(Professor and Head of Department of Obstetrics and
Seth G.S. Medical
College and K.E.M
Hospital, .) Mumbai, India
Determination of viability of ovarian tissue in a case of a torsion of an ovarian cyst is important in a young woman. If the ovarian tissue is not viable, an oophorectomy is performed. But if it is viable, the ovary is conserved by performing an ovarian cystectomy. Viability of ovarian tissue is determined by Doppler studies preoperatively. The final diagnosis is made intraoperatively using a new simple test described here.
Torsion of an ovarian cyst is its twisting on its ligamentous supports. It can result in a compromise of its blood supply. It is the fifth most common gynecologic emergency requiring operative treatment. Though it can occur at any age, it is most common during the reproductive age, about 15-20% cases occurring during pregnancy. Depending on the degree and duration of the torsion, the blood supply of the ovary may get compromised more or less. The diagnosis is essentially clinical. The diagnostic features are sharp, localized right or left lower abdominal pain and tenderness, a palpable abdominopelvic tender mass, peritoneal signs, sometimes nausea, vomiting and pyrexia.[3,4] Initially, the twists in the vascular pedicle compromise venous and lymphatic outflow. However, arterial inflow is sustained because arteries have thicker and muscular walls. The resultant diffuse ovarian edema and enlargement lead to pressure on the ovary, arterial thrombosis, ovarian ischemia and infarction. In such cases, the ovary has to be removed along with the ovarian cyst. If torsion is left untreated, the cyst may rupture. But if the ovarian cyst is benign, and the blood supply of the ovary is maintained, an ovarian cystectomy can be performed, and the ovarian function can be preserved. This is important in young girls and women, for preservation of both the menstrual and reproductive functions. Ovarian circulation can be assessed preoperatively by color Doppler studies. However, even if the blood flow is found to be interrupted, it is always advisable to assess ovarian circulation intraoperatively, and if it is found to be present after removal of the torsion, ovarian cystectomy and reconstruction should be performed. A simple method is described to determine ovarian circulation and viability.
In case there is no blood flow in the ovarian pedicle on a Doppler study, or if a Doppler study is not available, the ovarian circulation is checked during a laparotomy. If the ovarian vessels are found to be thrombosed and the ovarian mass, usually with the fallopian tube, is found to be blue-black and necrotic, the ovary is considered to be infracted and not salvageable. In such cases an oophorectomy is done. But if the ovarian vessels do not appear to be thrombosed and the ovarian mass appears relatively healthy, the torsion in the pedicle is removed by untwisting. Then an incision is made in the capsule of the ovarian cyst and the ovarian cyst is dissected out of the capsule, leaving behind the capsule and ovarian stroma. If the cur edges of the capsule and the exposed ovarian stroma ooze blood or actually bleed, ovarian blood supply is considered to be intact and the ovary is considered to be salvageable. Then it is reconstructed by closure of its cavity with a series of horizontal mattress sutures of No. 3-0 monofilament nylon, and cut edges of the capsule are sutured with a continuous stitch of No. 5-0 monofilament nylon.
In presence of clinical features of torsion of ovarian mass, presence of multiple peripheral cysts in the enlarged ovary is helpful in diagnosing ovarian torsion. On gray-scale USG a twisted vascular pedicle is seen as an echogenic round or beaked mass with multiple concentric, hypoechoic, targetlike stripes. During color Doppler sonography of the twisted vascular pedicle, visualization of circular or coiled vessels is the whirlpool sign. The most frequent finding is either decrease or absence of venous flow. An absence of arterial flow is the classic color Doppler sonographic finding in ovarian torsion. But it appears later than occlusion of venous flow. Viable twisted ovaries show the presence of central venous flow. Ovaries without flow in the vascular pedicle during color Doppler USG are necrotic or infarcted at surgery. But if the occlusion is recent, it might be reversible on untwisting the pedicle. Such ovaries can be conserved. The value of the simple intraoperative sign described lies in saving such ovaries, which will be removed if one relied solely on color Doppler study. Untwisting of the pedicle of an ovarian mass which had undergone torsion was not recommended in the past for fear of thromboembolism. However untwisting has been to be safe in a number of studies, even when the appearance of the ovaries was necrotic.[6,7,8] In such cases, another operation can be performed after 4-6 weeks, when the edema and hemorrhage have resolved.
1. Hibbard LT. Adnexal torsion. Am J Obstet Gynecol 1985; 152(4): 456–461.
2. Bouguizane S, Bibi H, Farhat Y, et al. Adnexal torsion: a report of 135 cases. J Gynecol Obstet Biol Reprod 2003;32(6):535–540.
3. Bider D, Mashiach S, Dulitzky M, Kokia E, Lipitz S, Ben-Rafael Z. Clinical, surgical and pathologic findings of adnexal torsion in pregnant and nonpregnant women. Surg Gynecol Obstet 1991;173(5):363-6.
4. Griffin D, Shiver SA. Unusual presentation of acute ovarian torsion in an adolescent. Am J Emerg Med 2008;26(4):520.e1-3.
5. Lee EJ, Kwon HC, Joo HJ, Suh JH, Fleischer AC. Diagnosis of ovarian torsion with color Doppler sonography: depiction of twisted vascular pedicle. J Ultrasound Med1998;17(2):83–89.
6. Breech LL, Hillard PJ. Adnexal torsion in pediatric and adolescent girls. Curr Opin Obstet Gynecol 2005;17(5):483–489.
7. Oelsner G, Shashar D. Adnexal torsion. Clin Obstet Gynecol 2006;49(3):459–463.
8. RhaSE, Byun JY, Jung SE, et al. CT and MR imaging features of adnexal torsion. RadioGraphics 2002;22(2): 283–294.