Laparoscopic Detorsion of the Adnexa in the Second Trimester of Pregnancy: a Case Report

Background: Adnexal torsion refers to partial or complete rotation of an ovary and/or fallopian tube around its ligamentous support structures, resulting in limited blood flow to the adnexa. The diminished flow leads to tissue ischemia, causing pain and occasionally necrosis. Adnexal torsion is one of the most common gynecological surgical emergencies affecting females of all ages. Pregnancy is a known risk factor for adnexal torsion, especially in patients with a history of ovarian cysts. Objective: We present a case of ovarian torsion managed with laparoscopic surgery in the second trimester of pregnancy and review the outcomes of the surgery. Adnexal torsion is typically managed laparoscopically in a non-pregnant patient. The gravid abdomen poses unique challenges for the management of adnexal torsion with minimally invasive surgery. Case Report: A 21-year-old female, G3P1011, at 24 weeks gestation with a history of a right ovarian cyst presented with a 4-hour duration of right lower abdominal pain, nausea and vomiting. A pelvic ultrasound showed a large right ovarian cyst with preserved blood flow to the right adnexa. Despite reassuring doppler flow, there was a high index of concern for adnexal torsion due to the presence of the ovarian cyst and clinical presentation of severe right lower quadrant pain. After confirming reassuring fetal status and no sign of preterm labor causing her pain, she underwent urgent laparoscopic surgery, which confirmed the presence of a right adnexal cyst torsion. The right ovary was detorsed and a right ovarian cystectomy was performed with the right ovary preserved. She was observed for threatened preterm labor after her surgery. The patient was discharged home the next day and eventually delivered a healthy male infant at term. Several points of interest are present in this case. First, the doppler flow was present for the ovarian artery. This is due to early compression of the veins and a large amount of pressure needed to completely stop the arterial flow. Therefore, presence of flow to the adnexa does not exclude torsion. The uterine fundus above the umbilicus often requires LUQ entrance for the case and attention is needed to avoid the uterus with trocars. Surgical visualization is typically affected due to the fundus reducing complete views of the adnexa, and "port hopping" may be needed to complete the case safely. Additionally, preterm delivery of a 24 week fetus is not ideal and tocolysis is occasionally needed to prevent preterm delivery after surgical intervention. Conclusion: Although rapid surgical intervention for ovarian torsion is key for favorable outcomes, any abdominal surgery during pregnancy carries risks to the patient and their unborn fetus. Thus, the choice of surgical technique necessitates accounting for these risks based on the presenting condition, the patient's gestational age and known medical history.