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Torsion of the fallopian tube following tubal sterilization by electrocoagulation via a laparoscope
297
Europ. J. Obstet. Gynec. reprod. Bioi., 19 (1985) 297-300
Elsevier
EJO 00209
Case report
Torsion of the fallopian tube following tubal sterilization by electrocoagulation via a laparoscope Bent Ottesen,
M.H. Shokouh-Amiri
and Jack Hoffmann
Department of Surgery I, Kommunehospitalet,
Accepted
for publication
*
Copenhagen, 1399 Denmark
18 December
1984
OTTESEN, B., SHOKOUH-AMIRI, M.H. and HOFFMANN, J. (1985): Torsion of the fallopian tube following tubal sterilization by electrocoagulation via a laparoscope. Europ. J. Ohsret. Gynec,. reprod. B/o/. I Y, 297-300.
Sterilization of the fallopian tube via a laparoscope is being performed with increasing frequency. A rare but serious late complication of this procedure is tubal torsion, which occurs especially after monopolar electrocoagulation where the mesosalpinx is extensively damaged. We present a case in which this complication occurred after bipolar electrocoagulation. fallopian
tube torsion;
sterilization;
electrocoagulation
Case report A 37-yr-old woman was admitted to our department of general surgery with an acute abdomen. She had previously had two normal pregnancies. Eleven months before the current admission she had undergone sterilization by bipolar electrocoagulation of her fallopian tubes via a laparoscope at another hospital. She had suffered no symptoms between the sterilization procedure and her current admission, when she presented with a 36-h history of constant right iliac fossa pain which had gradually spread to the entire lower abdomen. She was nauseated but had no other gastrointestinal symptoms. She was in the middle of the menstrual cycle. On examination, her rectal temperature was 38°C and her white cell count 6.9. 109/1. There were signs of peritonitis in the lower abdomen. On vaginal examination there was no discharge and a tender resistance suggestive of a mass was felt in the right adnexa. The left adnexa was tender with no palpable mass. A preoperative diagnosis of torsion of an ovarian cyst was made and the patient was operated upon immediately. The operation was done by a general surgeon because our hospital has no gynecological department. The peritoneal cavity contained a small amount of * To whom correspondence
0028-2243/85/$03.30
should
be addressed.
0 1985 Elsevier Science Publishers
B.V. (Biomedical
Division)
298
blood-tinged fluid. The uterus was normal. The right adnexa, including the entire fallopian tube and ovary, was infarcted. It presented as a 10 X 7 X 4 cm mass which had undergone a torsion of 540”. On the left, a hydrosalpinx was found, with no torsion. The left ovary was normal. A right salpingo-oophorectomy and a left salpingectomy was performed. Microscopic examination confirmed the gross findings of infarction of the right adnexa and a left hydrosalpinx. 1. Discussion 675 000 tubal sterilizations are performed annually in the United States (Gregory, 1981). In Denmark (population 5 million) 6888 women underwent this procedure in 1981 (personal communication, Danish National Board of Health). Long-term complications following tubal sterilization such as chronic abdominal hydrosalpinx and tubal rupture have been reported pain, bleeding disorders, (Gregory, 1981; Stock, 1977; Kruger and Dahl, 1983). In addition, the possibility of tubal pregnancy, which can result in tubal abortion or tubal rupture, should be mentioned. Tubal torsion has also been sporadically described after various methods of tubal sterilization. Fourteen cases have been reported since 1956 and are summarized in Table I. Ours is the sixth case documented after electrocoagulation of the fallopian tube via a laparoscope. The interval between the sterilization procedure and presentation with torsion varies between 5 months and 8 years. Many patients present at the middle of their menstrual cycle, suggesting an association with ovulation. There is a history of acute onset of abdominal pain which may be generalized, or localized to the lower
TABLE Torsion
1 of the fallopian
tube following
tubal sterilization:
review of previous
publications
Authors
Year
Method of sterilization
Side
Interval following sterilization (months)
Kohl Sandler Kendrick Shapiro et al. Stock Pujari et al.
1956 1958 1965 1976 1977 1978
Bernardus
1981
Pomeroy Pomeroy Pomeroy coagulation coagulation Pomeroy Pomeroy Pomeroy Pomeroy coagulation coagulation coagulation Pomeroy clip coagulation
right right right right right right right left left right right left right bilateral right
17 72 96 8 14 24 72 48 72 5 12 84 11 8 11
and van der Slikke
Behrendt Present case
1983 1984
299
abdomen or either iliac fossa, most commonly the right. The pain, which may radiate to the loin or thigh, is colicky or constant and frequently unassociated with gastrointestinal symptoms. The latter fact may help to distinguish torsion of the fallopian tube from acute appendicitis. Unlike acute salpingitis, there is no fever or leucocytosis in early cases, but these may develop if the diagnosis is delayed. There are signs of peritoneal irritation in the iliac fossa involved and an adnexal mass can usually be palpated on vaginal examination. Some patients have been treated with antibiotics under a misdiagnosis of salpingitis, resulting in delays in surgical treatment of as long as eight days (Bernardus and van der Slikke, 1981). Preoperative diagnosis, previously rare, is now being made more frequently either clinically or laparoscopically. At operation the fallopian tube lateral to the site of sterilization is found twisted and infarcted with or without involvement of the ovary. The contralateral adnexa may be normal or the seat of a hydrosalpinx. Bilateral simultaneous torsion has been reported by Behrendt (1983). Treatment is by salpingectomy or salpingo-oophorectomy. Stock (1977) performed a total abdominal hysterectomy with bilateral salpingo-oophorectomy. Attempts to save the salpinx by detorsion and fixation have been suggested (Youssef et al., 1962) but do not seem appropriate in patients who have chosen sterilization. The aetiology of tubal torsion has been previously reviewed (Shapiro et al., 1976; Bernardus and van der Slikke, 1981; Youssef et al., 1962; Hansen, 1970). A multitude of disparate conditions of the adnexa and surrounding structures are propounded as factors predisposing to torsion. Basically it seems, however, that one or both of two situations are required before a fallopian tube will undergo torsion. namely abnormal mobility and abnormal bulk of the tube. This predisposing background is well known in torsion of other organs, for example the testis or the sigmoid colon. The coincidence of factors following tubal sterilization thus makes the fallopian tube pre-eminently susceptible to undergoing torsion: increased mobility is afforded by severing, or at least constricting, the attachment of the tube to the uterus. This is aggravated if the broad ligament too is damaged during the procedure. The increased bulk of the tube is produced when secretions from the tube can no longer take their natural path into the uterus, resulting in a hydrosalpinx. This presupposes that retrograde emptying of the tube into the peritoneal cavity has been thwarted by a preexisting blockage of the fimbrial end of the tube. The pathogenesis of hydrosalpinx following tubal sterilization is described by Gregory (1981). It is interesting to note that many of the cases occur during midcycle, a time when increased tubal vascularity and secretion might add to the ‘bulk’ of the tube. Youssef et al. (1962) maintain that a normal fallopian tube may undergo torsion, while more esoteric factors such as sudden changes in body position or exaggerated peristalsis have been quoted as having a bearing upon the aetiology of tubal torsion (Hansen, 1970). The predominance of right-sided torsion gives grounds for speculation, but the contention that this is a phenomenon of skewed sampling seems to be the most plausible (Bernardus and van der Slikke, 1981; Youssef et al., 1962). That is to say, a woman presenting with pain and peritoneal irritation in the right iliac fossa is more likely to be operated upon than one with a left-sided presentation where the diagnosis may be overlooked. Another possible explanation is that quite often there
are congenital tubal mobility
adhesions between the sigmoid colon and left tube. This might impede after coagulation, thereby preventing subsequent torsion.
References Behrendt, W. (1983): A rare complication following the insertion of a Bleier-Secu-Clip. Geburtsh. u. Frauenheilk., 43, 248-249. Bernardus, R.E. and van der Slikke, J.W. (1981): Tubal torsion, a late complication of sterilization? Ned. T. Geneesk., 125, 707-710. Gregory, M.G. (1981): Post tubal ligation syndrome or iatrogenic hydrosalpinx. J. Tenn. Med. Ass., 74, 712-714. Hansen, O.H. (1970): Isolated torsion of the fallopian tube. Acta obstet. gynec. stand., 49, 3-6. Kendrick, J.G. (1965): Torsion of the tube following Pomeroy sterilization. Obstet. and Gynec., 25, 124-125. Kohl, G.C. (1956): Torsion of the uterine tube following Pomeroy sterilization. Obstet. and Gynec., 7, 396-398. Kruger, S. and Dahl, C. (1983): Tubal rupture in a sterilized woman. Ugeskr. Lazg., 145, 3667. Pujari, B.D., Pujari, M.B. and Deodhare, S.G. (1978): Poststerilization tubal torsion. Int. Surg., 63, 84-86. Sandier, M.J. (1958): Torsion of the fallopian tube following tubal ligation. Amer. J. Obstet. Gynec., 76, 41-43. Shapiro, H.I., Hughes, W.F. and Adler, D.H. (1976): Torsion of the oviduct following laparoscopic sterilization. Amer. J. Obstet. Gynec. 126. 733-734. Stock, R.J. (1977): Torsion of a segment of fallopian tube: A case report of a long-term complication of sterilization by laparoscopic coagulation. J. Reprod. Med., 19, 241-242. Youssef, A.F., Fayad, M.M. and Shafeek, M.A. (1962): Torsion of the fallopian tube. A clinico-pathological study. Acta obstet. gynced. stand., 41, 292-309.
Europ. J. Obstet. Gynec. reprod. Bioi., 19 (1985) 297-300
Elsevier
EJO 00209
Case report
Torsion of the fallopian tube following tubal sterilization by electrocoagulation via a laparoscope Bent Ottesen,
M.H. Shokouh-Amiri
and Jack Hoffmann
Department of Surgery I, Kommunehospitalet,
Accepted
for publication
*
Copenhagen, 1399 Denmark
18 December
1984
OTTESEN, B., SHOKOUH-AMIRI, M.H. and HOFFMANN, J. (1985): Torsion of the fallopian tube following tubal sterilization by electrocoagulation via a laparoscope. Europ. J. Ohsret. Gynec,. reprod. B/o/. I Y, 297-300.
Sterilization of the fallopian tube via a laparoscope is being performed with increasing frequency. A rare but serious late complication of this procedure is tubal torsion, which occurs especially after monopolar electrocoagulation where the mesosalpinx is extensively damaged. We present a case in which this complication occurred after bipolar electrocoagulation. fallopian
tube torsion;
sterilization;
electrocoagulation
Case report A 37-yr-old woman was admitted to our department of general surgery with an acute abdomen. She had previously had two normal pregnancies. Eleven months before the current admission she had undergone sterilization by bipolar electrocoagulation of her fallopian tubes via a laparoscope at another hospital. She had suffered no symptoms between the sterilization procedure and her current admission, when she presented with a 36-h history of constant right iliac fossa pain which had gradually spread to the entire lower abdomen. She was nauseated but had no other gastrointestinal symptoms. She was in the middle of the menstrual cycle. On examination, her rectal temperature was 38°C and her white cell count 6.9. 109/1. There were signs of peritonitis in the lower abdomen. On vaginal examination there was no discharge and a tender resistance suggestive of a mass was felt in the right adnexa. The left adnexa was tender with no palpable mass. A preoperative diagnosis of torsion of an ovarian cyst was made and the patient was operated upon immediately. The operation was done by a general surgeon because our hospital has no gynecological department. The peritoneal cavity contained a small amount of * To whom correspondence
0028-2243/85/$03.30
should
be addressed.
0 1985 Elsevier Science Publishers
B.V. (Biomedical
Division)
298
blood-tinged fluid. The uterus was normal. The right adnexa, including the entire fallopian tube and ovary, was infarcted. It presented as a 10 X 7 X 4 cm mass which had undergone a torsion of 540”. On the left, a hydrosalpinx was found, with no torsion. The left ovary was normal. A right salpingo-oophorectomy and a left salpingectomy was performed. Microscopic examination confirmed the gross findings of infarction of the right adnexa and a left hydrosalpinx. 1. Discussion 675 000 tubal sterilizations are performed annually in the United States (Gregory, 1981). In Denmark (population 5 million) 6888 women underwent this procedure in 1981 (personal communication, Danish National Board of Health). Long-term complications following tubal sterilization such as chronic abdominal hydrosalpinx and tubal rupture have been reported pain, bleeding disorders, (Gregory, 1981; Stock, 1977; Kruger and Dahl, 1983). In addition, the possibility of tubal pregnancy, which can result in tubal abortion or tubal rupture, should be mentioned. Tubal torsion has also been sporadically described after various methods of tubal sterilization. Fourteen cases have been reported since 1956 and are summarized in Table I. Ours is the sixth case documented after electrocoagulation of the fallopian tube via a laparoscope. The interval between the sterilization procedure and presentation with torsion varies between 5 months and 8 years. Many patients present at the middle of their menstrual cycle, suggesting an association with ovulation. There is a history of acute onset of abdominal pain which may be generalized, or localized to the lower
TABLE Torsion
1 of the fallopian
tube following
tubal sterilization:
review of previous
publications
Authors
Year
Method of sterilization
Side
Interval following sterilization (months)
Kohl Sandler Kendrick Shapiro et al. Stock Pujari et al.
1956 1958 1965 1976 1977 1978
Bernardus
1981
Pomeroy Pomeroy Pomeroy coagulation coagulation Pomeroy Pomeroy Pomeroy Pomeroy coagulation coagulation coagulation Pomeroy clip coagulation
right right right right right right right left left right right left right bilateral right
17 72 96 8 14 24 72 48 72 5 12 84 11 8 11
and van der Slikke
Behrendt Present case
1983 1984
299
abdomen or either iliac fossa, most commonly the right. The pain, which may radiate to the loin or thigh, is colicky or constant and frequently unassociated with gastrointestinal symptoms. The latter fact may help to distinguish torsion of the fallopian tube from acute appendicitis. Unlike acute salpingitis, there is no fever or leucocytosis in early cases, but these may develop if the diagnosis is delayed. There are signs of peritoneal irritation in the iliac fossa involved and an adnexal mass can usually be palpated on vaginal examination. Some patients have been treated with antibiotics under a misdiagnosis of salpingitis, resulting in delays in surgical treatment of as long as eight days (Bernardus and van der Slikke, 1981). Preoperative diagnosis, previously rare, is now being made more frequently either clinically or laparoscopically. At operation the fallopian tube lateral to the site of sterilization is found twisted and infarcted with or without involvement of the ovary. The contralateral adnexa may be normal or the seat of a hydrosalpinx. Bilateral simultaneous torsion has been reported by Behrendt (1983). Treatment is by salpingectomy or salpingo-oophorectomy. Stock (1977) performed a total abdominal hysterectomy with bilateral salpingo-oophorectomy. Attempts to save the salpinx by detorsion and fixation have been suggested (Youssef et al., 1962) but do not seem appropriate in patients who have chosen sterilization. The aetiology of tubal torsion has been previously reviewed (Shapiro et al., 1976; Bernardus and van der Slikke, 1981; Youssef et al., 1962; Hansen, 1970). A multitude of disparate conditions of the adnexa and surrounding structures are propounded as factors predisposing to torsion. Basically it seems, however, that one or both of two situations are required before a fallopian tube will undergo torsion. namely abnormal mobility and abnormal bulk of the tube. This predisposing background is well known in torsion of other organs, for example the testis or the sigmoid colon. The coincidence of factors following tubal sterilization thus makes the fallopian tube pre-eminently susceptible to undergoing torsion: increased mobility is afforded by severing, or at least constricting, the attachment of the tube to the uterus. This is aggravated if the broad ligament too is damaged during the procedure. The increased bulk of the tube is produced when secretions from the tube can no longer take their natural path into the uterus, resulting in a hydrosalpinx. This presupposes that retrograde emptying of the tube into the peritoneal cavity has been thwarted by a preexisting blockage of the fimbrial end of the tube. The pathogenesis of hydrosalpinx following tubal sterilization is described by Gregory (1981). It is interesting to note that many of the cases occur during midcycle, a time when increased tubal vascularity and secretion might add to the ‘bulk’ of the tube. Youssef et al. (1962) maintain that a normal fallopian tube may undergo torsion, while more esoteric factors such as sudden changes in body position or exaggerated peristalsis have been quoted as having a bearing upon the aetiology of tubal torsion (Hansen, 1970). The predominance of right-sided torsion gives grounds for speculation, but the contention that this is a phenomenon of skewed sampling seems to be the most plausible (Bernardus and van der Slikke, 1981; Youssef et al., 1962). That is to say, a woman presenting with pain and peritoneal irritation in the right iliac fossa is more likely to be operated upon than one with a left-sided presentation where the diagnosis may be overlooked. Another possible explanation is that quite often there
are congenital tubal mobility
adhesions between the sigmoid colon and left tube. This might impede after coagulation, thereby preventing subsequent torsion.
References Behrendt, W. (1983): A rare complication following the insertion of a Bleier-Secu-Clip. Geburtsh. u. Frauenheilk., 43, 248-249. Bernardus, R.E. and van der Slikke, J.W. (1981): Tubal torsion, a late complication of sterilization? Ned. T. Geneesk., 125, 707-710. Gregory, M.G. (1981): Post tubal ligation syndrome or iatrogenic hydrosalpinx. J. Tenn. Med. Ass., 74, 712-714. Hansen, O.H. (1970): Isolated torsion of the fallopian tube. Acta obstet. gynec. stand., 49, 3-6. Kendrick, J.G. (1965): Torsion of the tube following Pomeroy sterilization. Obstet. and Gynec., 25, 124-125. Kohl, G.C. (1956): Torsion of the uterine tube following Pomeroy sterilization. Obstet. and Gynec., 7, 396-398. Kruger, S. and Dahl, C. (1983): Tubal rupture in a sterilized woman. Ugeskr. Lazg., 145, 3667. Pujari, B.D., Pujari, M.B. and Deodhare, S.G. (1978): Poststerilization tubal torsion. Int. Surg., 63, 84-86. Sandier, M.J. (1958): Torsion of the fallopian tube following tubal ligation. Amer. J. Obstet. Gynec., 76, 41-43. Shapiro, H.I., Hughes, W.F. and Adler, D.H. (1976): Torsion of the oviduct following laparoscopic sterilization. Amer. J. Obstet. Gynec. 126. 733-734. Stock, R.J. (1977): Torsion of a segment of fallopian tube: A case report of a long-term complication of sterilization by laparoscopic coagulation. J. Reprod. Med., 19, 241-242. Youssef, A.F., Fayad, M.M. and Shafeek, M.A. (1962): Torsion of the fallopian tube. A clinico-pathological study. Acta obstet. gynced. stand., 41, 292-309.