Adnexal/ovarian torsion - Clinical evaluation and surgical management

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Case Report

History

A 35 years old mother, P=V A=0, lactating a one-year old male child, presented to Bele Primary Hospital with a chief complaint of severe and intermittent crampy lower abdominal pain. She also complained of abdominal swelling, nausea, and constipation. Her symptoms had started 7 days earlier.

The mother was illiterate and married to a farmer with a low income for the last 20 years. Her menstrual history was irregular but had used contraceptives in the form of Depo injections 3 xs before one year. She had a long inter-pregnancy period of 15 years before the delivery of her last child.

She was treated with intravenous antibiotics at her local health center. But, with no improvement she was referred to our Hospital with the diagnosis of Acute Abdomen.

Clinical Examination

General

On presentation, she was acutely unwell and looking ill. She was not pale, not icteric and had wet bucal mucosa.

She had a pulse rate of 96 bpm, blood pressure of 100/60, respiratory rate of 26bpm and temperature of 37.1 degree celsius. No respiratory or cardiovascular abnormality was detected.

Abdominal examination

She had a distended abdomen which moved respiration, no old abdominal scar, no visible peristaltic bowel movement and normoactive bowel sounds

On palpation, there was a large intra abdominal mass which was smooth, round bordered, slightly mobile, advanced beyond umblical region and severely tender No palpable fetal poles. Dullness was present over the anterior margin of the intra abdominal mass.

Digital rectal examination

No palpable rectal mass, no PR bleeding or impacted fecal matter.

Genito-urinary examination

Cervix closed, no blood on examining finger, no cervical motion tenderness. Normal non gravid uterus.

Lab investigations

• Haematocrit: 35%
• HCG Urine Test: Negative

Complete Blood Count, Biochemistry and Sonography are not currently available at Bele hospital.

Management

Diagnosis

Acute abdomen likely secondary to Ovarian Cyst Torsion

Preoperative preparation

She was resuscitated with crystalloids, an NG tube was inserted and broad spectrum IV antibiotics were administered. Informed written signed consent for Emergency Explorative laparotomy was obtained after counselling her.

Surgery

Under general anaesthesia with endotracheal integration, emergency laparotomy was performed via a vertical midline incision.

A large ovarian cyst had caused left adnexal torsion resulting in a very ischemic left ovary and dark and edematous left adnexa pedicles. The adnexal mass had twisted anti-clockwise 4 times (4x). The right adnexa, uterus, bladder and bowel were healthy.

Detorsion or untwisting of the ischemic left ovarian mass and edematous fallopian tube was attempted to check for viability. With no evidence of viability, a left Salpingo-oopherectomy was performed to remove severely ischemic left adnexal torsion.

Postoperative Outcome

The patient made an uneventful postoperative recovery and was discharged home after 5 days in the hospital.

Thanks to the entire team at Bele Hospital including the anaesthetist, ward nurses, theatre staff as well as the administrative staff, this patient has had a good outcome and is very grateful for the care she received.

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