Obstetrics and Gynecology - A.M. Gromova 2000

"Acute Abdomen" in Gynecology
Impaired blood supply to internal genital tumors as a cause of "acute abdomen"
Torsion of the ovarian tumor pedicle

Torsion of an ovarian tumor stalk accounts for up to 20% of all gynecological emergencies involving the "acute abdomen." It most commonly occurs with mobile tumors of the adnexa.

Etiology AND Pathogenesis

Torsion of an ovarian tumor stalk is triggered by significant physical exertion, sudden body position changes, increased intestinal peristalsis, or Urinary Bladder overdistension.

The anatomical stalk of a tumor refers to the structures anchoring the Ovary within the pelvis: the suspensory ligament of the ovary, the proper ovarian ligament, and the mesovarium. The surgical stalk comprises those structures that are transected during tumor removal. The surgical stalk includes all the anatomical stalk structures as well as the fallopian tube.

Torsion may be acute or gradual, complete or partial. Torsion leads to venous congestion and tumor enlargement; hemorrhages into its cavity and rupture with intraabdominal bleeding are possible. When arterial Blood supply is compromised, tumor necrosis may occur.

Clinical presentation

The severity of clinical symptoms is determined by the degree of tumor torsion and the speed of its onset, rather than The Nature of the underlying tumor process. A hallmark feature is sudden, sharp pain following physical exertion, accompanied by nausea and vomiting. Subsequently, body Temperature rises, accompanied by leukocytosis with a left shift in the differential WHITE BLOOD Cell count.

In cases of partial torsion, symptoms are vague. With complete torsion, patients present with pallor of the Skin and mucous membranes, and cold sweats. The pulse is rapid, body temperature is elevated, and the Tongue is dry with a white coating. The abdomen is tense and tender in the lower quadrants, displaying positive peritoneal irritation signs. Bimanual examination reveals a tender mass in the adnexal region. Culdocentesis via the posterior vaginal fornix yields no informative results. Establishing a history of an ovarian tumor in the patient, along with The Use of ultrasound Diagnostics, provides significant assistance in making an accurate Diagnosis.

Two hours after blood supply is cut off, necrotic processes begin in the ovarian tumor, leading to the destruction of Nerve Cells and the cessation of pain. The patient's condition subjectively improves—a phenomenon known as "false well-being"—yet one must not forget that diffuse Peritonitis may develop within just 4 to 6 hours.

Treatment

Patients presenting with torsion of an ovarian tumor stalk require immediate surgical intervention: adnexectomy is performed.

Removal of an Ovarian Tumor with Torsion of its Stalk

The abdominal wall incision may be performed via a Pfannenstiel incision or a midline laparotomy.

The specifics of this surgery involve potential adhesions and the fusion of the tumor with the abdominal wall and adjacent Internal Organs.

Following laparotomy, the surgeon must carefully evaluate the Nature of the adhesions formed between the tumor and adjacent organs. It is best to begin by detaching the omentum; if this is not feasible, the omentum may be resected. Adhesions involving the bowel are best divided using scissors, gradually cutting through the taut fibrous bands. Cutting poorly visualized adhesions is strictly prohibited, as this can result in injury to adjacent organs (such as the Uterus or urinary bladder).

After freeing the tumor from adhesions, it is delivered from the Abdominal cavity AND excised. Removal must be performed with extreme care because, As a result of stalk torsion and vascular compression, the tumor—particularly its capsule—undergoes edema and necrosis, making it prone to rupture. Untwisting the ovarian tumor stalk prior to ligating it is hazardous, as thrombi may be present within the Vessels of the twisted stalk. During untwisting, the dislodgement of a thrombus or its fragment into the bloodstream can trigger pulmonary artery embolism. Therefore, without untwisting the stalk, a ligature is applied proximal to the site of torsion; subsequently, the stalk is untwisted, clamps are applied, and the tumor is resected.

Finally, reperitonization and peritoneal lavage are performed, followed by layered closure of the abdominal wall wound.