Differential diagnosis
The diagnostic complexity of Torsio pedunculi tumoris ovarii lies in the need to distinguish this pathology from other acute conditions of the pelvic organs and abdominal cavity. In clinical practice, differentiation is carried out with the following processes:
- Interrupted intrauterine pregnancy (cervical canal dilatation, gestational sac on ultrasound, and decidual tissue with chorionic villi in the scraping are examined);
- Tubal abortion with dysfunctional uterine bleeding (in DUB, the abdomen is soft, the uterus and appendages are unchanged, the test is negative, and culdocentesis reveals no blood);
- Fallopian tube rupture (the condition requires emergency intervention, similar to ovarian apoplexy or rupture of parenchymal organs);
- Progressive tubal pregnancy and cervical pregnancy (ultrasound and $\beta$-hCG levels are used for verification).
Surgical approaches and interventions
The choice of approach directly depends on the patient's clinical status. Laparoscopy is the preferred method due to its minimal invasiveness, reduced hospital stay, and the possibility of organ-preserving manipulations. Laparotomy is indicated in the event of hemorrhagic shock or severe grade IV adhesive disease.
The scope of surgical intervention may be:
- Radical — performance of salpingectomy (most common);
- Organ-preserving (conservative plastic) — "milking" of the gestational sac, tubotomy (longitudinal incision over the gestational sac), or tubal segment resection.
Contraindications and special clinical cases
Conservative plastic surgeries have strict limitations. Contraindications to organ-preserving interventions:
- Repeat ectopic pregnancy in a previously operated tube;
- Pronounced scarring of the tissue;
- Patient's refusal to preserve reproductive function;
- Fallopian tube rupture;
- Gestational sac diameter greater than 3.0 cm.
For intramural (interstitial) localization, salpingectomy with resection of the uterine horn is performed.
Infusion therapy and autologous blood
In a severe patient condition with massive blood loss, emergency infusion-transfusion therapy is carried out with early initiation of plasma and plasma expanders to restore BCC, as well as packed red blood cells for life-saving indications.
> Important rule: It is strictly forbidden to raise blood pressure with vasopressor drugs prior to surgical arrest of bleeding.
During surgery, autologous blood reinfusion is permitted if the blood spilled into the abdominal cavity is uninfected and non-hemolyzed, and the duration of the condition does not exceed 12 hours. Changes in its composition must be taken into account: a drop in platelet and fibrinogen levels, an increase in free hemoglobin, and the presence of fibrinogen degradation products.
Briefly: answers to topical questions
What constitutes the anatomical pedicle of an ovarian tumor?
The anatomical pedicle of an ovarian tumor includes stretched ligaments, as well as blood vessels, lymphatic vessels, and nerves passing through them.
The ligamentous apparatus of the anatomical pedicle includes:
- Infundibulopelvic ligament (ligamentum infundibulopelvicum) — contains the nourishing vessels.
- Ovarian proper ligament (ligamentum ovarii proprium) — located between the medial margin of the ovary and the uterine horn.
- Ovarian mesentery — part of the ligamentous apparatus.
The contents of the pedicle include the ovarian artery, a branch of the ascending part of the uterine artery, lymphatic vessels, and nerves.
What anatomical structures form the surgical pedicle of an ovarian tumor during its torsion?
The surgical pedicle of an ovarian tumor includes all the structures of the anatomical pedicle, as well as the stretched fallopian tube involved in the torsion (tuba uterina).
The surgical pedicle does not exist initially, but is formed directly as a result of the torsion itself. It includes the entire conglomerate of anatomical structures twisting around their axis. It is precisely this formed surgical pedicle that is transected by the surgeon during the surgical intervention to remove the affected appendages.
What degrees of ovarian tumor pedicle torsion are distinguished in clinical practice?
In clinical practice, two degrees of ovarian tumor pedicle torsion are distinguished, depending on the angle of rotation of the formation.
- Complete torsion — rotation of the tumor by 360° or more. Leads to a rapid and abrupt disruption of tissue nutrition.
- Partial torsion — rotation of less than 360°. With this degree, venous outflow is impaired first while arterial inflow remains relatively preserved, and secondary changes (necrosis, hemorrhage) develop gradually.
With which acute diseases of the abdominal cavity and pelvic organs is it necessary to perform differential diagnosis of ovarian tumor pedicle torsion?
Differential diagnosis of ovarian tumor pedicle torsion is carried out primarily with acute appendicitis, especially with a pelvic location of the vermiform appendix, and renal colic. Plain abdominal radiography, ultrasound of the abdominal cavity and retroperitoneal space, and laparoscopy are used for clarification.
What clinical symptoms are characteristic of complete ovarian tumor pedicle torsion?
Complete ovarian tumor pedicle torsion is characterized by a sudden onset, sharp pain in the lower abdomen on the affected side, nausea, vomiting, and constipation and gas retention due to intestinal paresis. Upon examination, pallor of the skin and cold sweat may be noted.
Which types of ovarian tumors and cysts are most commonly subject to torsion?
The pedicle of any tumor, as well as an unchanged ovary or uterine adnexa, can undergo torsion. Torsion is frequently associated with a cyst or benign tumor, especially a dermoid cyst of the ovary. Predisposing factors include an asymmetric shape, uneven density, and excessive mobility of the mass.
What is the surgical strategy when necrotic adnexa are discovered in the setting of torsion?
When necrotic adnexa are discovered in the setting of torsion, the surgical strategy consists of the radical removal of the affected tissues without attempts to preserve them.
In such cases, adnexectomy (removal of the uterine adnexa) is performed on the affected side. The most important rule of surgical technique in the presence of necrosis is that the twisted pedicle of the tumor must never be untwisted before resection. This is necessary to prevent the risk of blood clots from the vessels of the pedicle entering the systemic circulation.
What is the sequence of actions for the surgeon in case of ovarian tumor pedicle torsion without signs of tissue ischemia and necrosis?
If signs of tissue viability are preserved, detorsion is permissible — the gentle untwisting of the twisted pedicle of the uterine adnexa. The further scope of the surgery is determined after visual inspection of the gross specimen, and in some cases, after urgent histological examination.
Which surgical approach is preferred in the surgical treatment of ovarian tumor pedicle torsion?
Laparoscopic access is preferred in the surgical treatment of ovarian tumor pedicle torsion. Laparoscopy allows for establishing the diagnosis, assessing the degree of circulatory impairment, and performing differential diagnosis. In girls and young women, when removing a tumor, a laparoscopic approach with the mandatory use of an endobag is preferred. A laparotomic approach may also be used.
What specific ultrasound features (including Doppler sonography) indicate ovarian tumor pedicle torsion?
Specific ultrasound features of ovarian tumor pedicle torsion include changes in the dimensions, structure of the organ, and blood flow parameters.
The main echographic signs include:
- Enlargement of the ovary — a size $\ge$7 cm is the most consistent sign.
- Specific sign — multiple follicles located peripherally in the cortical layer of a unilaterally enlarged and hyperechoic ovary.
- Structural changes — the presence of septa or a "fluid-debris" level.
- Doppler ultrasonography (CDI): absence of blood flow within the mass. However, due to the dual blood supply of the ovary, this sign is considered less reliable.
Laparoscopy is the method of choice for tubal conservation; laparotomy is indicated in cases of shock and adhesions.
Class and exam questions
Which surgical access is the method of choice?
Laparoscopy, as it reduces complication rates, shortens recovery time, and allows for fertility-sparing surgery.
When are fertility-sparing tubal surgeries strictly contraindicated?
In cases of complete tubal rupture, a gestational sac diameter greater than 3 cm, pronounced scarring, recurrent ectopic pregnancy, or patient refusal.
Is it permissible to raise the blood pressure of a patient with intraabdominal hemorrhage prior to surgery?
No, the administration of blood pressure-raising drugs is strictly contraindicated prior to surgical hemostasis, as this will exacerbate bleeding.
What else to study on this topic
- Pathophysiology of blood shed into the abdominal cavity during reinfusion
- Technique of laparoscopic tubotomy and expression of the gestational sac
- Differential diagnosis of the acute abdomen in gynecology
- Infusion and transfusion therapy for massive blood loss
- Specific features of gestational sac localization in the intramural segment
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