Unexpected Gynecologic Findings During Abdominal Surgery

Abstract

As general surgeons, we are often asked to evaluate acute abdominal pain. The differential diagnosis of abdominal pain is broad, and includes disorders of the gastrointestinal, urogenital, gynecologic, vascular, and pulmonary systems. Abdominal pain may be caused by infectious, inflammatory, anatomic, or neoplastic processes. The management of abdominal pain varies by etiology, and accurate diagnosis is key to avoiding inappropriate treatment. Specifically, abdominal pain in women presents an additional diagnostic dilemma. Disease processes found exclusively in women should be kept in mind when presented with a female patient with abdominal pain. In women of childbearing age, pregnancy and conditions causing acute abdominal pain only during pregnancy must be considered, and all women of childbearing age should have either a serum or urine β-human chorionic gonadotropin (HCG) level as part of the initial diagnostic workup. In a pregnant patient, the differential diagnosis is modified, and should include disorders specific to pregnancy. Gynecological disorders that specifically occur during pregnancy include ectopic pregnancy, threatened abortion, retroverted gravid uterus, spontaneous uterine rupture, and chorioamnionitis. In addition, there are disease processes that are not specific to, but frequently occur during pregnancy. These may include torsion of a normal ovary or ovarian cyst or mass, pyelonephritis, pelvic inflammatory disease, acute salpingitis, tubo-ovarian abscess, pyosalpinx, torsion or degeneration of a uterine fibroid, and hemorrhage or rupture of an ovarian cyst. Accurate recognition and treatment of the disease is integral in order to achieve the best outcome for both the mother and developing fetus. Finally, both pregnant and non-pregnant women experience typical general surgical problems, including acute cholecystitis, appendicitis, diverticulitis, bowel obstruction, and perforated ulcers. However, the treatment of these diseases may be modified during pregnancy. For example, acute cholecystitis is often managed non-operatively during the first and third trimesters of pregnancy, while surgical intervention is recommended in the second trimester. For other conditions, surgical intervention is recommended regardless of gestational age. For instance, given the risk of rupture with acute appendicitis during pregnancy, appendectomy is indicated regardless of gestational age. Acute appendicitis is the most common surgical emergency,1 and is also the most common cause of non-gynecological pelvic pain.2 Many gynecologic conditions can mimic acute appendicitis, making the diagnosis unclear. Pelvic pathology may also be confused with other intraabdominal disease processes. For example, diverticulitis may be mimicked by an ovarian cyst or tubo-ovarian abscess; pelvic inflammatory disease may be misdiagnosed as generalized peritonitis secondary to a perforated viscera; acute cholecystitis may be confused with ovarian, appendiceal, or uterine pathology in the right upper quadrant during pregnancy. Despite vast improvements in imaging over the last three decades, at times it may still be difficult to differentiate between gynecologic and nongynecologic causes of abdominal pain prior to laparotomy or laparoscopy. The first step in the evaluation of a woman with abdominal or pelvic pain should include a complete history and physical examination. History-taking should include the history of present illness and characterization of the abdominal pain, medical and surgical history (in particular, previous pelvic surgeries, including hysterectomy and oophorectomy), sexual and contraceptive histories, and last menstrual period. Physical exam should include abdominal, pelvic, and bimanual examinations. In particular, careful questioning about and inspection for vaginal discharge or bleeding on pelvic exam should be performed. Physicians are commonly taught that cervical motion tenderness is pathognomonic for pelvic inflammatory disease (PID). However, any disease process causing pelvic inflammation may result in cervical motion tenderness, and other diagnoses should not be excluded based on the presence of this sign.3 In women of childbearing age who have not had a hysterectomy, including those on contraceptives, those with an intrauterine device in place, and those with partners who have had a vasectomy, a pregnancy test via urine β-HCG should be performed. When the diagnosis is unclear and a gynecological cause is included in the differential diagnosis, a gynecology consult should be considered. In all pregnant patients with abdominal pain, a gynecology consult is strongly recommended to optimize fetal and maternal outcomes. If diagnostic uncertainty exists, laparoscopy with direct visualization of the pelvis and abdominal cavity is often the best modality for investigating pelvic pain in women. The goal of this chapter is to discuss common obstetric and gynecologic abnormalities which the general surgeon may encounter in the evaluation of the female patient with acute abdominal pain. We will differentiate those gynecologic conditions that are specific to pregnancy and those that are less common during pregnancy. As many of these conditions can be diagnosed preoperatively, the diagnostic workup for each will be discussed. In cases where the diagnosis is unclear or recognized intraoperatively, we will discuss the surgical management of each entity. At times, pelvic pathology is incidentally found during elective abdominal procedures for other diagnoses; in this case, the appropriate intraoperative management of incidentally recognized obstetrical/gynecological pathology will be discussed.