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Adenxal torsion in adolescent

Aboubakr Elnashar

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Adenxal torsion in adolescent

  1. 1. 9/18/2020 1 Adnexal Torsion in Adolescents ACOG, 2019 Prof. Aboubakr Elnashar Benha university Hospital, Egypt ABOUBAKR ELNASHAR 9/18/2020 2 CONTENTS 1.INTRODUCTION 2.EVALUATION 3.MANAGEMENT 4.CONCLUSION ABOUBAKR ELNASHAR
  2. 2. 9/18/2020 3 1. INTRODUCTION 1.1. Definition  Torsion of  a normal or pathologic ovary  fallopian tube, paratubal cyst, or a combination of these conditions ABOUBAKR ELNASHAR 9/18/2020 4 1.2. Incidence  5th most common gynecologic emergency.  30% of all cases of adnexal torsion occur in females younger than 20 years.  5 of 100,000 females aged 1–20 years are affected  Girls older than 10 years at increased risk {hormonal influences & gonadal growth: an increased frequency of physiologic and pathologic masses}. ABOUBAKR ELNASHAR
  3. 3. 9/18/2020 5 1.3. Risk Factors 1. Pelvic masses exceed 5 cm.  The most common  functional ovarian cysts &  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 9/18/2020 6 1.4.Site  64% of torsions occur on the right side.  The lower rate of torsion on the left side {the protective nature of the descending colon} ABOUBAKR ELNASHAR
  4. 4. 9/18/2020 7 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 9/18/2020 8 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
  5. 5. 9/18/2020 9 2.1. Symptoms: 1. Pain:  The most common clinical sym  Sudden -onset  Intermittent , nonradiating 2. Nausea and vomiting  in 62% and 67% of cases, respectively.  more commonly in premenarchal patients ABOUBAKR ELNASHAR 9/18/2020 10 2.2. Signs 1. Abdominal tenderness In 88% 2. Rebound and peritoneal signs in only 12–27% of patients. 3. Palpable adnexal mass bimanual examination generally is not necessary or tolerated ABOUBAKR ELNASHAR
  6. 6. 9/18/2020 11 2.3.Investigations  Tests  Not useful  Leukocytosis , pyuria  C-reactive protein, ESR  Interleukin -6  D-dimer ABOUBAKR ELNASHAR 9/18/2020 12  TAUS:  Imaging modality of choice.  Sensitivity: 92%  Specificity: 96%  A completely normal-appearing ovary on US is unlikely to be twisted. ABOUBAKR ELNASHAR
  7. 7. 9/18/2020 13 1. Unilateral ovarian enlargement 2. Ovarian edema: 1. Hyperechogenic ovary {echogenic stroma} 2. Peripherally displaced follicles 3. Free fluid 4. Coiled vascular pedicle (“whirlpool sign”)  highly specific  technically difficult to visualize on TAS ABOUBAKR ELNASHAR 9/18/2020 14 3. Doppler studies  Limited {low sensitivity& operator dependency}.  Presence of Doppler arterial flow does not rule out torsion  Normal Doppler arterial flow  In 60% of surgically confirmed cases {intermittent torsion, collateral blood supply from the utero-ovarian vessels or infundibulopelvic vessels, or a torsed paratubal cyst}.  Alone should not guide clinical decision making. ABOUBAKR ELNASHAR
  8. 8. 9/18/2020 15 Ultrasound whirlpool sign in ovarian torsion (A and B). Color flow on Doppler ultrasonographic image demonstrates 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 9/18/2020 16  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  multiple small peripherally located follicles ABOUBAKR ELNASHAR
  9. 9. 9/18/2020 17  Scores:  Adnexal torsion is a surgical diagnosis  To reduce the number of negative laparoscopies  Combine clinical& radiologic findings:  vomiting  adnexal volume  adnexal volume ratio [volume of affected ovary/ volume of unaffected ovary])  Further studies are needed to validate these scores. ABOUBAKR ELNASHAR 9/18/2020 18 3. MANAGEMENT  Although viability of an ovary declines as time elapses from the onset of pain to surgical detorsion, the ovary’s dual blood supply makes it resistant to vascular injury  Duration of vascular interruption needed to cause irreversible damage to the ovary is unknown.  The appearance of the ovary at surgery is not a reliable indicator of ovarian viability. ABOUBAKR ELNASHAR
  10. 10. 9/18/2020 19  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.  Preserve the ovary regardless of its appearance and the timing of presentation. ABOUBAKR ELNASHAR 9/18/2020 20 Ovarian torsion treated with untwisting: second look 36 hours after untwisting. ABOUBAKR ELNASHAR
  11. 11. 9/18/2020 21 3.1. Operative Considerations  Preoperative Counseling  Consent:  includes the patient’s parent(s)  procedural risks  possibility of a negative laparoscopy  potential for a two-staged procedure  need for postprocedure surveillance  risk of recurrent ovarian torsion. ABOUBAKR ELNASHAR 9/18/2020 22 3.2. Surgical Approach  Appreciation of the physiologic, anatomic, and surgical characteristics unique to this population  Minimally invasive approach with laparoscopy is prefered ABOUBAKR ELNASHAR
  12. 12. 9/18/2020 23  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 9/18/2020 24 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
  13. 13. 9/18/2020 25 6. The process of insufflation requires modification {tolerable maximum distention pressure is lower in pediatric and adolescent patients}. 1. Weighing 20 kg or greater: starting insufflation pressure of 12 mm Hg and flow rates of 3–6 L/min 2. Weighing less than 20 kg: Lower pressure ranges and flow rates ABOUBAKR ELNASHAR 9/18/2020 26 3.3. Management of Adnexal Masses  Cancer: rare (0.4 to 5%).  Edema of the ovary:  Enlargement  ± interpreted mistakenly as an ovarian tumor on imaging studies.  It is reasonable to proceed with a concomitant cystectomy. ABOUBAKR ELNASHAR
  14. 14. 9/18/2020 27  Severely edematous and friable: {cystectomy: ovarian tissue damage and bleeding that may lead to oophorectomy}  If a cystectomy is not performed: consider incision and drainage for large cysts.  US to reevaluate the cyst at 6–12 w  Simple cysts resolve within 6–8 w.  Persistent cysts: laparoscopic ovarian cystectomy can be performed given the risk of recurrent torsion ABOUBAKR ELNASHAR 9/18/2020 28  Cysts measuring 5 cm or more  treated in accordance to guidelines.  Ovulation suppression  with COC or depot medroxyprogesterone acetate  can be initiated to prevent recurrent physiologic cysts ABOUBAKR ELNASHAR
  15. 15. 9/18/2020 29 3.4. Oophoropexy  Indications  Repeat torsion  An absent contralateral ovary  Recurrence rate  low  2% to 12%  Higher in spontaneously torsed normal adnexa ABOUBAKR ELNASHAR 9/18/2020 30 3.4. Pain Management  Measures after laparoscopy  Avoid excessively high or prolonged IAP  Remove all insufflating carbon dioxide at the end of the procedure  Infiltrating all trocar sites with local anesthetic  NSAI in combination with a short course (3 days or less) of opiates.  {Opioids , including tramadol, as few as 7 days can develop dependence} ABOUBAKR ELNASHAR
  16. 16. 9/18/2020 31 3.5. Postoperative Counseling and Follow-up  Adolescents generally recover well from surgery and resume activity quickly.  Weight-based lifting restrictions often are minimal, and most adolescents will self-limit activities because 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 9/18/2020 32  The postoperative visit  Diagnosis and procedure  Prevention and likelihood of recurrence  Potential effect on future fertility  Need for additional imaging ABOUBAKR ELNASHAR
  17. 17. 9/18/2020 33 Diagnosis and management of adnexal torsion in the adolescent. ABOUBAKR ELNASHAR 9/18/2020 34 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
  18. 18. 9/18/2020 35  Education of emergency, general, pediatric, and gynecologic surgeons about current treatment recommendations for adnexal torsion in adolescent  Adolescents are a unique population with specific needs; thus, special care for placement of ports and lower insufflation pressure may be indicated.  Multispecialty collaboration to optimize care and ensure that minimally invasive detorsion with ovarian preservation is the standard treatment ABOUBAKR ELNASHAR 9/18/2020 36 You can get this lecture & 455 lectures from: 1.My scientific page on Face book: Aboubakr Elnashar Lectures. https://www.facebook.com/groups/2277448840913 51/ 2.Slide share web site 3.elnashar53@hotmail.com 4.My clinic: Elthwara St. Mansura ABOUBAKR ELNASHAR