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Oophoropexy to prevent sequential or recurrent torsion
August 1997, Vo[. 4, No. 4
TheJournal of the American Associationof Gynecologic Laparoscopists
Oophoropexy to Prevent Sequential or Recurrent Torsion Theodore C. Nagel, M.D., James Sebastian, M.D., and John W. Malo, M.D. Abstract Laparoscopic oophoropexy may prevent recurrent (repeat torsion of the same ovary) or sequential (subsequent torsion of the contralateral ovary) ovarian torsion. Two adolescent girls with sequential ovarian torsion underwent laparoscopic plication of utero-ovarian ligaments. Neither patient has had recurrence in the 6.5 and 2 years, respectively, since surgery.
(l Am Assoc Gynecol Laparosc 4(4):419--498, 1997)
7 months, but the girl continued to have intermittent pain, now located in the right lower quadrant. At age 10 years 3 weeks, pain was exacerbated and persistent. Laparotomy was performed with a preoperative diagnosis of appendicitis; however, the appendix was normal. The right ovary was found to have undergone torsion and was necrotic; it was removed. It was described as measuring 5.5 x 2.9 by 2.2 cm, and edematous and purple. No pathology was found other than evidence of necrosis. Two months later the girl experienced another episode of periumbilical pain that was diagnosed as enteritis. She subsequently developed episodic left lower quadrant pain, similar to that experienced on the right, that occurred with increasing frequency. When she was seen in our office at age 10 years 7 months, the pain was occurring weekly. It was of variable duration, from less than 1 hour to several hours. It frequently limited the girl's activity, and she would lie down until she experienced relief.
Sequential ovarian torsion has been described, 1-8 and in almost every instance the authors raised the question of whether or not oophoropexy should have been done at the time of the initial episode of torsion. In virtually every instance the second ovary was removed and the patient rendered menopausal. In two patients with sequential ovarian torsion the ovary was saved and oophoropexy performed laparoscopically in an effort to prevent recurrence. Case Reports
Patient No. 1
The patient was known to have umbilical hernia from birth. At age 9 years she began having intermittent abdominal pain associated with nausea and vomiting. The pain occurred primarily in the evening and was periumbilical. The hernia was repaired at age 9 years
From the Reproductive Health Associates, St. Paul, and Department of Obstetrics and Gynecology, University of Minnesota, Minneapolis, Minnesota (Drs. Nagel and Malt); and Duluth Obstetric-Gynecologic Association, Duluth, Minnesota (Dr. Sebastian). Address reprint requests to Theodore C. Nagel, M.D., Reproductive Health Associates, P.A., 360 Sherman Street, Suite 350, St. Paul, MN 55102; fax 612 222 8657.
495
Oophoropexy to PreventOvarian Torsion Nagel et al
Physical examination revealed a normal adolescent, 59 inches tall and weighing 105 lbs. Breasts and pubic hair were Tanner stage IV.9 She had not yet begun menstruating. Pelvic ultrasound showed a left ovary measuring 3.6 • 2.0 x 2.8 cm. Numerous cysts were present, the largest measuring 16 x 12 x 17 mm. The endometrium was well developed. At laparoscopy, the right ovary was absent. Fimbriae of the right tube were adherent to the cecum. The left ovary appeared large and smooth, resembling a polycystic ovary. The utero-ovarian ligament appeared excessively long, as did the mesovarium. The uteroovarian ligament was plicated. The patient has done well since surgery, and the pain has resolved. Puberty continued normally, and at age 16 she is having regular menses.
FIGURE 1. A remnant of the left tube. The probe at the left passes behind the twisted tube. No definitely identifiable ovary is seen.
Patient No. 2 A 13-year-old premenarchal girl experienced right lower quadrant pain for 4 or 5 days. It occurred intermittently and became progressively worse. Pelvic ultrasound revealed a 6-cm right ovarian cyst, and the patient was referred to one of the authors (JS) for further care. On examination there was marked tenderness at McBurney's point. The ovarian mass was palpable rectally, and palpation markedly exacerbated the pain. Laparoscopy disclosed an enlarged right ovary that had undergone torsion. The torsion was released and the ovary appeared to be viable. An incision was made into the ovary and the cyst was removed; it proved to be a simple cyst. The left adnexa consisted of a remnant of tube twisted back on itself (Figure 1). The left ovary was essentially gone. The tube was twisted in such a way that it was possible that torsion had occurred previously on this side, even though the girl had no history of an episode of pain. The patient was prescribed oral contraceptives after the procedure to prevent development of further physiologic cysts. Because of concern about recurrence, given the fact that the left ovary was absent and appeared to have undergone torsion, laparoscopy was repeated 2 months later. The ovary remained enlarged. There was a single avascular adhesion from the ovary to the broad ligament. The utero-ovarian ligament, which was very long (Figure 2), was plicated. Oral contraceptives were discontinued and the patient has remained asymptomatic.
Operative Procedure The technique of plication was essentially as described earlier. 1~ Permanent suture was passed through the utero-ovarian ligament at the ovarian insertion, through the midportion of the ligament in the opposite direction, and then back through the ligament at its uterine origin (Figure 3). The suture was then tied. In the first case knotting was intracorporeal, and in the second it was extracorporeal. The result was
FIGURE 2. The uterus is to the left; note the elongated uteroovarian ligament.
496
August 1997, Vd. 4, No. 4
The Journal of the American Association of Gynecologic Laparoscopists
flow in the ovary has ceased. 12However, this finding is not present at a time when the adnexa is most readily salvageable, that is, while there is still blood flow.~3 Numerous authors reported untwisting the adnexa 3, 9, 14 despite admonitions about the risk of embolization. One group ~4was unable to find reported cases of embolization as a result of untwisting an adnexal torsion. Two case reports 3' 10indicate preservation of function in these untwisted ovaries. Longterm follow-up of 40 patients whose torsion was treated by untwisting the ovary showed preservation of function in ovaries that appeared necrotic at initial surgery.15 The postoperative course was also surprisingly benign in these women. Preservation of the ovary and presumably its function was reported in an ovary that was untwisted after Doppler sonography showed absence of blood flow. 16 We believe our two patients are examples of sequential torsion. In the first girl the right ovary underwent torsion. At laparoscopy, the right ovary was necrotic, and no other pathology was found. The patient had numerous episodes of abdominal and fight lower quadrant pain before the episode that resulted in laparotomy. This was present in 10% of patients reported by others, a' s, u The recurrent episodes of left lower quadrant pain the girl experienced later were reminiscent of her earlier right lower quadrant pain. Laparoscopic plication of her elongated utero-ovarian ligament resulted in relief of pain, which has not recurred. In the second patient the correct diagnosis of right ovarian torsion was made before surgery. At laparoscopy it was apparent that she had lost the left ovary to earlier torsion, despite the absence of a history of pain. However, torsion has occurred in infants and even in utero, l' 17In one of these infants) 7 laparotomy was performed at 2 weeks of age. A pseudocyst was removed, followed by fixation of the contralateral ovary. It is not clear whether or not plication of the uteroovarian ligament will have adverse effects on ovarian function or long-term effects on fertility. It is reassuring to note that 6 and 2 years postoperatively, respectively, our patients have established regular menses.
FIGURE 3. The suture has been placed in the right uteroovarian ligament in preparation for plication.
shortening of the utero-ovarian ligament and prevention of subsequent torsion (Figure 4). Discussion Most reported cases of ovarian torsion are unilatera!, but several cases of sequential torsion have been described. The right side is affected more frequently than the left. u Often underlying ovarian pathology is present, such as a benign neoplasm, however, torsion of normal ovaries is common. 1-3,6,8,11The symptoms may be varied, and as a result, the diagnosis is often delayed, leading to loss of the involved ovary. Doppler ultrasound will diagnose torsion accurately once blood
Summary Ovarian torsion must be considered in the differential diagnosis of pelvic pain, and especially in a patient with a history of torsion. Consideration should
FIGURE 4. The suture has been tied, plicating the right uteroovarian ligament.
497
Oophoropexy to Prevent Ovarian Torsion Nagel et al
7. Shun A: Unilateral childhood ovarian loss: An indication for contralateral oophoropexy? Aust NZ J Surg 60:791-794, 1990
be given to plication of the contralateral utero-ovarian ligament prophylactically in women undergoing surgical treatment if the ligament appears abnormally elongated. Unfortunately, this is a subjective judgment at present. We do recommend plication of the utero-ovarian ligament on the affected side if possible, although edema and other factors may make this difficult at the time of initial surgery. Patients with a history of torsion who subsequently develop intermittent lower abdominal or pelvic pain are candidates for laparoscopy. If other pathology does not explain the pain, plication of the utero-ovarian ligaments should be considered.
8. Grunewald B, Keating J, Brown S: Asynchronous ovarian torsion--The case for prophylactic oophoropexy. Postgrad Med J 69:318-319, 1993 9. Tanner JM: Growth at Adolescence, 2nd ed. Oxford, Blackwell, 1962 10. Vancaillie T, Schmidt EH: Recovery of ovarian function after laparoscopic treatment of acute adnexal torsion: A case report. J Reprod Med 32:561-562, 1987 11. Hibbard LT: Adnexal torsion. Am J Obstet Gynecol 152:456-461, 1985
References
12. Van VoohisBJ, Schwaiger J, Syrop CH, et al: Early diagnosis of ovarian torsion by color Doppler ultrasonography. Fertil Steril 58:215-217, 1992
1. Bower RJ, Adkins JC: Surgical ovarian lesions in children. Am J Surg 47:474--478, 1981
13. Rasado W, Tranabert M, Gosink B, et al: Adnexal torsion: Diagnosis by using Doppler sonography. AJR 159:1251-1253, 1992
2. Dunnihoo DR, Wolff J: Bilateral torsion of the adnexa: A case report and a review of the world literature. Obstet Gynecol 64:55S-59S, 1984
14. Wagaman R, Williams RS: Conservative therapy for adnexal torsion: A case report. J Reprod Med 35:833-834, 1990
3. Worthington-Kirsh RL, Raptopoulos V, Cohen IT: Sequential bilateral torsion of normal ovaries in a child. J Ultrasound Med 5:663-664, 1986 4. Buss JG, Lee RA: Sequential torsion of the uterine adnexa. Mayo Clin Proc 62:623-625, 1987
15. Oelsner G, Bider G, Goldenberg M, et al: Long-term follow-up of the twisted ischemic adnexa managed by detorsion. Fertil Steril 60:976-979, 1993
5. Wakamatsu M, Wolf P, Bernischke K: Bilateral torsion of the normal ovary and oviduct in a young girl. J Fam Pract 28:101-102, 1989
16. Gordon JD, Hopkins KL, Jeffrey RB, et al: Adnexal torsion: Color Doppler diagnosis and laparoscopic treatment. Fertil Steril 61:383-385, 1994
6. Davis AJ, Feins NR: Subsequent asynchronous torsion of normal adnexa in children. J Pediatr Surg 25:687-689, 1990
17. Mordehai J, Mares AJ, Barki Y, et al: Torsion of uterine adnexa in neonates and children: A report of 20 cases. J Pediatr Surg 26:1195-1199, 1991
498
TheJournal of the American Associationof Gynecologic Laparoscopists
Oophoropexy to Prevent Sequential or Recurrent Torsion Theodore C. Nagel, M.D., James Sebastian, M.D., and John W. Malo, M.D. Abstract Laparoscopic oophoropexy may prevent recurrent (repeat torsion of the same ovary) or sequential (subsequent torsion of the contralateral ovary) ovarian torsion. Two adolescent girls with sequential ovarian torsion underwent laparoscopic plication of utero-ovarian ligaments. Neither patient has had recurrence in the 6.5 and 2 years, respectively, since surgery.
(l Am Assoc Gynecol Laparosc 4(4):419--498, 1997)
7 months, but the girl continued to have intermittent pain, now located in the right lower quadrant. At age 10 years 3 weeks, pain was exacerbated and persistent. Laparotomy was performed with a preoperative diagnosis of appendicitis; however, the appendix was normal. The right ovary was found to have undergone torsion and was necrotic; it was removed. It was described as measuring 5.5 x 2.9 by 2.2 cm, and edematous and purple. No pathology was found other than evidence of necrosis. Two months later the girl experienced another episode of periumbilical pain that was diagnosed as enteritis. She subsequently developed episodic left lower quadrant pain, similar to that experienced on the right, that occurred with increasing frequency. When she was seen in our office at age 10 years 7 months, the pain was occurring weekly. It was of variable duration, from less than 1 hour to several hours. It frequently limited the girl's activity, and she would lie down until she experienced relief.
Sequential ovarian torsion has been described, 1-8 and in almost every instance the authors raised the question of whether or not oophoropexy should have been done at the time of the initial episode of torsion. In virtually every instance the second ovary was removed and the patient rendered menopausal. In two patients with sequential ovarian torsion the ovary was saved and oophoropexy performed laparoscopically in an effort to prevent recurrence. Case Reports
Patient No. 1
The patient was known to have umbilical hernia from birth. At age 9 years she began having intermittent abdominal pain associated with nausea and vomiting. The pain occurred primarily in the evening and was periumbilical. The hernia was repaired at age 9 years
From the Reproductive Health Associates, St. Paul, and Department of Obstetrics and Gynecology, University of Minnesota, Minneapolis, Minnesota (Drs. Nagel and Malt); and Duluth Obstetric-Gynecologic Association, Duluth, Minnesota (Dr. Sebastian). Address reprint requests to Theodore C. Nagel, M.D., Reproductive Health Associates, P.A., 360 Sherman Street, Suite 350, St. Paul, MN 55102; fax 612 222 8657.
495
Oophoropexy to PreventOvarian Torsion Nagel et al
Physical examination revealed a normal adolescent, 59 inches tall and weighing 105 lbs. Breasts and pubic hair were Tanner stage IV.9 She had not yet begun menstruating. Pelvic ultrasound showed a left ovary measuring 3.6 • 2.0 x 2.8 cm. Numerous cysts were present, the largest measuring 16 x 12 x 17 mm. The endometrium was well developed. At laparoscopy, the right ovary was absent. Fimbriae of the right tube were adherent to the cecum. The left ovary appeared large and smooth, resembling a polycystic ovary. The utero-ovarian ligament appeared excessively long, as did the mesovarium. The uteroovarian ligament was plicated. The patient has done well since surgery, and the pain has resolved. Puberty continued normally, and at age 16 she is having regular menses.
FIGURE 1. A remnant of the left tube. The probe at the left passes behind the twisted tube. No definitely identifiable ovary is seen.
Patient No. 2 A 13-year-old premenarchal girl experienced right lower quadrant pain for 4 or 5 days. It occurred intermittently and became progressively worse. Pelvic ultrasound revealed a 6-cm right ovarian cyst, and the patient was referred to one of the authors (JS) for further care. On examination there was marked tenderness at McBurney's point. The ovarian mass was palpable rectally, and palpation markedly exacerbated the pain. Laparoscopy disclosed an enlarged right ovary that had undergone torsion. The torsion was released and the ovary appeared to be viable. An incision was made into the ovary and the cyst was removed; it proved to be a simple cyst. The left adnexa consisted of a remnant of tube twisted back on itself (Figure 1). The left ovary was essentially gone. The tube was twisted in such a way that it was possible that torsion had occurred previously on this side, even though the girl had no history of an episode of pain. The patient was prescribed oral contraceptives after the procedure to prevent development of further physiologic cysts. Because of concern about recurrence, given the fact that the left ovary was absent and appeared to have undergone torsion, laparoscopy was repeated 2 months later. The ovary remained enlarged. There was a single avascular adhesion from the ovary to the broad ligament. The utero-ovarian ligament, which was very long (Figure 2), was plicated. Oral contraceptives were discontinued and the patient has remained asymptomatic.
Operative Procedure The technique of plication was essentially as described earlier. 1~ Permanent suture was passed through the utero-ovarian ligament at the ovarian insertion, through the midportion of the ligament in the opposite direction, and then back through the ligament at its uterine origin (Figure 3). The suture was then tied. In the first case knotting was intracorporeal, and in the second it was extracorporeal. The result was
FIGURE 2. The uterus is to the left; note the elongated uteroovarian ligament.
496
August 1997, Vd. 4, No. 4
The Journal of the American Association of Gynecologic Laparoscopists
flow in the ovary has ceased. 12However, this finding is not present at a time when the adnexa is most readily salvageable, that is, while there is still blood flow.~3 Numerous authors reported untwisting the adnexa 3, 9, 14 despite admonitions about the risk of embolization. One group ~4was unable to find reported cases of embolization as a result of untwisting an adnexal torsion. Two case reports 3' 10indicate preservation of function in these untwisted ovaries. Longterm follow-up of 40 patients whose torsion was treated by untwisting the ovary showed preservation of function in ovaries that appeared necrotic at initial surgery.15 The postoperative course was also surprisingly benign in these women. Preservation of the ovary and presumably its function was reported in an ovary that was untwisted after Doppler sonography showed absence of blood flow. 16 We believe our two patients are examples of sequential torsion. In the first girl the right ovary underwent torsion. At laparoscopy, the right ovary was necrotic, and no other pathology was found. The patient had numerous episodes of abdominal and fight lower quadrant pain before the episode that resulted in laparotomy. This was present in 10% of patients reported by others, a' s, u The recurrent episodes of left lower quadrant pain the girl experienced later were reminiscent of her earlier right lower quadrant pain. Laparoscopic plication of her elongated utero-ovarian ligament resulted in relief of pain, which has not recurred. In the second patient the correct diagnosis of right ovarian torsion was made before surgery. At laparoscopy it was apparent that she had lost the left ovary to earlier torsion, despite the absence of a history of pain. However, torsion has occurred in infants and even in utero, l' 17In one of these infants) 7 laparotomy was performed at 2 weeks of age. A pseudocyst was removed, followed by fixation of the contralateral ovary. It is not clear whether or not plication of the uteroovarian ligament will have adverse effects on ovarian function or long-term effects on fertility. It is reassuring to note that 6 and 2 years postoperatively, respectively, our patients have established regular menses.
FIGURE 3. The suture has been placed in the right uteroovarian ligament in preparation for plication.
shortening of the utero-ovarian ligament and prevention of subsequent torsion (Figure 4). Discussion Most reported cases of ovarian torsion are unilatera!, but several cases of sequential torsion have been described. The right side is affected more frequently than the left. u Often underlying ovarian pathology is present, such as a benign neoplasm, however, torsion of normal ovaries is common. 1-3,6,8,11The symptoms may be varied, and as a result, the diagnosis is often delayed, leading to loss of the involved ovary. Doppler ultrasound will diagnose torsion accurately once blood
Summary Ovarian torsion must be considered in the differential diagnosis of pelvic pain, and especially in a patient with a history of torsion. Consideration should
FIGURE 4. The suture has been tied, plicating the right uteroovarian ligament.
497
Oophoropexy to Prevent Ovarian Torsion Nagel et al
7. Shun A: Unilateral childhood ovarian loss: An indication for contralateral oophoropexy? Aust NZ J Surg 60:791-794, 1990
be given to plication of the contralateral utero-ovarian ligament prophylactically in women undergoing surgical treatment if the ligament appears abnormally elongated. Unfortunately, this is a subjective judgment at present. We do recommend plication of the utero-ovarian ligament on the affected side if possible, although edema and other factors may make this difficult at the time of initial surgery. Patients with a history of torsion who subsequently develop intermittent lower abdominal or pelvic pain are candidates for laparoscopy. If other pathology does not explain the pain, plication of the utero-ovarian ligaments should be considered.
8. Grunewald B, Keating J, Brown S: Asynchronous ovarian torsion--The case for prophylactic oophoropexy. Postgrad Med J 69:318-319, 1993 9. Tanner JM: Growth at Adolescence, 2nd ed. Oxford, Blackwell, 1962 10. Vancaillie T, Schmidt EH: Recovery of ovarian function after laparoscopic treatment of acute adnexal torsion: A case report. J Reprod Med 32:561-562, 1987 11. Hibbard LT: Adnexal torsion. Am J Obstet Gynecol 152:456-461, 1985
References
12. Van VoohisBJ, Schwaiger J, Syrop CH, et al: Early diagnosis of ovarian torsion by color Doppler ultrasonography. Fertil Steril 58:215-217, 1992
1. Bower RJ, Adkins JC: Surgical ovarian lesions in children. Am J Surg 47:474--478, 1981
13. Rasado W, Tranabert M, Gosink B, et al: Adnexal torsion: Diagnosis by using Doppler sonography. AJR 159:1251-1253, 1992
2. Dunnihoo DR, Wolff J: Bilateral torsion of the adnexa: A case report and a review of the world literature. Obstet Gynecol 64:55S-59S, 1984
14. Wagaman R, Williams RS: Conservative therapy for adnexal torsion: A case report. J Reprod Med 35:833-834, 1990
3. Worthington-Kirsh RL, Raptopoulos V, Cohen IT: Sequential bilateral torsion of normal ovaries in a child. J Ultrasound Med 5:663-664, 1986 4. Buss JG, Lee RA: Sequential torsion of the uterine adnexa. Mayo Clin Proc 62:623-625, 1987
15. Oelsner G, Bider G, Goldenberg M, et al: Long-term follow-up of the twisted ischemic adnexa managed by detorsion. Fertil Steril 60:976-979, 1993
5. Wakamatsu M, Wolf P, Bernischke K: Bilateral torsion of the normal ovary and oviduct in a young girl. J Fam Pract 28:101-102, 1989
16. Gordon JD, Hopkins KL, Jeffrey RB, et al: Adnexal torsion: Color Doppler diagnosis and laparoscopic treatment. Fertil Steril 61:383-385, 1994
6. Davis AJ, Feins NR: Subsequent asynchronous torsion of normal adnexa in children. J Pediatr Surg 25:687-689, 1990
17. Mordehai J, Mares AJ, Barki Y, et al: Torsion of uterine adnexa in neonates and children: A report of 20 cases. J Pediatr Surg 26:1195-1199, 1991
498