Complicated Ovarian Cyst (Adnexal Torsion) Overview:
– It refers to the complete or partial rotation of the ovary with the fallopian tube on its ligamentous supports, often resulting in impedance of its blood supply.
– An ovarian physiologic cyst (functional cyst, corpus luteum) or a neoplasm is the most likely factor to predispose to ovarian torsion, but also ovarian torsion may also occur in patients with normal ovaries (no mass and not enlarged).
– The right ovary appears to be more likely to torse than the left, possibly because the right utero-ovarian ligament is longer than the left and/or that the presence of the sigmoid colon in the left side of the colon may help to prevent torsion.
Complicated Ovarian Cyst (Adnexal Torsion) Presentation:
– Acute onset of moderate to severe pelvic pain, often with nausea and possibly vomiting, in a woman with an adnexal mass.
– Take care, torsion may occur in the absence of an adnexal mass. So, a high index of suspicion is required to make the diagnosis as it may end by gangrene and loss of the ovarian function.
Complicated Ovarian Cyst (Adnexal Torsion) Examination:
– Most patients exhibit pelvic and/or abdominal tenderness, although tenderness on examination is absent in as many as ⅓ of patients.
– Tenderness may be localized to the side of an adnexal mass or may be diffuse.
– A palpable pelvic mass may or may not be present.
– Peritoneal signs are present in a small number of patients and should raise concern for adnexal necrosis.
– Low grade fever may be a sign of adnexal necrosis (with leukocytosis).
– Some patients with torsion present with a slightly high HR or blood pressure, typically in association with the severe pelvic pain.
Complicated Ovarian Cyst (Adnexal Torsion) Investigations:
– Pregnancy test to exclude ectopic pregnancy dt.the acute pelvic pain.
– WBC as adnexal necrosis then infection are associated with leukocytosis which when present, it raise concern for a severe adnexal damage.
– If an adnexal mass is present and malignancy is suspected, serum tumor markers should be drawn.
– Ultrasound is the initial imaging study of choice for patients with suspected ovarian torsion with these findings (NOT all findings are necessary):
1. An enlarged ovary compared with the contralateral ovary due to edema, vascular and lymph engorgement.
2. An ovarian mass: In torsion, the patient will have pain ipsilateral to the mass.
3. Abnormal ovarian location: in Cul de sac or anterior to uterus.
4. Decreased or absent Doppler flow within the ovary: since the ovary has a dual blood supply, flow can be present even in the presence of torsion. Arterial flow in systole without flow in diastole is evidence for outflow obstruction, but venous flow in the setting of torsion is associated with ovarian viability. It is helpful when performing U/S for torsion to ensure that Doppler flow settings are set appropriately by obtaining flow tracings in the contralateral ovary prior to examining the symptomatic ovary.
5. Rupture of an ovarian cyst is often accompanied by hematoperitoneum or free fluid in the pelvis.
– The decision to proceed with surgery is based upon combination of presentation, examination & U/S findings.
Complicated Ovarian Cyst (Adnexal Torsion) Laparotomy or Laparoscopy:
– The diagnosis of torsion is confirmed by direct visualization of the rotated ovary, tube or paraovarian cyst.
– Surgeons should document the findings with laparoscopic photographs of the adnexa.
– Most torsed ovaries are considered potentially viable, unless there is a clearly necrotic appearance.
– Ovarian conservation is the preferred approach for premenopausal women & most ovaries should be considered viable unless there is a high degree of certainty that the ovary is not viable due to the CLEARLY necrotic appearance.
– An ovary that is dark and enlarged likely has vascular and lymphatic congestion and may have hemorrhagic lesions. Traditionally, ovaries with this appearance have been thought to be nonviable, but multiple studies have found that many women (even those with a blue or black ovary) retain ovarian function following detorsion .
– Rarely, ovarian or tubal necrosis are present at time of surgery.
– The appearance on gross inspection of a necrotic ovary or tube includes a loss of normal anatomic structure and a gelatinous or friable consistency.
– A technique to assess whether ovarian perfusion is present is the ovarian bivalving, in which the ovary is untwisted and the ovarian cortex incised. This method allows visualization of whether blood flow is present at the incision. In addition, there is a potential therapeutic effect by relieving the increased pressure exerted by the lymphatic and venous congestion.
– The key factor is to perform detorsion as quickly as possible as the risk of ovarian ischemic damage increase with an increasing the interval between symptoms to surgery.
– There is also no evidence of an increase of adverse events with detorsion.
Complicated Ovarian Cyst (Adnexal Torsion) Interventions:
• For most premenopausal patients with ovarian torsion, detorsion and ovarian conservation is recommended rather than salpingo-oophorectomy.
• Patients with an ovarian mass that is suspicious for malignancy require salpingo-oophorectomy.
• After detortion, if a benign mass is present, ovarian cystectomy is often performed.
• Ovaries that are hemorrhagic and/or edematous are most likely viable, so oophorectomy should be reserved for necrotic/gelatinous/dead-tissue.
• Salpingo-oophorectomy is also reasonable for postmenopausal women.
– Irreversible ischemic damage to the adnexa can occur and may lead to infection if a necrotic ovary is retained, so postoperative care should include observation for signs of peritonitis or sepsis.