Laparoscopic Management of Adnexal Torsion - Dr. R.K. Mishra

Laparoscopy for Adnexal Torsion

Adnexal torsion is a rare gynecologic emergency of women who are mostly at reproductive ages. So there is an increasing trend towards a conservative approach for the preservation of fertility in young women. Literature has all come to a point of agreement that as minimal surgery as possible and sparing of adnexa for these women of reproductive age since torted adnexa has benign histopathology mostly. Operative laparoscopic procedures are being performed increasingly in gynecology in recent years. It presents some main advantages over laparotomy. Smaller surgical scars that have a better healing process than a single big scar reduced postoperative pain and morbidity; and shorter hospital stays, recovery periods with a lower cost are the major advantages of laparoscopy. For a number of gynecologic conditions (ectopic pregnancy, benign ovarian cysts, tubal peritoneal infertility, etc. The results of laparoscopic treatment are comparable with those of laparotomy. For these reasons, operative laparoscopy has become the surgical treatment of choice for the conditions listed above. Like all surgery, operative laparoscopy does bring with it a risk of complications which need to be assessed.

Laparoscopic Management of Adnexal Torsion
Laparoscopic Management of Adnexal Torsion

Since mostly the lesions are benign in nature simply detorsion of the torted adnexa and if necessary the cyst excision is the preferred procedure. But what is very important is the time period between the diagnosis and treatment of the pathology. Since the torsion of adnexa causes relative ischemia of the ovarian tissue, it may result in failure and loss of ovarian function. In older studies, it was advised to remove the necrotic adnexa since they thought that it would cause pulmonary emboly. But in recent literature, it is not advised to remove the adnexa even if the adnexa looks necrotic because even severely necrotic looking adnexa may save its function after surgery. Some literature suggests that only simple detorsion procedure may cause retorsion and the rate of retortion is higher patients with normal-looking adnexa and is lower in the patients who have pathologic adnexa and some other procedure also applied with detorsion. Ovariopexy may be applied additionally if especially there is a long ovarian pedicle, more studies are needed to evaluate its value.

In the literature, it is shown in retrospective studies that in the patient selection for laparoscopic surgery, the size of the adnexal cystic pathology are important criteria that are the mean size of the cyst is smaller in laparoscopic surgeries compared to laparotomy. Risk factors for conversion to laparotomy are studied in some articles and it is found that the most important risk factor for conversion to laparotomy is previous pelvic surgery and especially hysterectomy. In cases where laparoscopic access can not be performed, mini-laparotomy is an alternative method and the results are comparable to laparoscopic surgery. Adnexal torsion in pregnant patients may occur due to drugs used for ovarian hyperstimulation at infertility therapy that increases the size of an ovary or due to the persistence of corpus luteum or other pathologic procedures of the adnexa. Laparoscopic detorsion and cyst excision procedures were safely applied in pregnant patients even in the third trimester of pregnancy. The maternal and fetal outcomes after the procedure were satisfactory and comparable to laparotomy. Open laparoscopy technique is advised in literature for the safety of the procedure in advanced pregnancy.

In the case of premenarchal and adolescence period, although very rare, adnexal torsion may occur and sometimes an additional congenital malformation accompany. With the advent of new and smaller instrumentation, laparoscopic surgery has extended to include the neonate as well as the pediatric patient. Laparoscopic detorsion and the sparing of the adnexa is the type of treatment encouraged in the literature in case of benign neoplasm, although the patient’s numbers are very limited. Some authors suggest contralateral oophoropexy in the case of the normal-appearing adnexa. In postmenopausal women due to an increase in the rate of malignant formations, preoperative investigations for predicting malignant and benign lesions are very important. Literature supports that in case of good analyses of the patient preoperatively and the criteria for the lesion to be benign are fulfilling, laparoscopic surgery is safe and if the intraoperative histopathological diagnosis is also benign, bilateral salpingo-oophorectomy is the treatment of choice. But in advanced centers with a skilled surgeon at malignant procedures, laparoscopic surgery, and laparoscopic staging may be performed in case suspicion of malignancy.

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