Torsion of the surgical pedicle of an ovarian tumor
The surgical pedicle, which is transected during surgery, always includes a stretched fallopian tube. The pathology is frequently triggered by abrupt movements (gymnastics, dancing), a sudden spike in intra-abdominal pressure, or increased peristalsis. Due to inertia, the tumor rotates, twisting the nourishing vessels.
- Complete torsion (from 360°): causes acute ischemia, necrosis, and rapid development of aseptic inflammation progressing to peritonitis. Clinical presentation is prominent: sudden severe pain, vomiting, intestinal paresis, and a positive Shchetkin-Blumberg sign.
- Partial torsion: venous outflow is compromised first while arterial inflow remains intact. Symptoms may escalate gradually or temporarily subside.
Diagnosis is based on ultrasound and bimanual examination (revealing a sharply tender mass). In girls, examination is frequently difficult due to pain and muscle guarding, requiring general anesthesia.
Surgical management: Laparoscopic approach is preferred. If necrosis of a benign lesion is diagnosed, adnexectomy (removal of the adnexa) on the affected side is performed. Importantly, the pedicle is never untwisted to avoid thromboembolism.
However, the modern paradigm requires maximum organ preservation, especially in children and adolescents. If there are no visual signs of tissue death, the pedicle is detorsed (untwisted). If blood flow is restored, the adnexa are preserved, limiting the intervention to ovarian resection. In cases of peritonitis, the surgery is concluded with abdominal cavity drainage.
Impaired blood supply and necrosis of a myometrial node
This complication occurs in 7% of patients with myoma, frequently manifesting during pregnancy or postpartum due to decreased myometrial blood flow and rapid node growth. Causes include torsion of a subserous node pedicle or vascular insufficiency.
- Acute course: typical for torsion. Manifests with cramping pain, vomiting, and peritoneal signs. Laparoscopy reveals a cyanotic-purple edematous node. Requires emergency surgery.
- Subacute course: associated with impaired node nutrition. Pain is aching in nature and builds up gradually. Ultrasound reveals signs of ischemia: structural heterogeneity and the appearance of fluid-filled cavities.
Management strategy: When blood supply is impaired, conservative infusion and pharmacotherapy are initiated first (antispasmodics, microcirculation-improving drugs). If there is no effect within 24–48 hours, the condition worsens, or peritonitis develops, surgical intervention is indicated. In women of reproductive age, organ-sparing conservative myomectomy is performed; in pre- and postmenopause, supracervical hysterectomy or total hysterectomy is performed.
Ovarian apoplexy
Apoplexia ovarii is a sudden rupture of ovarian tissue, typically occurring in the mid-cycle or second phase during the peak of gonadotropic hormones. Predisposing factors include inflammatory processes, pelvic varicosities, and coagulopathies, while triggers include physical exertion, abdominal trauma, or vigorous sexual intercourse.
Two main forms are distinguished, which determine the management strategy:
- Pain form: intra-abdominal hemorrhage is absent, hemodynamics are stable. Ultrasound reveals a corpus luteum with hemorrhage, but no free fluid in the pelvis. Treatment is predominantly conservative in a hospital setting (strict bed rest, ice to the abdomen, hemostatics, antispasmodics).
- Hemorrhagic form: accompanied by bleeding into the abdominal cavity, blood pressure drop, tachycardia, pallor, and the risk of hemorrhagic shock. Culdocentesis (puncture of the posterior vaginal fornix) yields dark, non-clotting blood.
Surgical treatment: In the hemorrhagic form, emergency surgery with concurrent infusion-transfusion therapy is indicated. The gold standard is laparoscopy with coagulation or suturing of the rupture. Ovarian removal (oophorectomy) is acceptable only in cases of massive, irreparable destruction. If the patient has developed hemorrhagic shock with unstable hemodynamics or has severe adhesions, the creation of pneumoperitoneum is contraindicated—laparotomy is performed.
Briefly: answers to topical questions
What structures form the surgical pedicle of an ovarian tumor?
The surgical pedicle of an ovarian tumor consists of the anatomical pedicle and the stretched fallopian tube. It is the surgical pedicle that is transected during surgical intervention. Structurally, it includes the following elements:
- Anatomical pedicle — consists of the ovarian proper ligament (lig. ovarii proprium) and the suspensory ligament of the ovary (lig. suspensorium ovarii).
- Fallopian tube — the stretched part complementing the surgical pedicle.
What structures form the anatomical pedicle of the ovary?
The anatomical pedicle of the ovary includes:
- Ovarian ligament (lig. ovarii proprium).
- Suspensory ligament of the ovary (lig. suspensorium ovarii).
Which blood vessels are compressed during the torsion of an ovarian tumor pedicle?
During the torsion of an ovarian tumor pedicle, the nourishing vessels are kinked:
- Ovarian branches of the uterine artery.
- Ovarian artery.
- Accompanying veins.
In partial torsion, venous outflow is compromised first while arterial inflow remains relatively intact. Secondary changes—necrosis and hemorrhages—develop gradually. Circulatory impairment can lead to necrosis, aseptic inflammation, and peritonitis.
Which acute conditions must ovarian apoplexy be differentiated from?
Ovarian apoplexy must be differentiated from a number of acute gynecological and surgical conditions. The list of pathologies for differential diagnosis includes:
- Ectopic pregnancy — including ruptured fallopian tube.
- Acute appendicitis — acute surgical pathology of the abdominal cavity.
- Acute salpingo-oophoritis — acute inflammation of the uterine adnexa.
- Adnexal torsion — or torsion of an ovarian lesion pedicle.
- Torsion or necrosis of a myometrial node — a complication of uterine fibroids.
- Intestinal obstruction — acute pathology of the gastrointestinal tract.
- Perforated gastric ulcer — surgical pathology.
- Renal colic — urological condition.
- Rupture of parenchymatous organs — liver or spleen injury from trauma.
In adnexal torsion in young patients, the modern rule applies: «No necrosis — untwist». Unlike historical dogmas, the pedicle is now detorsed to preserve the organ if the tissues are visually viable.
Class and exam questions
Why is untwisting of a twisted ovarian pedicle now permitted?
The modern approach aims at organ preservation, especially in young patients. If there are no visual signs of necrosis, the pedicle is untwisted and the restoration of blood flow is monitored, avoiding unjustified adnexal removal.
What is the difference between the pain and hemorrhagic forms of ovarian apoplexy?
In the pain form, there are no signs of intra-abdominal hemorrhage, hemodynamics are stable, and treatment is usually conservative. The hemorrhagic form is accompanied by blood loss, a drop in blood pressure, and requires emergency surgery.
When is emergency surgery indicated for myomatous node necrosis?
Intervention is necessary in cases of subserous node pedicle torsion, deterioration of the patient's condition, the appearance of peritoneal signs, or if conservative therapy has failed to produce an effect within 24–48 hours.
What else to study on this topic
- Differential diagnosis of acute abdomen with appendicitis and renal colic.
- Clinical manifestations and diagnosis of tubal abortion.
- Fallopian tube rupture in ectopic pregnancy.
- Prevention of recurrent ovarian apoplexy using oral contraceptives.
- Features of diagnosing ovarian cyst torsion in children and adolescents.
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