
be gained from either the ovarian or uterine arteries.
Every gynecologist should be aware of this novel
option to preserve childbearing function as an
alternative to using routine extirpation of ovaries in
young female patients.
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