Surgical Management of Adnexal Torsion

Abstract & Commentary

By Frank W. Ling, MD, Clinical Professor, Dept. of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, TN, is Associate Editor for OB/GYN Clinical Alert.

Dr. Ling reports no financial relationship to this field of study.

Synopsis: Despite data supporting conservative management, oophorectomy continues to be commonly used in the management of adnexal torsion.

Source: Ogburn T, et al. Adnexal torsion: experience at a single university center. J Reprod Med. 2005;50:591-594.

Ogburn and colleagues report on their experience with adnexal torsion at one university medical center from 1990 to 2001. A chart review identified 68 patients in whom laparoscopic management was accomplished 32% of the time (n = 22) and ovarian conservation in 21% (n = 14). The rate of laparoscopy (rather than laparotomy) and ovarian conservation (rather than oophorectomy) did not differ prior to 1996 when compared with the time period after 1996. The discussion by Ogburn et al questions why the findings are as reported. Given that the literature supports the use of laparoscopy for both diagnosis of and treatment of adnexal torsion, is laparotomy used merely because of the lack of a skilled surgeon? Is ovarian conservation eschewed because of the persistent fear of embolic phenomena from the ovarian pedicle, again despite the data? Ogburn et al conclude that even though their university medical center did not follow their recomendations, the literature clearly supports a management plan in all cases of torsion in reproductive-aged women to include consideration of laparoscopy, untwisting of the adnexa, and ovarian conservation.

Commentary

Would you rather have 20 years of experience or 1 year of experience 20 times? Ogburn et al seem to be asking this very question. I can just imagine how this retrospective review came about. You can picture the discussion at a weekly Morbidity & Mortality conference in which they are reviewing the case of a reproductive-aged woman with an acute abdomen who undergoes laparotomy and oophorectomy for adnexal torsion. An attending wants the resident to describe the work-up and the resident dutifully explains that they had ruled out appendicitis, tubo-ovarian complex, ectopic pregnancy, pyelonephritis, and diverticular disease. The ultrasound showed a cystic adnexal mass so the faculty on call that night proceeded to perform a laparotomy because of the suspicion of torsion but with the possibility that it was a malignancy. When the abdomen was opened, the torsion diagnosis was confirmed, but the attending instructed the resident to perform an oophorectomy even though she knew that the risk of embolic phenomena from the pedicle was minimal.

At the conference, there is a call for a "protocol" to manage subsequent cases. Some say that there should be a standardized fashion in which torsion is managed only via laparoscopy. Others say that the medicolegal climate is such that even though the literature says that it is acceptable to untwist the pedicle, the "safe" way to treat this patient is oophorectomy. Another attending confirms that he would also have done a laparotomy because of the chance of malignancy in the ovary. A resident states that he wondered why oophorexy wasn’t done to prevent a recurrence. Eventually, one staff member offers to review all the cases that the institution has seen in the past decade and report back what had been done and what could be done in the future.

To me, that’s logically how this paper could have started. In fact, Ogburn et al might be re-telling the same story that is found at most university centers. Each decision made is often independent of the ones before unless there is some continuity or "corporate memory" of cases of a certain type. As a result, it appears that the laparotomy and oophorectomy are done because "that’s the way I was trained." Hopefully, however, each of us doesn’t practice based on how we were trained. We use that as a base, but we build on the face using our own experiences as well as those of others, ie, the literature.

Without question, in any woman with suspected torsion, malignancy is a consideration. Ultrasound can help us determine that risk to some extent so that performing the laparotomy just because malignancy is suspected can be targeted to truly higher risk cases. Similarly, laparoscopic management can be performed in virtually all cases unless laparoscopy itself is contra-indicated. Even if cancer is found, consultation can be sought or the procedure converted to an open one. Untwisting the pedicle is clearly an appropriate treatment option. Ogburn et al cite more than 400 cases of conservative management in the literature without a case of embolus.

So what’s a clinician to do? Hopefully, the right thing for his/her patient. The less morbid laparoscopy is certainly preferable to laparotomy, and ovarian conservation is preferable to oophorectomy. Should they be done in every case? Maybe not, but they should be the procedure of choice unless there are extenuating circumstances. I am hopeful that each of us problem-solves for each of our patients, be they surgical, obstetric, or ambulatory, in a fashion that reflects the most up-to-date information available, not just what we were taught in residency.