Aboubakr Elnashar

1. 9/18/2020
1
Adnexal Torsion
in Adolescents
ACOG, 2019
Prof. Aboubakr Elnashar
Benha university
Hospital, Egypt
ABOUBAKR ELNASHAR
9/18/2020
2
CONTENTS
1.INTRODUCTION
2.EVALUATION
3.MANAGEMENT
4.CONCLUSION
ABOUBAKR ELNASHAR

2. 9/18/2020
3
1. INTRODUCTION
1.1. Definition
 Torsion of
 a normal or pathologic ovary
 fallopian tube, paratubal cyst, or a combination of
these conditions
ABOUBAKR ELNASHAR
9/18/2020
4
1.2. Incidence
 5th most common gynecologic emergency.
 30% of all cases of adnexal torsion occur in females
younger than 20 years.
 5 of 100,000 females aged 1–20 years are affected
 Girls older than 10 years at increased risk
{hormonal influences & gonadal growth: an increased
frequency of physiologic and pathologic masses}.
ABOUBAKR ELNASHAR

3. 9/18/2020
5
1.3. Risk Factors
1. Pelvic masses exceed 5 cm.
 The most common
 functional ovarian cysts &
 benign teratomas.
 Torsion of malignant ovarian masses is rare.
2. Congenitally long ovarian ligaments
3. Excessive laxity of the pelvic ligaments, or a relatively
small uterus:
more space for the adnexa to twist on its axis
ABOUBAKR ELNASHAR
9/18/2020
6
1.4.Site
 64% of torsions occur on the right side.
 The lower rate of torsion on the left side
{the protective nature of the descending colon}
ABOUBAKR ELNASHAR

4. 9/18/2020
7
1.5. Contents
 In contrast to adnexal torsion in adults
 adnexal torsion in adolescent involves an ovary
without an associated mass or cyst in as many as
46% of cases.
 Rare cases of
 isolated tubal torsion and bilateral adnexal torsion
 almost always associated with tubal pathology,
such as hydrosalpinx or paratubal cyst
ABOUBAKR ELNASHAR
9/18/2020
8
2. EVALUATION
 No clinical or imaging criteria sufficient to confirm the
preoperative diagnosis of adnexal torsion.
 Emergent diagnostic laparoscopy in
 clinical suspicion for adnexal torsion
 DD of an adolescent presenting with abdominal pain
 Broad
 Presentation of adnexal torsion is nonspecific.
ABOUBAKR ELNASHAR

5. 9/18/2020
9
2.1. Symptoms:
1. Pain:
 The most common clinical sym
 Sudden -onset
 Intermittent , nonradiating
2. Nausea and vomiting
 in 62% and 67% of cases, respectively.
 more commonly in premenarchal patients
ABOUBAKR ELNASHAR
9/18/2020
10
2.2. Signs
1. Abdominal tenderness
In 88%
2. Rebound and peritoneal signs
in only 12–27% of patients.
3. Palpable adnexal mass
bimanual examination generally is not necessary or
tolerated
ABOUBAKR ELNASHAR

6. 9/18/2020
11
2.3.Investigations
 Tests
 Not useful
 Leukocytosis , pyuria
 C-reactive protein, ESR
 Interleukin -6
 D-dimer
ABOUBAKR ELNASHAR
9/18/2020
12
 TAUS:
 Imaging modality of choice.
 Sensitivity: 92%
 Specificity: 96%
 A completely normal-appearing ovary on US is
unlikely to be twisted.
ABOUBAKR ELNASHAR

7. 9/18/2020
13
1. Unilateral ovarian enlargement
2. Ovarian edema:
1. Hyperechogenic ovary {echogenic stroma}
2. Peripherally displaced follicles
3. Free fluid
4. Coiled vascular pedicle (“whirlpool sign”)
 highly specific
 technically difficult to visualize on TAS
ABOUBAKR ELNASHAR
9/18/2020
14
3. Doppler studies
 Limited {low sensitivity& operator dependency}.
 Presence of Doppler arterial flow does not rule out
torsion
 Normal Doppler arterial flow
 In 60% of surgically confirmed cases
{intermittent torsion, collateral blood supply from
the utero-ovarian vessels or infundibulopelvic
vessels, or a torsed paratubal cyst}.
 Alone should not guide clinical decision making.
ABOUBAKR ELNASHAR

8. 9/18/2020
15
Ultrasound whirlpool sign in ovarian torsion (A and B).
Color flow on Doppler ultrasonographic image demonstrates
the twisted pedicle (arrows) in a 12-year-old girl with a large,
mature cystic teratoma (T) arising from the left adnexa,
representing the lead point for left adnexal torsion.
ABOUBAKR ELNASHAR
9/18/2020
16
 CT or MRI:
 often is performed while evaluating a patient for
causes of abdominal pain.
 CT:T2- weighted images
 decreased ovarian enhancement post contrast
 asymmetric enlargement of the ovary
 uterine deviation toward the pathologic side
 multiple small peripherally located follicles
ABOUBAKR ELNASHAR

9. 9/18/2020
17
 Scores:
 Adnexal torsion is a surgical diagnosis
 To reduce the number of negative laparoscopies
 Combine clinical& radiologic findings:
 vomiting
 adnexal volume
 adnexal volume ratio [volume of affected ovary/
volume of unaffected ovary])
 Further studies are needed to validate these
scores.
ABOUBAKR ELNASHAR
9/18/2020
18
3. MANAGEMENT
 Although viability of an ovary declines as time
elapses from the onset of pain to surgical detorsion,
the ovary’s dual blood supply makes it resistant to
vascular injury
 Duration of vascular interruption needed to cause
irreversible damage to the ovary is unknown.
 The appearance of the ovary at surgery is not a
reliable indicator of ovarian viability.
ABOUBAKR ELNASHAR

10. 9/18/2020
19
 Multiple studies report future ovarian function despite
a grossly ischemic appearance at the time of surgery.
 After detorsion, improvements in the color of the
ovary may not be seen intraoperatively
 at second-look laparoscopy, near-normal appearing
ovaries are seen 36 hours after untwisting a blue-
black ovary
 No cases of VTE after detorsion.
 Preserve the ovary regardless of its appearance and
the timing of presentation.
ABOUBAKR ELNASHAR
9/18/2020
20
Ovarian torsion treated with
untwisting: second look 36
hours after untwisting.
ABOUBAKR ELNASHAR

11. 9/18/2020
21
3.1. Operative Considerations
 Preoperative Counseling
 Consent:
 includes the patient’s parent(s)
 procedural risks
 possibility of a negative laparoscopy
 potential for a two-staged procedure
 need for postprocedure surveillance
 risk of recurrent ovarian torsion.
ABOUBAKR ELNASHAR
9/18/2020
22
3.2. Surgical Approach
 Appreciation of the physiologic, anatomic, and
surgical characteristics unique to this population
 Minimally invasive approach with laparoscopy is
prefered
ABOUBAKR ELNASHAR

12. 9/18/2020
23
 When performing laparoscopy
1. Abdominal wall tissue integrity varies {fascial wall
tension and strength increases with age through
adolescence}: wide range of abdominal wall
puncture pressure that should be considered to
avoid injury to underlying structures
2. Adolescents are at higher risk of vascular injury
involving the aorta, inferior vena cava, or left
common iliac vein {distance from these major
vessels to the umbilical entry site is short}.
ABOUBAKR ELNASHAR
9/18/2020
24
3. Placement of secondary trocars (and laparotomy
incisions when needed) requires an appreciation for the
attenuated cranial to caudal distance and lateral
abdominal and pelvic distances in the adolescent.
4. The smallest possible trocars should be used
5. Fascial closure should be considered {increased risk
of fascial herniation when compared with adults}
ABOUBAKR ELNASHAR

13. 9/18/2020
25
6. The process of insufflation requires modification
{tolerable maximum distention pressure is lower in
pediatric and adolescent patients}.
1. Weighing 20 kg or greater: starting insufflation
pressure of 12 mm Hg and flow rates of 3–6 L/min
2. Weighing less than 20 kg: Lower pressure ranges
and flow rates
ABOUBAKR ELNASHAR
9/18/2020
26
3.3. Management of Adnexal Masses
 Cancer: rare (0.4 to 5%).
 Edema of the ovary:
 Enlargement
 ± interpreted mistakenly as an ovarian tumor on
imaging studies.
 It is reasonable to proceed with a concomitant
cystectomy.
ABOUBAKR ELNASHAR

14. 9/18/2020
27
 Severely edematous and friable:
{cystectomy: ovarian tissue damage and
bleeding that may lead to oophorectomy}
 If a cystectomy is not performed: consider incision
and drainage for large cysts.
 US to reevaluate the cyst at 6–12 w
 Simple cysts resolve within 6–8 w.
 Persistent cysts: laparoscopic ovarian
cystectomy can be performed given the risk of
recurrent torsion
ABOUBAKR ELNASHAR
9/18/2020
28
 Cysts measuring 5 cm or more
 treated in accordance to guidelines.
 Ovulation suppression
 with COC or depot medroxyprogesterone acetate
 can be initiated to prevent recurrent physiologic
cysts
ABOUBAKR ELNASHAR

15. 9/18/2020
29
3.4. Oophoropexy
 Indications
 Repeat torsion
 An absent contralateral ovary
 Recurrence rate
 low
 2% to 12%
 Higher in spontaneously torsed normal adnexa
ABOUBAKR ELNASHAR
9/18/2020
30
3.4. Pain Management
 Measures after laparoscopy
 Avoid excessively high or prolonged IAP
 Remove all insufflating carbon dioxide at the end
of the procedure
 Infiltrating all trocar sites with local anesthetic
 NSAI in combination with a short course (3 days or
less) of opiates.
 {Opioids , including tramadol, as few as 7 days can
develop dependence}
ABOUBAKR ELNASHAR

16. 9/18/2020
31
3.5. Postoperative Counseling and Follow-up
 Adolescents generally recover well from surgery and
resume activity quickly.
 Weight-based lifting restrictions often are minimal,
and most adolescents will self-limit activities because
of discomfort.
 Patients in whom a cyst was noted but not removed
at the time of detorsion should be counseled to limit
high-impact activities pending interval US findings.
ABOUBAKR ELNASHAR
9/18/2020
32
 The postoperative visit
 Diagnosis and procedure
 Prevention and likelihood of recurrence
 Potential effect on future fertility
 Need for additional imaging
ABOUBAKR ELNASHAR

17. 9/18/2020
33
Diagnosis and management of adnexal torsion in the adolescent.
ABOUBAKR ELNASHAR
9/18/2020
34
4. CONCLUSION
 The differential diagnosis of an adolescent presenting
with abdominal pain should include adnexal torsion.
 A minimally invasive surgical approach is
recommended with detorsion and preservation of the
adnexal structures regardless of the appearance of
the ovary.
 Surgeons should not remove a torsed ovary unless
oophorectomy is unavoidable, such as when a
severely necrotic ovary falls apart.
ABOUBAKR ELNASHAR

18. 9/18/2020
35
 Education of emergency, general, pediatric, and
gynecologic surgeons about current treatment
recommendations for adnexal torsion in adolescent
 Adolescents are a unique population with specific
needs; thus, special care for placement of ports and
lower insufflation pressure may be indicated.
 Multispecialty collaboration to optimize care and
ensure that minimally invasive detorsion with ovarian
preservation is the standard treatment
ABOUBAKR ELNASHAR
9/18/2020
36
You can get this lecture & 455 lectures from:
1.My scientific page on Face book: Aboubakr
Elnashar Lectures.
https://www.facebook.com/groups/2277448840913
51/
2.Slide share web site
3.elnashar53@hotmail.com
4.My clinic: Elthwara St. Mansura
ABOUBAKR ELNASHAR