1. Seattle Children’s Hospital Bijiibaa’ Garrison R1 – UW General Surgery

2. JH - 890771 6 yo F with 4 days of periumbilical abdominal pain, low-grade fever, decreased PO intake 2/2 abdominal pain Seen by PCP 1 day prior to admission. – UA with WBCs, started on cephalexin (received 4 doses). Abdominal pain worsened and developed nausea. No emesis. No diarrhea. OSH ED – US done, “concern for appendicitis” – Mildly compressible appendix Transferred to SCH.

3. JH PMH: vesicoureteral reflux, frequent UTIs. None since age 3. No PSH. No prior hospitalizations. No sick contacts. Lives in Everett with parents. Rabbit named “Two-and-a-Half”

4. JH Physical Examination – Temp 38.2, HR 128, BP 102/69, RR 24 – Well nourished female, no acute distress – Abd soft, nondistended. Mild tenderness in RLQ and suprapubic region. No rebound or guarding. Labs – WBC 19.3. PMNs 76% – Na 134, K 4.3, Cl 98, HCO2 22, BUN 11, Cr 0.39 – UA – negative for UTI

5. US - appendix

6. US – right and left ovaries

7. US – left ovary

8. JH Repeat Ultrasound – Appendix: normal in diameter, no hyperemia or fluid collections. Adjacent fat mildly hyperechoic – Normal gallbladder, right kidney, uterus. – Right ovary: normal in size (2.1 x 1.3 x 2.8cm – volume 4mL). Normal vascularity by doppler – Left ovary: Enlarged (2.9 x 2.9 x 4.3cm – volume 18.9mL). No arterial or venous flow on doppler. Ovary located near midline. Greatest point of pain during US exam. Left ovarian torsion Consented for laparoscopic ovarian detorsion, possible appendectomy.

9. Ovarian Torsion Complete or partial rotation of ovary on its ligamentous supports – Infundibulopelvic ligament and tubo-ovarian ligament – Fallopian tube often twists with ovary – Adnexal torsion Gynecologic emergency Compression of ovarian vessels. – Arterial profusion with blocked outflow -> edema Ovarian necrosis, infarction, local hemorrhage – Potential decrease in fertility. Risk of pelvic thrombophlebitis, thromboembolism, peritonitis.

10. Ovarian Torsion Most likely to occur at or before age of reproduction Increased length and laxity of ovarian suspensory ligaments Right side more frequently affected, 3:2 ratio – Right utero-ovarian ligament is longer than left, sigmoid on left reduces space needed for torsion to occur. Increases in adnexa weight – Ovarian cysts, dermoid cysts, paratubal cysts – Pregnancy – presence of corpus luteum cyst – Ovarian stimulation – Malignancy

11. Clinical presentation Abdominal or pelvic pain – Unilateral – Constant or colicky – Lasting several days – Radiating to lumbar area, groin, flank Nausea, vomiting Low-grade fever Leukocytosis Palpable mass

12. Differential Diagnosis Appendicitis Kidney stone Incarcerated hernia Mesenteric adenitis PID Gastroenteritis Ectopic pregnancy

13. Diagnosis Ultrasound – Complex adnexal mass – Enlarged 12x greater than contralateral ovary Doppler – Lack of flow within ovary CT scan, MRI Surgery – Inspection Laparoscopy, laparotomy

14. Treatment Classic tx has been resection of an ischemic appearing ovary and/or fallopian tube. Conservative treatment – Detorsion: untwist and preserve adnexa. – Risks: thromboembolic complications secondary to untwisting of ischemic adnexa, malignancy in ovary. – Repeat ultrasound 6 weeks post-op. – Allows ovary function to return. Radical treatment – Adnexectomy. Adnexa appears necrotic and does not return to viable appearance. Oophoropexy – Asynchronous bilateral torsion (torsion of each ovary at different times) – rare but can be devastating for fertility. – Shortening the utero-ovarian ligament or suturing ovary to the uterosacral ligament. – Optimal site for pexing are not well established.

15. Things to consider In pediatric or adolescent patients … If unilateral torsion occurs and affected ovary cannot be preserved, should you pexy the remaining ovary to preserve future fertility? – Risks of pexing include potential interference to tubal blood supply, tubal function, or ovarian communication with fallopian tube  iatrogenically causing infertility. If bilateral oophorectomy occurs, these patients will require hormonal therapy for development and maintenance of secondary sexual characteristics and treatment for infertility as adults.

16. JH Laparoscopy – Blue/black left ovary and fallopian tube twisted clockwise around – Detorsion of adnexa – Appendectomy Plan to repeat ultrasound to assess size and flow of left ovary ~6 wks post-operatively.

17. References Breech L, Hillard P. Adnexal torsion in pediatric and adolescent girls. Curr Opin Obstet Gynecol 2005; 17:483- 489. Cass D. Ovarian torsion. Seminars in Pediatric Surgery 2005; 14:86-92. Huchon C, Fauconnier A. Adnexal torsion: a literature review. European J of Obstet Gynecol Repro Biology 2010; 150:8-12. Rossi BV, Ference EH, Zurakowski D, et al. The clinical presentation and surgical management of adnexal torsion in the pediatric and adolescent population. J Pediatr Adolesc Gynecol 2012; 25:109-113.