Ovarian torsion (and laparoscopy)

Question 1

Define ovarian torsion.

Answer 1

Ovarian torsion is a twisting, or torsion, of the ovary around its ligamentous supports. This may result in loss of blood supply to both the ovary and the fallopian tube.

Question 2

How common is ovarian torsion?

Answer 2

3% of all gynae emergencies

Occur in 5 in 10,000 pregnancies = mostly 6-14 weeks’

Question 3

What are the risk factors for ovarian torsion?

Answer 3

• Ovarian neoplasm or ovarian cyst - redisposes ovary to swing on its vascular pedicle or its ligamentous support
• Infertility treatment - because it causes ovarian enlargement

Other:

• Pregnancy - uncommon
• Strenuous exercise
• Sudden increased abdominal pressure e.g. coughing
• PCOS - larger ovaries prone to torsion

Question 4

What is the pathophysiology of ovarian torsion?

Answer 4

1. Enlargement of the ovary allows it to rotate on its pedicle around its ligamentous supports.
2. Twisting of vasculature impedes blood flow to the ovary, and possibly the fallopian tube.
3. Total blockage may result in ischaemia, necrosis, and haemorrhage.
4. This may eventually result in peritonitis.

NB: venous is compromised more than arterial, as the vein walls are thinner and more compressible –> continued arterial perfusion –> enlargement and oedema.

Question 5

What are the clinical features of ovarian torsion?

Answer 5

• Pelvic/abdominal pain - may radiate to back, flank, groin
• Nausea, vomiting, diarrhoea - non-specific
• Abdo/pelvic tenderness - localised, diffuse or adnexal
• Palpable adnexal mass

Peritoneal signs and fever may also sometimes be present.

Question 6

What investigations should be done to diagnose ovarian torsion?

Answer 6

Bloods/urinalysis:

• Pregnancy test - exclude ectopic
• Urinalysis - exclude renal colic, UTI
• FBC - leukocytosis may be seen
• G&S
• CRP
• High vaginal swab - N. gonorrhoea, C trichomatis may suggest PID.

Imaging/invasive:

• Urgent USS + Doppler flow - TVUSS or abdominal. TVUSS should not be done in children or women who have never been sexually active. Assess blood flow to ovary; venous may be more affected. Late sign to have a loss of arterial perfusion.
• Laparoscopy - definitive diagnosis + treatment

Question 7

How do you manage ovarian torsion?

Answer 7

Suspect ovarian torsion early and arrange rapid investigations - reduced risk of damage to the ovary and to preserve ovarian function.

Untwisting of the ovary (detorsion) with laparoscopy - even if the ovary has a dusky, blue-black appearance, allows preservation and return of normal function and fertility in most cases.

In patients not wishing to preserve their fertility/non-viable ovary - salpingo-oophorectomy.

Question 8

What procedure may be carried out to prevent recurrence of ovarian torsion?

Answer 8

Oophoropexy

Question 9

What is the prognosis with ovarian torsion?

Answer 9

Excellent prognosis if managed quickly - discharged within 24 hours of surgery in uncomplicated laparoscopic cases.

Ovarian function usually returns to normal

Recurrence is more common if no underlying pathology was found at time of torsion

Question 10

What are the complications of ovarian torsion?

Answer 10

Ovarian atrophy - if not resolved quickly

Peritonitis - if necrotic ovary is left in place following de-torsion

Question 11

What is done during diagnostic laparoscopy?

Answer 11

The peritoneal cavity is insufflated with carbon dioxide after carefully passing a small hollow Veress needle through the abdominal wall.

This enables a sharp trocar to be inserted through the umbilicus with less risk of damaging organs or major blood vessels.

A laparoscope is then passed down the trocar to enable visualization of the pelvis

Question 12

What are some indications for laparoscopy?

Answer 12

Laparoscopy is used to assess macroscopic pelvic disease in the management of:

• pelvic pain and dysmenorrhoea
• infertility (when dye is passed through the cervix to assess tubal patency: ‘lap and dye’)
• suspected ectopic pregnancy
• pelvic masses.

It is also used for operative laparoscopy: e.g.

• sterilisation,
• ovarian cystectomy or oophorectomy,
• to treat endometriosis with cautery or laser
• hysterectomy
• lymph node biopsy
• omentectomy
• myomectomy

Question 13

What % of laparoscopies fail to show a cause for chronic pelvic pain?

Answer 13

40%

Question 14

What are the complications of laparoscopy?

Answer 14

Complications are uncommon, but include:

• Damage to any of the intra-abdominal structures, such as bowel and major blood vessels.
• Damage to the bladder - always emptied prior to the procedure to avoid bladder injury.
• Incisional hernia has been reported.