Page 35 - World Journal of Laparoscopic Surgery

Antenatally Diagnosed Ovarian Cysts with Torsion Managed Laparoscopically
This procedure has been extensively studied as a safe mode of and also due to the presence of a sigmoid colon on the left side. It
management as it involves easy removal of the specimen. With is also evident in a patient with a history of in vitro fertilization and
LESS, abdominal entry is safely accomplished using an open-entry ovarian hyperstimulation syndrome. 10,14–16 As the ovary enlarges,
technique. No additional incisions or ports are required. Also, it it twists on its vascular pedicle and undergoes torsion. Pregnancy
enhances the safety of the open-entry technique and facilitates itself increases the risk of ovarian torsion. Other factors identified
directly visualized fascia closure. This is a relatively new technique include the previous cesarean section and large ovaries, ovarian
that has been considered for surgery between 10 weeks and 20 tumors, and prior tubal ligation. Intraoperatively, findings range
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weeks. One concern with regards to LESS is the possibility of from a mature teratoma like a dermoid cyst, simple ovarian cyst,
umbilical hernia, especially because of the laxity and abdominal benign para-ovarian cyst, and corpus luteal cyst. 18
stress during pregnancy. Nevertheless, a recent report revealed an This condition is more commonly seen in the reproductive age
overall low risk of umbilical hernia with the LESS procedure with group though it can be seen in any age group. Also, in pregnancy,
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a running mass closure with delayed absorbable suture. Other it is encountered mostly during the first trimester with a few
drawbacks are technical difficulties and limited working space. cases seen in the second trimester as well. While some antenatal
Blind abdominal access techniques, such as, direct insertion women have unilateral ovarian torsion, bilateral torsion has also
of trocars or use of a Veress needle should be performed carefully been cited, not to mention the recurrence of torsion on the same
to avoid causing injury to the enlarged gravid uterus or displaced or contralateral side. 12
viscera. One should aim to practice minimal handling of the gravid Antenatal women usually present with abdominal pain,
uterus in any laparoscopic management of ovarian torsion. nausea, and vomiting with tenderness and rebound tenderness
Ovariopexy involves the fixation of the ovary to the abdominal on abdominal palpation. However, clinical findings alone can be
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wall. Munshi et al. have done ovariopexy after ovarian detorsion misleading, involving a spectrum of differential diagnoses. Hence,
and puncture of bilateral torted ovarian cyst in a case of a transvaginal ultrasound plays a pivotal role in contributing to the
spontaneous ovarian hyperstimulation syndrome in a singleton clinical diagnosis. Doppler ultrasonography is highly specific for the
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pregnancy. This secures the ovaries to its anatomical sites, reducing adnexal torsion, but it is not a sensitive test. Arterial blood flow
the recurrence of torsion. may be seen in adnexal torsion cases, leading to false-negative
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Hosny has illustrated oophoropexy as a method of results. The presence of flow does not exclude the torsion, instead
management in emergency cases of ovarian torsion. This involves suggests the viability of the ovary. Since torsion may be intermittent
the fixation of the ovary by transfixing the trocar site closure needle or one of the arteries may be twisted (uterine or ovarian) or only
with absorbable vicryl 2-0 suture through the ovary then picking venous thrombosis may occur, blood flow may be observed in
the suture from another transfixing point through the ovary then Doppler findings. The sonographic diagnosis is inaccurate in a third
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tying the suture out around the sheath. Oophoropexy is a debatable of cases. Torsion without the involvement of the ovary does not
procedure. While it is easier, faster, and more comfortable for exhibit any of the classic ultrasound findings other than a torted
managing ovarian torsion in pregnancy, it requires more training pedicle and therefore a sonographic diagnosis may be difficult.
for suturing by laparoscopy. Discolored ovaries had a normal appearance at future surgeries,
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Weitzman et al. have elaborately explained about the reinforcing the concept that an oophorectomy (after detorsion)
shortening of the utero-ovarian ligament by laparoscopic Endoloop should be the exception rather than the rule even if the ovary is
as an alternative to oophoropexy in the management of recurrent bluish-black. This has some implications in our clinical practice.
ovarian torsion. In this novel approach, a grasping forceps was Training in pelvic ultrasound to complement clinical judgment and
passed through an Endoloop and then used to tent up the utero- regular audits of treatment must be conducted to minimize pitfalls
ovarian ligament in the midsection. The Endoloop was then in diagnosis and management. An ultrasound examination cannot
tightened, pulling the ovary close to the uterus, and shortening be used as a sole diagnostic criterion to confirm or exclude torsion
the utero-ovarian ligament. This method decreases ovarian and a clinical assessment takes precedence.
mobility and the risk of bleeding. As much as this technique sounds Until 1989, salpingo-oophorectomy has been the standard
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promising, technical expertise is required and surgeons have to be method of management for ovarian torsion until Mage et al.
trained appropriately. introduced ovarian detorsion as a conservative alternative method
Adnexal torsion with or without additional surgical procedures for the same condition. This has proved to be a great success as the
does not have much of an effect on the gestational age at delivery. majority of ovarian torsion occurs in the reproductive age group
Neither does it cause any adverse maternal or fetal outcome. where fertility is the main concern. By preserving the ovaries, one
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Daykan et al. did a retrospective case–control study of pregnancy avoids premature ovarian failure and its consequences. In certain
outcomes after surgical intervention for adnexal torsion, in which situations, even if the ovaries appear bluish-black or hemorrhagic
both study and control groups provided similar results. The intraoperatively, detorsion has been fruitful. The ovarian function
gestation age at delivery was around 38 weeks in both groups, has been observed following that in subsequent transvaginal
so was the rate of preterm delivery. Also, there was no significant ultrasound for follicular study, future unrelated laparotomy, and
difference between the two groups in terms of neonatal outcome. in vitro fertilization. As much is said regarding the benefits of
Postoperatively, there was a 3.5% first-trimester miscarriage. This detorsion, the risks associated with this procedure include sepsis,
study further emphasizes the efficacy and safety of laparoscopic peritonitis due to toxins released by the ovary following reperfusion,
management of ovarian torsion in pregnancy. and probable pulmonary embolism.
While laparoscopic ovarian detorsion helps to restore blood
discussion supply to the ovaries and preserve its function, one cannot predict
Torsion of the ovary is more commonly seen in the right ovary the possibility of retorsion of the same ovary in the future. There
than the left ovary as the right tubo-ovarian ligament is longer are many novel approaches found by experts to prevent detorsion,

134 World Journal of Laparoscopic Surgery, Volume 13 Issue 3 (September–December 2020)