The Laparoscopic Approach to Uterine Adnexal Torsion in Childhood

By Zahavi Cohen, Daniel Shinhar, Gideon Kopernik, and Abraham J. Mares

Beer-Sheva, Israel

6 Seven girls with adnexal torsion (of varying degrees) torsion and to assess the viability of the organ. In all patients, the
were treated laparoscopically during a B-month period. All adnexa regained good blood supply and was spared. The second
had associated adnexal pathology. Six had simple follicular step consists of aspirating the cyst content, followed by cystectomy.
cysts (>4 cm in diameter), and one had a lo-cm dermoid cyst. In five patients, a drain was introduced m the Douglas pouch and
Detorsion with resection of the cyst and preservation of removed within 24 hours postsurgery.
ovarian tissue was performed in all cases. No intraoperative
or postoperative complications were encountered. Video- RESULTS
assisted minimally invasive surgery is suitable for the treat-
The mean time between admission and surgery was
ment of adnexal pathology in children; the hospitalization
period is short, the cosmetic results are excellent, and the 7.3 hours. All patients underwent detorsion of the
return to normal activity is rapid. twisted adnexa, aspiration of the cystic content, and
Copyright o 1996 by W. B. Saunders Company cystectomy. The ovary was viable and was spared in
all patients. No intraoperative complications were
INDEX WORDS: Uterine adnexa, torsion, laparoscopy.
encountered. The operating time ranged from 55 to
170 minutes (mean, 101.4 minutes). The postopera-
T ORSION OF UTERINE adnexa in children is
rare1-3 and usually is approached surgically, via
an “open” lower abdominal laparotomy. Although
tive course was uneventful for all patients. The
postoperative hospitalization period ranged from 1 to
4 days (mean, 2.7 days). Histological examination
the laparoscopic approach has been used for many confirmed the diagnosis of functional cysts in six and a
years in adult gynecologic surgery, its use in child- benign dermoid cyst in one. All patients have had
hood pelvic surgery is very limited.4-6 We have used follow-up with ultrasonography for 1 to 3 months
the laparoscopic approach in seven girls who had since the surgery. The ultrasonography showed nor-
torsion of the uterine adnexa, with excellent results. mal sizes and configuration of the involved ovaries in
all patients. In two of them, small cysts (1 cm x 1 cm)
MATERIALS AND METHODS were discovered. These girls will continue to have
From August 1994 to February 1995, seven girls underwent follow-up and repeat ultrasonographic evaluations.
laparoscopic detorsion of twisted adnexa, and resection of the
associated cysts. Their age range was 9.5 to 16 years (mean, 13.5 DISCUSSION
years). Five girls had right-sided torsion of adnexa, and two girls
had left-sided torsion. All patients presented with lower abdominal Adnexal torsion is encountered infrequently in
pain, the duration of which ranged from a few hours to 3 days chiidren.l--i Fewer than 300 cases of adnexal torsion in
before admission. In addition. four patients had nausea or vomit- infancy and childhood have been reported since
ing. Two girls had a history of recurrent episodes of lower 1890.1~2~7JIn 1991, we reported our experience with
abdominal pain. The physical examination showed lower abdomi-
nal tenderness in all patients. An abdominal mass was not 20 cases; six had antenatal torsion, and 14 had
palpable. Rectal examination was suggestive of a mass in only one postnatal torsion. Six involved torsion of normal
case. Body temperature was normal for all patients. The white uterine adnexa.2 Since then, we have encountered
blood cell count ranged from 6,300/mm3 to 13.700/mm3 (mean, more cases, all of which were treated with the
10.070/mm3). conventional surgical approach. Although minimally
In all patients, a preoperative diagnosis of adnexal torsion was
suspected, which was confirmed by ultrasonography in four cases. invasive surgical procedures were introduced in pedi-
Table 1 summarizes the ultrasonographic and the surgical findings
for each patient.
From the Departments of Pedratnc Surge? and Gynecology B.
Soroka Medical Center, Faculty of Health Sciences, Ben-Gunon
Surgical Technique University of the Negel: Beer-Sheva, Israel.
With the patient under general anesthesia, a nasogastric tube Address repnnt requests to Abraham J Mares, Department of
and a bladder Foley catheter are introduced. The patient ISplaced Pediatric Surgery. Sorokn Medical Center. Facula of Health Sciences,
supme in the Trendelenburg position. A CO* pneumoperitoneum Ben-Gution University of the Negev, PO Box 1.51, Beer-Sheva 84101,
is estabhshed through a Veress needle in the lower margin of the Israel.
umbilicus, to a pressure of 14 mm Hg. Figure 1 shows the sites and Copynghi 0 1996 by W.B. Saunders Cornpan?
sizes of the trocar insertion. The first step is to untwist the adnexal 0022.3468/9613111-0020$03.0010

JournalofPed/atr/cSurgery, Vol31, No 11 (November), 1996: pp 1557-1559 1557

1558 COHEN ET AL

Table 1. Findings From Preoperative Ultrasonography and Surgery 101 minutes) than that of the “open” technique. We
Case Age Preoperative expect it to be shorter as more experience is gained. It
No. W Ultrasonographic Frndings Surgrcal Findings
appears that postoperative pain is less, as judged by
1 9.5 Right adnexal well-defined 360” torsion of right adnexa;
the decreased need for analgesic drugs in comparison
cystic mass measuring simple ovarian cyst
6 x 4.5 cm; free fluid in to the need with “open” surgery. Other benefits
Douglas pouch observed are shorter postoperative hospitalization
2 16 Right adnexal cystic mass 540” torsion of right adnexa; (mean, 2.7 days) and earlier return to school and
measuring 6.4 x 4.7; free simple ovarian cyst
other daily activities. The cosmetic results are excel-
fluid in Douglas pouch
3 13 Right adnexal septated < 360” torsion of right lent. The issue of decreased early and late postopera-
cystic mass measuring adnexa: simple ovarian tive adhesions is still debatable and requires long-
6.2 x 7.7 cm: no fluid in cyst term follow-up.
Douglas pouch.
4 15 Right adnexal cystic mass < 360” torsion of right
Preoperative diagnosis of adnexal torsion is diffi-
measuring 6 x 10 cm, adnexa; dermoid cyst cult to establish because the symptoms and signs
with area suggestive of often are indistinguishable from those of acute appen-
calcification; no fluid in dicitis when the right side is involved.‘s* In the present
Douglas pouch
Right adnexal cystrc mass
series, the differential diagnosis of torsion was enter-
5 11 360” torsion of nght adnexa;
measuring 4.7 x 5 cm; simple ovarian cyst tained in all cases because of a high index of suspicion
fluid in Douglas pouch based on previous experience, followed by the imme-
6 14 Left adnexal cystic mass 720” torsion of left adnexa; diate use of ultrasonography.
measuring 3.5 x 4 cm; simple ovarian cyst
fluid in Douglas pouch
Four of the seven cases had clear ultrasonographic
7 16 Left adnexal cystic mass < 360” torsion of left evidence of adnexal torsion. In the other three,
measuring 6 x 7 cm; no adnexa; simple ovarian ultrasound imaging showed adnexal cysts without
fluid rn Douglas pouch cyst
clear-cut evidence of torsion. These findings, along
with the acute clinical symptoms and signs, led us to
atric surgery over the last 5 years, the use of laparos- prompt surgery.
copy was seldom reported for juvenile adnexal pathol- All adnexae were detorsed and salvaged, including
~gy.~J Our recent laparoscopic experience in the the four with torsion of greater than 360”. The
treatment of uterine adnexal torsion shows that associated pathology (six simple cysts, one benign
detorsion and cystectomy can be performed easily by dermoid cyst) was resected. This high success rate in
this method, although operating time is longer (mean, salvaging twisted adnexa is unusual in comparison to
other reports1p5T9J0and even to our own previous
experience.2y8
One of the seven patients had torsion due to a
benign dermoid cyst. The laparoscopic surgical ap-
proach to ovarian teratomas is debatable. Mezhat et
al have discussed this issue with respect to women
who present electively with an ovarian mass and
have concluded that malignancy is very uncommon
in patients under 14 years of age (1% to 3%) and
that expert laparoscopic management, in selected
cases, with careful technique in order to minimize the
chance of spillage, is a safe and beneficial alternative
to laparotomy. I1 On the other hand, we are aware
(from a large accumulated seriesl*) that ovarian
teratomas have a higher incidence of malignancy
(15%) in patients under 16 years of age. If malignancy
is suspected during the initial phase of laparoscopy,
conversion to the open technique is warranted.
In conclusion, our experience proved the feasibility
of the laparoscopic approach to adnexal torsion and
Fig 1. Trocar insertions: sites and sizes. associated pathology in children and adolescents.
LAPAROSCOPY FOR ADNEXAL TORSION 1559

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