Left Adnexal Torsion Research Articles

Adnexal Torsion of a 28 cm Paratubal Cyst: A Case Report

Objective: To report a rare case of a 28 cm left adnexal torsion requiring surgical intervention including detorsion and salpingectomy Methods: Case report. Results: An 18-year-old nulliparous female with morbid obesity presented to the emergency department complaining of one week of sharp right lower quadrant pain with nausea and vomiting that had acutely worsened. Vital signs were notable for tachycardia, but otherwise within normal ranges. She had a significant leukocytosis. Her pregnancy test was negative. A CT abdomen/pelvis was obtained that demonstrated a large multiloculated complex cystic mass measuring 28.5 x 19.8 x 13.3 cm with possible origin from the ovaries that could represent a serous cystadenoma. Additionally, the scan was remarkable for a heterogeneous and enlarged left ovary measuring 7.6 x 5.9 x 7.2 cm, surrounded by free fluid and mesenteric edema. On examination, she did not demonstrate any surgical abdomen findings. Her pain improved with pain medication. She was admitted, tumor markers obtained, and an ultrasound ordered. The ultrasound demonstrated normal appearing right ovary with present doppler flow and a simple cyst measuring 6.6 x 5.1 x 6.1 cm. The left adnexa was noted to have a complex versus solid mass with unclear boundaries of the ovary. Also noted on the ultrasound were two large simple midline cysts measuring 10.5 x 9.1 x 11.8 cm inferiorly and 18.2 x 15.5 x 17.2 cm superiorly. No free fluid was seen within the right upper quadrant on ultrasound. The view of the left upper quadrant was suboptimal. Due to these findings, Gynecologic Oncology service was also consulted and after discussion, decision made to proceed urgently to diagnostic laparoscopy with robotic assisted cystectomy versus oophorectomy. Upon laparoscopic entry into the abdomen, a large necrotic-appearing left adnexal mass was visualized coming from the left fallopian tube. Both the left fallopian tube and left ovary were necrotic, with the left ovary being torsed numerous times. After resection of the large left fallopian tube and cyst, the left ovary was detorsed, and the decision was made to leave the ovary in situ. It still appeared necrotic, but its blood supply was intact. There was a large simple paratubal cyst on the right fallopian tube that was also drained and excised. Postoperatively, her right lower quadrant pain resolved, and she was discharged on post-operative day 1. She prescribed a two-week course of doxycycline and metronidazole as pelvic inflammatory disease could not be ruled out. At outpatient follow-up, she was asymptomatic and ready to begin working again. Her pathology report confirmed a large left paratubal cyst with associated findings of ischemia due to torsion and a large right paratubal cyst. Conclusions: Adnexal torsion is a rare gynecologic disorder caused by the partial or complete rotation of the ovary and/or the fallopian tube on its vascular support, which can negatively impact fertility. Prompt diagnosis is key, but definitive diagnosis is only by direct visualization. The differential diagnosis for acute onset of severe pelvic pain with nausea and vomiting is broad and includes ectopic pregnancy, pelvic inflammatory disease, endometriosis, ruptured ovarian cyst, urologic issues and gastrointestinal issues. Commonly, ultrasound is used to help evaluate a possible torsion with several classic findings that were not noted in this case, other than a mass. The two best known risk factors for adnexal torsion are a mobile ovarian mass and a history of prior torsion. Although large ovarian masses greater than 5 cm are more likely to cause torsion, some experts hypothesize that very large masses are less likely to torse given the constraints of the pelvis. However, such was not the case here. Additionally, it has been observed that adnexal torsion typically affects the right adnexa due to theoretical protection from the descending colon on the left. Given that the case presented did not have any of the typical imaging findings for adnexal torsion and that her pain was on the right but the torsion on the left, it is important to maintain a high level of suspicion when evaluating patients with acute onset pelvic pain of any location with nausea and vomiting.

Not every twist is ovarian torsion: a case report of isolated torsion of the fallopian tube in a child.

A 15-year-old girl presented with complaints of sudden onset left lower quadrant pain, nausea, and vomiting. There was tenderness in the left iliac fossa. Ultrasonography revealed inconclusive findings and contrast-enhanced computed tomography of the abdomen and pelvis suggested possible left adnexal torsion. Hence, she underwent a diagnostic laparoscopy which revealed a twisted, edematous, and congested left fallopian tube. The diagnosis of isolated left fallopian tube torsion was made and she was managed with unilateral salpingectomy. Women of the reproductive age group are usually affected by this condition. The common presentations are abdominal pain, nausea, and vomiting. The physical examination may reveal abdominal and cervical motion tenderness. Per abdominal ultrasound is the first go-to modality in children. Magnetic resonance imaging, if available, is advised in children if the ultrasound is inconclusive because of the absence of radiation. However, it may require sedation. Therefore, contrast-enhanced computed tomography abdomen gives an added advantage in such scenarios as in our case. This condition is managed by surgery with salpingectomy or tube detorsion with preservation of the tube, depending on the intraoperative findings. Clinicians should be aware of the condition given the rarity and challenges in the diagnosis of isolated fallopian tube torsion.

Double Adnexal Twist

PE with pain on the left lower abdominal quadrant, vaginal bimanual examination with Chandelier's sign positive. Blood work with Lymphocytosis of > 14,000 cells/microL, D-dimer by ELISA testing was 1,500 ng/mL. Laparoscopic surgery was performed (Figure 1), showing double left adnexal torsion (Figure 2). The evidence of necrotic tissue was visualized (Figure 3), and a left salpingo-oophorectomy was performed. The patient's recovery was unremarkable, without any complicated issues.

Torsion of a large ovarian cyst presented as an acute abdomen: Case report

Patients with acute abdominal pain often end up in the emergency department for surgical treatment. Ovarian cysts can lead to an acute abdomen due to torsion (twisting) or rupture. In this case report we are going to present a 70 y/o female patient with left adnexal torsion, due to a presence of ovarian cyst, presented as an acute abdomen. The patient was enrolled in the emergency department with acute abdomen, nausea and vomiting. After the initial evaluation including a Computerized tomography [CT] scan, the cyst presented as a solid hypodense mass behind the front abdominal wall, with the dimensions of Anteroposterior diameter [APd] 13cm, Laterolateral diameter [LLd] 11cm and Craniocaudal diameter [CCd] 15cm. The possible differential diagnosis [DDx] included cystic tumor [TU] mass on the mesentery as well as a cystic TU on the Urogenital tract (UGT). Intraoperatively adnexal torsion due to an ovarian cyst was found. The cyst and the left adnexa were then removed. Histopathological report showed ovarian hemorrhagic infarction due to a cystic tumor and torsion in the left adnexa. The diagnosis in such cases is often challenging because often the initial CT report can confuse the surgeon whether the mass arises from the mesentery or the urogenital tract.

Case report title information: Adnexal torsion in a premenarchal female with absence of contralateral ovary and fallopian tube

Abstract We report the case of a 9-year-old pre-menarchal female who presented with acute onset abdominal pain and findings concerning for left adnexal torsion. At the time of surgical intervention the patient was found to have absence of the contra-lateral ovary and fallopian tube. Awareness of the possibility of concomitant adnexal torsion and contralateral tubo-ovarian absence would help clinicians manage patients who present with similar symptoms. In such cases, early surgical intervention and ovarian preservation is critical, while delay in treatment can render the patient infertile.

Case Report: Sigmoid volvulus associated with a torsion of an ovarian cyst

Sigmoid volvulus is a life-threatening condition rarely seen in young adults. However, adnexal torsion is one of the top causes of gynecological emergencies, with prevalence increasing with the presence of an ovarian cyst. The association of sigmoid volvulus and adnexal torsion is exceptional. We report the case of a 33-year-old woman who presented to the emergency department for abdominal pain evolving for six hours, associated with gas and fecal matter obstruction. Clinical examination showed a restless patient with tachycardia and distended abdomen with severe tenderness in the left iliac fossa. A contrast-enhanced computed tomography (CT) scan of the abdomen revealed dilated large bowel loops showing bird beak-like narrowing of the sigmoid colon and whirl sign, suggestive of sigmoid volvulus with bowel wall compromise associated with left adnexal torsion secondary to a large pelvic mass. The patient underwent an emergency laparotomy. Exploration showed a torsion of the left adnexa secondary to a large cyst of the left ovary, carrying the sigmoid colon with it, which produces a volvulus of the sigmoid colon with 720° anticlockwise rotation. A sigmoid colectomy and Hartmann’s procedure associated with a left adnexectomy were performed. Although rare, the occurrence of a volvulus of the sigmoid in the young woman must be suggestive of torsion of the adnexa. Surgical management must be prompt, allowing both the ovary and the sigmoid to be saved.

Adnexal torsion in the third trimester of pregnancy: a case report and diagnostic value of MR imaging

BackgroundThe torsion of normal adnexa is rare during pregnancy, especially in the third trimester. Nonspecific symptoms and signs as well as the limitations of ultrasound (US) make the diagnosis difficult, resulting in the loss of adnexa and fetal compromise. The magnetic resonance imaging (MRI) features of the torsion of normal adnexa are not classically described during pregnancy and only reported in a few cases. We find some different MRI features of the torsion of normal adnexa in late pregnancy and its diagnosis and treatment values are discussed in our report.Case presentationA 27-year-old woman at 31 + 5 weeks’ gestation presented to the emergency department with a three-day history of the left lower abdominal pain. US discovered a mass of 87 × 61 mm in the left abdomen, but did not show whether the mass originated from the left ovary or the uterus. MRI showed the left ovary was increased in size to 82 × 42 × 85 mm with peripheral follicles. On fat-suppressed T2-weighted images, the signal intensity of the lesion was significantly decreased compared with the right ovary. The adjacent fallopian tube was found to be thickened. The radiologists diagnosed ovary infarction secondary to adnexal torsion. With the provisional diagnosis of adnexal torsion, the patient was taken to surgery. The left adnexal torsion was found during surgery. There was extensive hemorrhage and necrosis, so a left salpingo-oophorectomy was performed. The histopathology confirmed an extensively hemorrhagic fallopian tube and ovary with partial necrosis.ConclusionWe believe MRI is helpful where US is indeterminate in diagnosis of the torsion of normal adnexa in advanced pregnancy. We found that aside from hyperintensity on fat-saturated T1-weighted images, the low signal intensity on T2-weighted images can also reflect adnexal hemorrhage in conjunction with the torsion of normal adnexa.

3016 Management of Adnexal Torsion in Pregnancy

Video Objective The objective of this video is to review the risk factors, perioperative planning, and surgical management of adnexal torsion in advanced pregnancy. Setting The patient is a twenty-one-year-old gravida two para one at twenty-six weeks of gestational age who presented with left adnexal torsion. Her surgical management was performed at a tertiary care center that provides obstetrical and neonatal intensive care. Interventions A minimally invasive approach to the surgical management of adnexal torsion in advanced gestation is demonstrated. The procedure will be shown in a stepwise approach consisting of: identification of the anatomy, determination of accessory port placement, detorsion of the adenexa, and finally removal of the specimen. Furthermore, general pearls to utilize and pitfalls to avoid in laparoscopic surgery during pregnancy are discussed. Conclusion A minimally invasive approach to the management of adnexal torsion in advanced gestation can be safely accomplished through proper surgical planning, a stepwise approach, and minimal manipulation of the gravid uterus.

ADNEXAL TORSION IN 7-8 WEEKS PREGNANCY

Aim. Evaluation of clinico-laboratorial and sonographic signs of adnexal torsion. Materials and methods. Follow-up of the patient in the Perinatal Center of the Regional Clinical Hospital No. 2; ultrasound performed on Medison and Voluson E6; laparoscopy performed with the use of endoscopic devices KARL STORZ. Results. Left adnexal torsion was seen on ultrasound while the patient with a gestation period of 7-8 weeks was in the hospital. The main sonographic criteria for dynamic examination were: ovarian displacement and enlargement, changes in its echostructure, paraovarian cyst adherent to it, lack of blood flow in the ovary, and increasing hydroperitoneum. The 192 diagnosis was verified with laparoscopy and histological examination. Laparoscopic adnexectomy was performed. The postoperative period was unremarkable. Pregnancy progresses without complications. Conclusion . In the absence of convincing clinico-laboratorial, instrumental data indicative of adnexal torsion and an absolute indication for laparoscopy, ultrasound is necessary in dynamics. The above signs make possible to diagnose the adnexal torsion. Laparoscopy carried out in early pregnancy does not cause any complications in carrying of a pregnancy now.

Recurrent Adnexal Torsion

Abstract Background Adnexal torsion is a gynaecologic emergency caused by partial or complete twisting of the mesovarium; accounting for 3% of all gynaecological surgeries. We report a rare presentation of bilateral adnexal torsion within a period of 4 months in normal appearing ovaries. Case A 35-year-old women underwent total laparoscopic hysterectomy for third-degree uterine prolapse presented with left adnexal torsion within 45 days post surgery and later right adnexal torsion within a span of 2 months. She underwent laparoscopic left salpingo-oophorectomy and laparoscopic right oophoropexy later. Conclusion Predisposing factors for adnexal torsion is not known and its recurrence is definitely a concern. The importance of early diagnosis and surgical intervention in adnexal torsion is highlighted in a report showing delay of intervention for 36 h resulting in significant congestion and necrosis.

Ovarian Ligament Plication for Recurrent Adnexal Torsion

Abstract Background: Majority of the cases of adnexal torsion are associated with ovarian or paraovarian masses. Case: The authors report left adnexal torsion associated with a corpus luteal cyst. Following laparoscopic detorsion and cyst aspiration, the patient made an uneventful recovery. Twisting of the left adnexa recurred in the third month after surgery and was not associated with any obvious adnexal pathology. The left ovary was polycystic and both ovarian ligaments appeared elongated and hypermobile. Plication of bilateral ovarian ligaments was performed in addition to unwinding of the adnexa. Conclusion: The absence of adnexal masses does not preclude torsion. Concomitant shortening of long and lax ovarian ligaments along with detorsion can prevent recurrence in women with bulky polycystic ovaries who are prone to retorsion. (J GYNECOL SURG 31:229)

Laparoendoscopic single-site surgery for acute adnexal pathology during pregnancy: preliminary experience

Objective: To report the feasibility of laparoendoscopic single port surgical approach for the management of huge adnexal cysts and adnexal torsion during pregnancy. To discuss the optimal method of entry into the peritoneal cavity for pregnant patients.Design: Two case report.Method and patient(s): Two pregnant patients with adnexal mass. First patient, suffering from persistent and progressive abdominal distention and pain on her 12th week of pregnancy, was diagnosed with an ovarian cyst in 18 cm diameter on left ovary. The other patient had IVF twin pregnancy and presented with left adnexal torsion on the 25th week of pregnancyIntervention(s): Single-port laparoscopic ovarian cystectomy on the 12th week of pregnancy in patient one and single-port left adnexectomy in a twin pregnancy on the 25th week of pregnancy in patient two.Main outcome measure(s): Feasibility of single port laparoscopic intervention during pregnancy for adnexal mass.Result(s): Complete resolution of the symptoms for both pregnant women after the surgeries. No fetal and maternal complication was diagnosed during both pregnancies.Conclusion(s): Single port laparoscopy with open-entry technique is feasible and might be a better surgical option for the pregnant patients with adnexal pathology. However, further studies with larger sample size are needed to reach clear conclusion.

Torsion of the Fallopian Tube and the Haematosalpinx in Perimenopausal Women- A Case Report

An isolated fallopian tube torsion is a rare, often difficult to diagnose, but significant cause of acute lower abdominal pain in women of the reproductive age group. It is rare in the perimenopausal age group. We are presenting a literature review and the case of a 47 years old woman who presented with a sudden onset of acute lower abdominal pain . Her clinical examination revealed an 8x8 cm, tender, cystic mass in the left lower quadrant, with positive cervical movement tenderness. MRI revealed a gross hydrosalpinx with a small left ovarian cyst. With a diagnosis of left adnexal torsion, an emergency laparotomy was performed, which revealed an isolated left fallopian tube torsion which necessitated a left salpingo-oophorectomy. A tubal torsion should be suspected in females with acute lower abdominal pain, of any age group, especially in those with predisposing factors like pelvic infections, tumours and surgeries which include tubal ligation. Laparoscopy is the preferred modality for the diagnosis and treatment of a tubal torsion.

Adnexal torsion in the first trimester of pregnancy: A case report

Abstract Adnexal torsion is a rare cause of acute abdominal pain during pregnancy. It is frequently associated with ovarian stimulation for in vitro fertilization (IVF) or with ovarian masses, mainly of functional origin. It is uncommon for a normal-sized ovary to undergo torsion. Torsion of the ovary during pregnancy is common during third trimester. Adnexal torsion is rarely bilateral and is more common on the right side, perhaps because the sigmoid colon leaves a limited space for left adnexal mobility. Here we report a case of 23-year-old primigravida with 8 weeks pregnancy presented with sever left abdominal pain. Left abdominal tenderness was detected. Transabdominal ultrasound scan reported left adnexal torsion. Laparotomy and then left salpingo-oophorectomy were performed.

The Effect of High Dose Methylprednisolone on Experimental Ovarian Torsion/Reperfusion Injury in Rats.

Purpose: Aim of the study was to evaluate the effects of high dose methylprednisolone on experimental ovarian torsion-detorsion injury in rats. Materials and Methods: Twenty-two Sprague-Dawley rats were randomly divided into three groups. Group 1 (ischemia group, 8 rats) were subjected to left adnexal torsion for 2 h but received no treatment. Group 2 (methylprednisolone group, 8 rats) were subjected to left adnexal torsion for 2 h and received methylprednisolone (30 mg/kg, administered intraperitoneally) at the end of a 2-hour ischemic period followed by 24-hour reperfusion. Group 3 (control group, 6 rats) underwent a sham operation with no adnexal torsion and no treatment. Results: Serum malondialdehyde (MDA), ischemia-modified albumin (IMA), total oxidant status (TOS) and tissue MDA levels were increased in Group 1 rats; total antioxidant status (TAS) levels and oxidative stress index (OSI) were significantly decreased compared with rats in Groups 2 and 3 (p < 0.05). MDA, IMA, TOS and tissue MDA levels were lower and TAS levels and OSI were higher in Group 3 compared to Group 2. Ovarian damage scores in Group 1 were significantly higher compared with Groups 2 and 3 (p < 0.05). Conclusion: This study demonstrated that high dose methylprednisolone reduces ovarian ischemia/reperfusion injury.

Prevention of recurrent adnexal torsion

To report a case of adnexal torsion after in vitro fertilization (IVF) with two subsequent episodes of contralateral adnexal torsion and a novel approach for reducing the risk of recurrence. Case report. University-based IVF program. A 32-year-old woman who conceived with IVF and experienced sequential bilateral adnexal torsion. Left adnexal torsion was diagnosed with laparoscopic detorsion performed 2 days after embryo transfer. At 7 weeks' gestation, right adnexal torsion occurred and was managed with laparoscopic detorsion. Subsequently, right adnexal torsion recurred at 10 weeks' gestation, and laparoscopic detorsion with shortening of the uteroovarian ligament was performed. Gonadotropin ovulation induction, IVF, and laparoscopic detorsion of both right and left adnexa with shortening of the right uteroovarian ligament. Preservation of adnexa after torsion and successful pregnancy. Successful pregnancy and birth; resolution of torsion, prevention of recurrence with viable bilateral adnexa after detorsion and shortening of the utero-ovarian ligament with novel use of laparoscopic Endoloop. This is a unique case of multiple episodes of adnexal torsion following IVF with a new form of treatment using the laparoscopic Endoloop. Management of the infertility patient should be conservative and warrants ovarian preservation whenever possible. Multiple sequential episodes of adnexal torsion during a single pregnancy are a rare complication of IVF. Shortening of the utero-ovarian ligament is an alternative to oophoropexy to prevent recurrence.

Massive ovarian edema with torsion: unusual hemorrhage and the recovery of contrast enhancement

We report a case of massive ovarian edema due to left adnexal torsion. On initial magnetic resonance (MR), unusual hemorrhages were demonstrated as several hypointense areas on T2-weighted images. The lack of contrast enhancement was also observed in the left adnexa. Abdominal pain resolved spontaneously, and then follow-up MR demonstrated the recovery of enhancement and hemorrhages as hyperintense signals on T1-weighted images.

Successful pregnancy complicated by early and late adnexal torsion after in vitro fertilization

To report a case of unilateral adnexal torsion and subsequent contralateral adnexal torsion after in vitro fertilization. Case report and literature review. Academic fertility center; university hospital. A 28-year-old woman with tubal factor infertility conceived with IVF and experienced mild-to-moderate ovarian hyperstimulation syndrome. Right adnexal torsion occurred at 7 weeks of gestation, and laparoscopic detorsion was performed. Subsequent contralateral adnexal torsion occurred at 19 weeks and was managed with laparotomy and salpingo-oophorectomy. Laparoscopic right adnexal detorsion and laparotomy with salpingo-oophorectomy for left adnexal torsion. Preservation of torsed adnexa and successful pregnancy. Successful pregnancy and birth complicated by two episodes of adnexal torsion after IVF, and viable right adnexa after laparoscopic detorsion. Subsequent contralateral adnexal torsion is a rare complication of IVF and can occur in the second trimester. Data support preservation of the torsed adnexa despite the ovary's appearance.

Management of intermittent ovarian torsion by laparoscopic oophoropexy

Ovarian torsion is a serious gynecologic condition that often results in adnexal removal. If recurrent, this can result in castration of young patients. Torsion in the pediatric population is rare, but it presents more management challenges for gynecologists. There are few reports of prophylactic oophoropexy in patients with intermittent torsion. A patient with a history of left adnexal torsion was treated with salpingo-oophorectomy at age 10. She subsequently presented at age 12 with right lower quadrant pain, and was found to have a 7 x 6 cm right adnexal mass on ultrasound examination. She was diagnosed with ovarian edema secondary to intermittent torsion. At laparoscopy, she was found to have a 3-cm utero-ovarian ligament. She was treated with laparoscopic shortening of the utero-ovarian ligament, and has remained symptom-free for 1 year. We believe that this is the first reported case of laparoscopic triplication of the utero-ovarian ligament to prevent recurrent torsion. In young patients, this treatment may be a reasonable alternative to oophoropexy as prophylaxis for ovarian torsion.