Post-radical hysterectomy ovarian torsion-A gynecological emergency: a case series

Abstract

Background: Ovarian torsion is a surgical emergency whereby the ovary twists, or torts, on its ligamentous support and potentially compromises vascular supply to both the ovary and Fallopian tube. It accounts for 2-3% of all acute gynecological emergencies, yet is a condition that is rarely reported to occur after hysterectomy. While it is well established that ovarian torsion can occur after laparoscopic hysterectomy, we report on the rare occurrence of ovarian torsion occurring post the supposedly preventative ovarian transposition suspension procedure or ovariopexy. This highlights that further evaluation of laparoscopic surgical techniques are required to prevent this exquisitely painful gynecological condition occurring postoperatively.

Case presentation: We report two cases of ovarian torsion post-primary laparoscopic radical hysterectomy performed for cervical malignancy. Both patients were Caucasian, multiparous, premenopausal female patients, aged 37 and 39 years old. Ovarian transposition suspension was performed at the primary procedure to allow ovarian function to be preserved if the patient's required postoperative pelvic irradiation if surgically upstaged. Both patients underwent emergency laparoscopic detorsion, with one torsion due to reoccurrence of her cervical cancer.

Conclusions: Adnexal torsion is estimated to occur between 1% and 8% in post-hysterectomy cases. It can be a difficult to diagnose condition, with prudent history-taking, relevant investigations, and a low threshold to consider laparoscopy forming essential clinical acumen. Unfortunately, the suspension of the ovaries post-hysterectomy does not exclude future ovarian torsion. With rising rates of cervical cancer in premenopausal women, reportedly increasing by 37% in the 25-34 age range in the United Kingdom (National Cancer Registration and Analysis Service, Public Health England. 2021), further research is needed to improve techniques to allow for safe ovarian conservation for these patients while undergoing operative treatment of cervical cancer.

Keywords: Case report; Gynecological emergency; Laparoscopic hysterectomy; Ovarian torsion; Postoperative risk.

Fig. 1

a Computed tomography scan showing 6 cm LIF mass with evident surgical clip (Red arrow is pointing to the surgical clip)

Fig. 2

a Ultrasound (USS) scan showing 6.5 cm × 5.2 cm right ovary with absent Doppler color flow. b CT scan showing 7 cm LIF mass with surgical clip. c Laparoscopic image of ovarian torsion with associated hematosalpinx (Red arrow is pointing to the metal surgical clip)