Adnexal torsion is a gynecological emergency characterized by the twisting of the ovary and sometimes the fallopian tube around its vascular pedicle, leading to compromised blood supply. If left untreated, torsion can result in ischemia, necrosis, and eventual loss of ovarian function. In reproductive-age women, where fertility preservation is paramount, timely diagnosis and surgical intervention are essential. While detorsion of the adnexa restores blood flow and often salvages the ovary, recurrence is a significant concern, particularly in younger patients and those with predisposing anatomical factors. Laparoscopic oophoropexy, a procedure that involves fixation of the ovary to adjacent pelvic structures, has emerged as an effective strategy for preventing recurrent adnexal torsion.

Understanding Recurrent Adnexal Torsion

Adnexal torsion accounts for nearly 3% of gynecologic emergencies. It is commonly associated with predisposing conditions such as ovarian cysts, elongated utero-ovarian ligaments, hypermobility of adnexa, or absence of normal pelvic adhesions. Recurrent torsion is observed in cases where initial detorsion is performed without addressing underlying risk factors. The risk of recurrence is higher in adolescents and women with structurally normal adnexa.

Recurrence not only increases the risk of ovarian damage but also affects quality of life due to repeated emergency surgeries. In such cases, preventive procedures like oophoropexy are warranted to reduce the likelihood of repeated torsion while preserving ovarian function.

Principle of Oophoropexy

Oophoropexy refers to surgical fixation of the ovary to adjacent stable structures such as the pelvic sidewall, posterior uterine surface, or round ligament. The objective is to limit abnormal mobility of the ovary and thereby prevent torsion while maintaining ovarian function and reproductive potential. Laparoscopic oophoropexy offers a minimally invasive approach, ensuring precision, minimal tissue trauma, and faster recovery compared to open surgery.

Indications for Laparoscopic Oophoropexy

Recurrent adnexal torsion after initial detorsion.

Anatomical predispositions such as elongated utero-ovarian ligaments or hypermobile adnexa.

Torsion occurring in adolescents or young women with preserved ovarian function.

Cases where ovarian conservation is critical, such as in women with a single ovary or diminished ovarian reserve.

Surgical Technique

Preoperative Preparation
Patients undergo ultrasonography or MRI to evaluate adnexal anatomy, ovarian blood flow, and exclude malignancy. Baseline ovarian reserve testing may be considered in women seeking fertility.

Anesthesia and Positioning
The procedure is performed under general anesthesia. The patient is placed in a lithotomy position with a slight Trendelenburg tilt to optimize pelvic visualization.

Port Placement
A standard laparoscopic setup is employed with a 10-mm umbilical port for the laparoscope and two or three 5-mm accessory ports for instruments.

Detorsion of the Ovary
If torsion is present, the adnexa is carefully untwisted to restore blood flow. Immediate color change of the ovary is not always necessary for salvage, as ischemic-appearing ovaries can often regain function after detorsion.

Oophoropexy Techniques
Several techniques have been described for oophoropexy:

Fixation to the pelvic sidewall: The ovary is sutured to the lateral pelvic peritoneum using non-absorbable sutures, reducing mobility.

Utero-ovarian ligament plication: The elongated ligament is shortened by folding and suturing, limiting torsion risk.

Fixation to the round ligament or posterior uterine surface: Provides stability while keeping the ovary in a functional anatomical position.

Multiple point fixation: In recurrent cases, securing the ovary at more than one point reduces chances of retorsion.

Absorbable sutures may be used, but non-absorbable or delayed absorbable materials are often preferred for long-term fixation.

Completion
Hemostasis is ensured, ports are removed, and the patient is awakened from anesthesia.

Postoperative Care and Recovery

Recovery after laparoscopic oophoropexy is generally rapid. Patients are discharged within 24–48 hours, with mild postoperative pain managed by oral analgesics. Early ambulation and resumption of light activities are encouraged. Most women can return to normal daily routines within a week. Follow-up includes ultrasound monitoring of ovarian vascularity and position. Fertility counseling may be offered depending on reproductive goals.

Outcomes and Efficacy

Laparoscopic oophoropexy has demonstrated excellent outcomes in preventing recurrence of adnexal torsion. Fertility preservation is achieved in the majority of patients, and long-term ovarian function is maintained. Recurrence rates after fixation are significantly lower compared to simple detorsion alone. For adolescents and women desiring future fertility, oophoropexy provides reassurance against repeated torsion and associated ovarian damage.

Potential Complications

Though rare, possible complications include:

Ovarian atrophy if blood supply is compromised during surgery.

Adhesion formation at the fixation site.

Recurrence of torsion if fixation is inadequate.

Injury to adjacent structures such as bowel, bladder, or pelvic vessels.

Meticulous surgical technique and careful selection of fixation method minimize these risks.

Conclusion

Recurrent adnexal torsion poses a significant threat to ovarian function and fertility in women of reproductive age. Laparoscopic oophoropexy provides a minimally invasive, safe, and effective solution by stabilizing the ovary and preventing further torsion episodes. Through techniques such as ligament plication or ovarian fixation to stable pelvic structures, surgeons can preserve fertility and prevent repeated emergency surgeries. With its proven efficacy, rapid recovery, and fertility-preserving benefits, laparoscopic oophoropexy has become the standard approach for managing recurrent adnexal torsion.