ranges from 7% to 93%. As a general rule, those authors carried out adnexectomy when the adnexa appeared necrotic or did not return to a viable-looking appearance after untwisting ischaemic adnexa. However several studies showed poor assessment of adnexal necrosis by the surgeon. Furthermore, some studies found that simply untwisting the adnexa allowed ovarian function to return in patients presenting adnexa that appeared to be necrotic. Ovarian function is preserved in 88-100% of adnexal torsion assessed at a later date. Ideally, these patients should be operated on by gynaecology surgeons. The paradigm has now shifted from one of ovarian removal to one of ovarian evaluation and likely preservation, even in the face of a dusky, seemingly necrotic appearance. Shalev et al proposed more aggressive conservative attitude and recommended saving ischemic- hemorrhagic ovary without waiting for signs of adnexa recovery. Then Oelsner et al claimed that the black-bluish macroscopic appearance of the ovary is not a true indicator of the degree of ischemia. Philippe et al in their report of 45 cases of ovarian torsion when conservative management was performed in 26 cases, at follow-up, 17 ovaries were follicular, seven being black- bluish during surgery. Although very unlikely, the fear of missing malignancy must incite to proceed with caution and can lead, when the size of the twisted ovary is greater than 75mm, to prefer laparotomy to laparoscopy. A decision-making protocol was proposed that aids in the management of suspected ovarian torsion (see figure 4).
TO PREVENT RECURRENCE Ovariopexy is proposed by certain authors and indicated when: There is malformation or excessive length of the utero-ovarian ligament
Torsion of a solitary adnexa Contra-lateral pexy in case of adnexectomy of the twisted adnexa
All cases of childhood torsion of normal ovaries, but not routinely perform oophoropexy in cases of torsion resulting from an ovarian cyst. It is achieved by fixing the ovarian
extremity of the utero-ovarian ligament to the posterior surface of the broad ligament using a non-resorbable swaged suture. Suppression of ovarian cysts - use of higher dose oral contraceptives (≥50 mcg estrogen) results in fewer ovulations and cysts.
Arab Health OBS/GYNE 2012 13
Figure 4: Proposed decision-making protocol for suspected ovarian torsion
Clinical and imaging suspicion of ovarian torsion blood sampling for tumours markers
Enlarged ovary <75mm Laparoscopy Detorsion
± cyst aspiration
Enlarged ovary ≥ 75mm Laparotomy
Detorsion (peritoncal cavity protected) ± cyst aspiration
Biopsy and frozen section
No tumour or benign tumour
Ovarian preservation Ovarian ultrasonography (6 to 8 weeks after detorsion)
Regression Serial
ovarian US
until normal follicular ovary
Persistence or recurrence of cyst+ normal
tumors markers Laparoscopy +Cystectomy
Persistence of enlarged ovary
± anomaly of tumors markers
Laparotomy
CONCLUSION A high index of suspicion should exist amongst emergency physicians, general surgeons and gynaecologists whenever phasing a female patient with acute abdominal pain across all ages and during pregnancy. The clinical diagnosis of ovarian torsion should be considered with the triad of lower abdominal pain, an ovarian cyst/mass, and diminished or absent blood flow in the ovarian vessels, after exclusion of ectopic pregnancy, pelvic inflammatory disease, appendicitis, and leiomyoma-related
symptoms. Laparoscopy is the gold standard diagnosis. Surgical treatment should take place as an emergency in order to avoid any complications with a detrimental effect on their subsequent fertility. Surgical treatment should be conservative by laparoscopy. However the type of surgical treatment should be chosen considering the age of the patient and the desire to preserve fertility. ■
AH
REfERENCES References available on request (
magazine@informa.com)
Low-grade malignancy
Malignancy
Oophrectomie
According to pathology: Staging and
appropriate treatment
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