[size=20px]An 11-year old premenarchal girl presents with right lower quadrant pain and is taken to the operating room with the presumptive diagnosis of appendicitis. At laparoscopy her appendix is normal but she is found to have right adnexal torsion. The right ovary appears ischemic with a cyst. The left adnexa appears normal.

 

In addition to reduction of the right adnexal torsion and cyst drainage this patient requires

 

A nothing further.

 

B appendectomy.

 

C right oophoropexy.

 

D bilateral oophoropexy.

 

E right oophorectomy.[/size]

C

C

A

A

correct

 

The presence of a solid or cystic ovarian mass increases the risk of torsion. Recurrent ipsilateral torsion has been described in nine to 19% of cases and the rate of asynchronous contralateral ovarian torsion ranges from five to 13%. Ovarian fixation (i.e. oophoropexy) is proposed to prevent recurrence of ipsilateral or contralateral torsion. However, there is no widely agreed consensus on the need for oophoropexy at the time of detorsion. Case reports have recommended oophoropexy in patients who present with bilateral ovarian torsion, recurrent ipsilateral torsion, require oophorectomy or when torsion occurs in an ovary with an excessively long utero-ovarian ligament or polycystic ovarian disease.

 

Various procedures are used to secure the ovary. The ovary can be fixed to the posterior wall of the uterus, the lateral part of the pelvic wall or to the posterior peritoneum. Another method utilized is to shorten or plicate the utero-ovarian ligament. Recurrence has been described in patients on whom the plication approach was used. Risks of oophoropexy include changing the anatomy of the pelvic organs potentially affecting fertility. However, there are no long term studies documenting the effect of oophoropexy on fertility.

 

In this patient, cystectomy or fenestration of the cyst is recommended. However, ovarian fixation is not recommended at this time. Clinical assessment of ovarian viability is inaccurate. Therefore, ovarian sparing surgery is the current standard of care in patients with ovarian torsion that is not associated with malignancy.

 

Performing an appendectomy in this setting changes the wound class from clean to clean contaminated thereby increasing the chances of wound infection and is not recommended.

(Untitled)

 

A