INTRODUCTION

 

Ovarian torsion is the twisting of the ovary on its vascular support is the fifth most common gynecologic surgical emergency.1 The condition is more common in premenarcheal females (children or premenarcheal adolescents) constitute up to 15–50 % of adnexal torsion cases.2 The association of an ovarian cyst is a common finding in twisted ovaries, the size of the cyst is usually moderate (i.e. around 5 cm).3.4.5.6  Diagnosis is basically clinical, however, pelvic imaging, primarily by transvaginal ultrasound (TVUS) and Doppler evaluation of ovarian blood flow, confirms the diagnosis and excludes similar conditions.7,8

The gold standard to treat ovary torsion is surgery (laparoscopy and laparotomy.9 An ovarian cystectomy is often performed for a benign ovarian mass. If malignancy is highly suspected, a salpingo-oophorectomy is needed. According to many observational studies, detorsion is associated with preserved ovarian function. 10,11,12,13 

The risk of recurrence after detorsion, but the incidence and causes are unknown. 14,15,16,17 One method is suppression of ovarian cysts by oral contraceptives.18,19 Another method is an oophoropexy by plication of uteroovarian ligament 20,21

 

PRE-OPERATIVE PREPARATION:

 

1. Patient to be under General anesthetized

2. Patient return plate should be attached to the thigh.

3. Abdomen and perineum to be painted and draped

4. The surgeon has to be on the patient’s left side, an assistant on the right side and 2nd assistant if needed in between patients legs for uterine manipulation

5. Monitor to be placed 15 degrees below the visual axis of the surgeon on the opposite side. 

6. All the equipment placed on the opposite side of the surgeon

7. Camera, light source, insufflator, and electrosurgical unit to be plugged into their respective equipment and all cables tied over upper drape using a gauze and towel clip.

8. Telescope with a camera attached to the light source.

9. Laparoscopic mode to be “on “on the camera cable attachment instrument

10. White balancing and focussing of camera done by placing the camera at a focal length of 10cm from gauze piece.

OPERATIVE STEPS PROPER:

PNEUMOPERITONEUM

1. Over inferior crease of the umbilicus, place 2 Allis tissue holding forceps on either side and give 2mm stab incision with No.11 blade.

2. Dilate rectus muscle until rectus sheath with mosquito forceps 

3. Check Veress Needle of 12 cm for its spring action and patency

4. Lift up the abdominal wall at the umbilicus and assess its full thickness,

5. Veress Needle is held like a dart the thickness of the abdominal wall from its distal end.

6. Insertion of veress needle through the incision site in a manner that the veress needle makes an angle of 90’ with the abdominal wall and an angle of 45’ with the body of the patient, pointing towards the anus.

7. Insertion is achieved with two audible clicks; first of the Rectus Sheath and second of the

Peritoneum

8. Release the Allis forceps from the Abdominal wall

9. Hold the Veress Needle at an angle of 45’ making sure that no further length of the needle is advanced.

10. Confirm the intraperitoneal placement of the veress needle by aspiration test, irrigation test and hanging drop test.

11. Ensure that the Gas tubing is attached to the Insufflator and the Insufflator is switched ON. This will remove air from the Gas tubing and fill the gas tubing till its tip with CO2 gas.

12. Confirm Pre-Set Pressure to 15mmHg on the Insufflator and Attach the gas tubing to the veress needle and start the flow of CO2 gas at 1 liter per minute

13. Confirm obliteration of liver dullness and generalized distension of abdominal wall

14. Keep watch on patient’s vital parameters and EtCO2 readings during insufflation.

15. The total amount of gas and actual pressure should rise in a linear fashion.

16. When actual pressure has reached pre-set pressure and amount of gas used might vary between 1.5 to 6 liters for an averagely build young patient

17. Once the pressure reaches the pre-set pressure, remove the veress needle and use size 11 blade to make skin incision to fit a 10mm port. This can be prechecked by placing a 10mm port on the skin for estimation of incision size

 

PORT PLACEMENT

 

1. Insert the 10mm cannula with trocar by oscillatory screwing motion, the direction being

perpendicular till give way sensation is perceived and then change the direction towards the pelvis. Once you are in, the trocar should be removed and the telescope should be inserted to confirm the intraperitoneal placement

2. Connect the insufflator to the optical port and switch on the gas.

3. To begin with, an overview inspection of the entire abdomen must be done and noted.

4. Then reach out to the target organ (ovary of affected side), just about to touch it with the tip of the telescope, and trans-illuminate the anterior abdominal wall to delineate the site of the target.

5. Use the baseball diamond concept to mark the position of the additional 5 mm ports.

6. Make 15 to 30 degree Trendelenburg tilt aids in moving the bowel to the upper abdomen.

7. The surgeon must use transillumination to avoid any vessel injuries in prospective port sites. Use the size 11 blade to make small incisions to fit the 5mm ports at the pre-marked sites as per Baseball diamond concept.

8. Based on the baseball diamond concept, 2 ipsilateral 5mm secondary ports made. 1stport is 7.5cm from primary port and 2ndport, 7.5cm from 1stport along the 18 cm arc.

9. Insert both the 5mm ports under direct vision and using principles same as that used for the primary port to avoid inadvertent visceral and vascular injuries.

10. These ports have to be placed such that the manipulation angle is 60degrees, elevation angle is 30 degrees and azimuth angle from 30 degrees to a maximum of 60 degrees as they are ipsilateral ports

 

 

SURGICAL STEPS:

 

SALPINGOOOPHORECTOMY

 

1. The uterine manipulator can be used to lift up the uterus for proper visualization.

2. Grasp the ovary which has undergone torsion with an atraumatic grasper and with tritome puncture the cyst and aspire the contents.

3. Undo the torsion with the help of 2 graspers and wait for 3-5 minutes for the blood supply to return.

4. If the ovarian tissue has become gangrenous and has to be removed and so proceed with salpingooopharectomy with coagulate and cut infundibulo pelvicum ligament

5. Coagulate and cut ovarian ligament mesovarium, fallopian tube

6. Coagulate and cut mesosalpinx 3cm lateral to the uterus

 

OOPHOROPEXY

 

1. Oophoropexy  by suturing continues  and tightening the proximal to the distal end of the ovarii proprium ligament to prevent further torsion in the future

2. Take it out the cyst with endobag / take it out to the posterior fornix posterior wall vaginal with colpotomy 

3. Clean the peritoneal cavity with suction irrigation.

4. Keep watch on ETCO2 level during surgery

5. Deflate the abdomen, remove the ancillary port under the vision and the primary port removed along with trocar.

6. Close 10mm port with veress needle or port closure after desuffation

7. Extubate patient and shift patient to recovery room

Elaboration of Steps:

Position the patient in the supine position.

Administer general anesthesia.

Insert a urinary catheter to empty the bladder.

Preoperative antibiotics are administered.

Make a 10-12mm incision at the level of the umbilicus.

Use a Veress needle to insufflate CO2 into the abdomen.

Insert a 10mm trocar through the incision.

Insert a laparoscope through the trocar and visualize the abdominal cavity.

Identify the ovary and fallopian tube.

Assess the degree of torsion of the ovary.

If the ovary is viable, perform an oophoropexy by suturing the ovary to the surrounding tissue.

If the ovary is non-viable or the torsion is severe, perform a salpingoophorectomy by ligating the ovarian vessels and removing the ovary and fallopian tube.

Use a monopolar or bipolar electrosurgical device to coagulate the ovarian vessels.

Use a laparoscopic grasper to clamp and divide the ovarian vessels.

Remove the ovary and fallopian tube.

Use a laparoscopic grasper to retract the uterus.

Inspect the surgical site for any bleeding or hematomas.

Close the peritoneum with sutures.

Deflate the abdomen and remove the trocars.

Close the incisions with sutures or staples.

Apply sterile dressing to the incisions.

The patient is awakened from anesthesia.

Extubate the endotracheal tube.

Move the patient to the post-anesthesia care unit.

Administer analgesics for pain management.

Monitor vital signs and urine output.

Check the dressing for bleeding or drainage.

Observe the patient for any signs of infection or complications.

Advise the patient to avoid strenuous activity for 2-4 weeks.

Advise the patient to avoid lifting heavy objects for 2-4 weeks.

Schedule a follow-up appointment.

Evaluate the patient's postoperative course.

Monitor for any complications, such as bleeding or infection.

Evaluate the patient's recovery of bowel and bladder function.

Adjust medication as needed.

Evaluate the healing of the incisions.

Provide the patient with a detailed report of the procedure and postoperative care.

Advise the patient on any potential complications or side effects of the procedure.

Provide the patient with instructions on follow-up appointments and monitoring.

Advise the patient on when to resume normal activities, such as driving, work, and exercise.

The patient follows up with the surgeon at regular intervals.

The surgeon evaluates the patient's healing and progress at each follow-up appointment.

The surgeon orders any necessary imaging or laboratory tests to evaluate progress.

The surgeon adjusts medications or treatment as needed.

The surgeon monitors the patient for any signs of complications or side effects.

The surgeon communicates with the patient's primary care physician to ensure continuity of care.

The surgeon provides the patient with information on any further treatment or follow-up care.

The patient continues to follow the surgeon's instructions and attend regular follow-up appointments.

 

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