9/18/2020 9/18/2020

CONTENTS
1. INTRODUCTION
Adnexal Torsion
2. EVALUATION
in Adolescents 3. MANAGEMENT
ACOG, 2019 4. CONCLUSION

Prof. Aboubakr Elnashar

Benha university
Hospital, Egypt

ABOUBAKR ELNASHAR ABOUBAKR ELNASHAR

1 2
 9/18/2020 9/18/2020

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

ABOUBAKR ELNASHAR ABOUBAKR ELNASHAR

3 4
 9/18/2020 9/18/2020

1.3. Risk Factors

1.4.Site
1. Pelvic masses exceed 5 cm.
 64% of torsions occur on the right side.
 The most common
 The lower rate of torsion on the left side
 functional ovarian cysts &
{the protective nature of the descending colon}
 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 ABOUBAKR ELNASHAR

5 6
 9/18/2020
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
7 8
9/18/2020
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
 9/18/2020 9/18/2020

2.1. Symptoms: 2.2. Signs

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

ABOUBAKR ELNASHAR ABOUBAKR ELNASHAR

9 10
 9/18/2020 9/18/2020

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

ABOUBAKR ELNASHAR ABOUBAKR ELNASHAR

11 12
 9/18/2020 9/18/2020

1. Unilateral ovarian enlargement 3. Doppler studies

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

13 14
 9/18/2020 9/18/2020

 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
Ultrasound whirlpool sign in ovarian torsion (A and B).
Color flow on Doppler ultrasonographic image demonstrates
 multiple small peripherally located follicles
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 ABOUBAKR ELNASHAR

15 16
 9/18/2020 9/18/2020

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

17 18
 9/18/2020 9/18/2020

 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. Ovarian torsion treated with
 Preserve the ovary regardless of its appearance and untwisting: second look 36
hours after untwisting.
the timing of presentation.
ABOUBAKR ELNASHAR ABOUBAKR ELNASHAR

19 20
 9/18/2020 9/18/2020

3.1. Operative Considerations 3.2. Surgical Approach

 Preoperative Counseling  Appreciation of the physiologic, anatomic, and
 Consent: surgical characteristics unique to this population
 includes the patient’s parent(s)  Minimally invasive approach with laparoscopy is
 procedural risks prefered
 possibility of a negative laparoscopy
 potential for a two-staged procedure
 need for postprocedure surveillance
 risk of recurrent ovarian torsion.

ABOUBAKR ELNASHAR ABOUBAKR ELNASHAR

21 22
 9/18/2020
 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
23
9/18/2020
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
24
 9/18/2020 9/18/2020

6. The process of insufflation requires modification 3.3. Management of Adnexal Masses

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

ABOUBAKR ELNASHAR ABOUBAKR ELNASHAR

25 26
 9/18/2020 9/18/2020

 Severely edematous and friable:  Cysts measuring 5 cm or more

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

27 28
 9/18/2020 9/18/2020

3.4. Oophoropexy 3.4. Pain Management

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

29 30
 9/18/2020 9/18/2020

3.5. Postoperative Counseling and Follow-up  The postoperative visit

 Adolescents generally recover well from surgery and  Diagnosis and procedure
resume activity quickly.  Prevention and likelihood of recurrence
 Weight-based lifting restrictions often are minimal,  Potential effect on future fertility
and most adolescents will self-limit activities because  Need for additional imaging
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 ABOUBAKR ELNASHAR

31 32
 9/18/2020 9/18/2020

Diagnosis and management of adnexal torsion in the adolescent.

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 ABOUBAKR ELNASHAR

33 34
 9/18/2020 9/18/2020

 Education of emergency, general, pediatric, and

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

ABOUBAKR ELNASHAR ABOUBAKR ELNASHAR

35 36