Torsion of Ovary

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Torsion of Ovary

Torsion of the ovary occurs when there is some additional weight acquired by the normal ovary, usually in the form of an ovarian cyst (physiologic or pathologic). Embryologically, the ovary is a retroperitoneal structure and invaginates an envelope of peritoneum that covers it and the stalk of the ovary commonly referred to as the infundibulopelvic ligament. This arrangement allows the ovary to undergo torsion. In most cases, the torsion turns toward the midline, i.e., the right ovary twists clockwise, and the left ovary twists counterclockwise.

In the past, all such twisted ovaries were generally removed. It was accepted practice that the infundibulopelvic ligament be clamped prior to untwisting the ovary. Clamping the infundibulopelvic ligament first was said to prevent pulmonary embolism from the veins in the infundibuloplevic ligament. Very little data exists to confirm this point of view.

In younger women of the reproductive age group and those women who have completed their families but would still enjoy the benefits of a functioning ovary, salvage of this twisted ovary becomes an important issue. An ovary that has undergone torsion can be untwisted safely without pulmonary embolism. This can be done through an open laparotomy or through laparoscopy. The ovary can be safely untwisted and observed for the integrity of the vascular supply.

Physiologic Changes. The obvious physiologic change and the greatest threat to the ovary through torsion is loss of blood supply.

If the ovary can be salvaged, it can become a functional organ for the production of important estrogen and progesterone production as well as ovulation for those women who desire pregnancy.

Points of Caution. The vascular integrity of the ovary must be demonstrated prior to completing the operation. Those ovaries that have undergone gangrene should be removed. The offending ovary cyst that produced the torsion in the first place should be excised.

Technique

The right ovary has rotated toward the midline (clockwise).

The ovary must be untwisted by hand if a laparotomy has been performed or with instruments such as grasping forceps if laparoscopy has been performed. At this point, observation should be made for vascularity of the ovary. Ovarian cystectomy should be completed at this time. (see the technique for ovarian cystectomy). The performance of the ovarian cystectomy may give an excellent indication of the intact blood supply of the ovary by noting fresh arterial bleeding from the margins of the cystectomy site.

If there is doubt, fluorescein dye may be injected in a peripheral vein.

After 5-10 minutes, a Wood's lamp with its ultraviolet ray will cause an ovary with good blood supply to fluoresce a yellowish color. An ovary without arterial perfusion will show up as a dark purple under a Wood's lamp ultraviolet ray. These steps can assure the surgeon that the ovary has either a good vascular supply or no vascular supply. This will aid in the decision to remove the ovary or retain it.