Torsion of the leg of the tumor of the ovary

Torsion of the legs can be susceptible to tumors of different histological structure (epithelial, stroma of the genital tract, teratomas), not welded to neighboring organs and having a pronounced stem. As a rule, these are benign and borderline neoplasms, but malignancies can also occur.

Torsion of the anatomical and / or surgical leg of the ovarian tumor (with a twisting in these formations include the uterine tube, more rarely - epiploon, intestinal loops) is accompanied by the development of acute disruption of the nutrition of the tumor and the rapid development of necrotic processes.

Epidemiology

An "acute" abdomen in gynecological practice can be a consequence of the twisting of the mesentery of a pathologically altered or unchanged fallopian tube and ovary. But much more often there is a torsion of the foot of the tumor (cystoma) or a tumor-like, more often retentive, formation (cyst) of the ovary. This complication is observed in 10-20% of patients with this pathology.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12]

Causes of the torsion of the ovarian tumor

Torsion of the legs of the tumor or ovarian cyst can be associated with a change in body position, physical stress, increased intestinal peristalsis, overflow of the bladder, the transition of the cyst from the pelvis into the abdominal cavity, a long movable cyst leg. A certain role in this complication can play a rise in blood pressure in the veins of the leg of the cyst and cyst or in the education itself. It is known that, in comparison with healthy women, the increase in the intensity of blood filling, slowing of blood flow, venous stagnation against a background of decreased vascular tone from the affected side is revealed in women with diagnoses of cyst and ovarian cyst.

These complications are more common in girls, girls and young women. Typical is the relative frequency of torsion of the cyst leg in children and even in newborns.

Often, the torsion of the leg of the ovarian neoplasm occurs during pregnancy and in the postpartum period.

[13], [14], [15], [16], [17], [18], [19], [20], [21]

Pathogenesis

The anatomical leg of the tumor consists of an elongated ligament that hangs the ovary, its own ligament of the ovary and mesoovarius. In the leg are blood vessels that feed the tumor (ovarian artery, anastomosis with the uterine artery), as well as lymph vessels and nerves. Surgical leg is an education that has to be crossed during surgery when the tumor is removed. Most often in the surgical leg, in addition to the anatomical, is an overgrown fallopian tube.

A number of authors consider as twisting the turn of the cyst around its pedicle by 90 °, others - a turn of 120 ° - 180 °. However, it is difficult to agree with such a mechanical approach, since the degree of torsion does not yet determine the severity of the clinic of the disease. Sometimes even with a relatively slight twisting of the cyst's leg (by 90-120 °), severe symptoms of the disease appear, while at a greater degree of torsion (sometimes even up to 360 °) the symptoms of the disease may be absent or remain unexpressed.

Torsion of the foot of the ovarian tumor can occur suddenly (acutely) or gradually, is complete or partial. Pathological changes in the tumor with twisting of its legs depend on the speed with which the tumor rotates along the axis, and on the degree of twisting. If the twisting is slow and it is not complete, then first of all the changes are observed in the thin-walled, low-resistant veins of the leg due to their compression and the cessation of outflow of blood, while the elastic arteries continue to supply the tumor with arterial blood. As a result, pronounced venous congestion arises: the tumor rapidly increases in size, and often there are hemorrhages in its parenchyma. The tumor dramatically changes its color, its glossy, pearly-colored surface becomes yellowish-brown, copper-red, or blue-purple. Sometimes the tumor wall breaks, resulting in bleeding to the abdominal cavity. Torsion of the foot of the tumor, accompanied by clamping of the arteries, leads to necrotic changes in the tissues of the tumor and even to peritonitis.

[22], [23], [24], [25], [26], [27]

Symptoms of the torsion of the ovarian tumor

Symptoms of torsion of the cyst or cystoma are practically independent of the nature of the ovarian neoplasm and are rather characteristic. The disease, as a rule, begins with severe pain in the lower abdomen, accompanied by nausea and vomiting. The attack of pain sometimes coincides with physical activity, a sharp movement. The body temperature in the first hours of the disease remains normal, the leukocyte reaction is not expressed.

When the legs are partially twisted, all the phenomena are much less pronounced and can disappear even without treatment. In the future, the torsion of the cyst's legs may be an unexpected finding on the operation undertaken for ovarian cysts or some other abdominal disease.

When the legs of the cyst are completely twisted, the blood supply and nutrition of the tumor are severely impaired. Clinically, this is manifested by a picture of an "acute" abdomen. The patient takes a forced position in bed because of severe pains. When palpation revealed tension in the anterior abdominal wall, a positive symptom of Shchetkin - Blumberg, intestinal paresis, stool retention, less often - diarrhea. The body temperature can rise, the pulse is frequent, the pallor of the skin and mucous membranes, cold sweat are noted. With vaginal examination, a tumor is found in the area of the uterine appendages; attempts to shift it cause a sharp pain. An important diagnostic sign of twisting of the cystoma is an increase in its size, which is of great importance. However, it is possible to detect this only in cases when the patient is under the dynamic supervision of a doctor. Such patients need urgent surgery - removal of the tumor.

The infrequent torsion of the appendages of the uterus is also manifested by the picture of the "acute" abdomen. There are always pains in the abdomen and / or back, which grow gradually, but can be sudden. In 50% of women the pain is acute; sometimes go into dull and persistent, often localized in the right or left lower quadrant of the abdomen. Nausea and vomiting are noted in 2/3 of the patients, there are fewer violations of the urinary tract and a feeling of heaviness in the lower abdomen.

With an objective examination, signs of moderate intoxication are found: body temperature does not exceed 38 ° C; tachycardia within 100 beats / min.

When the palpation of the abdomen reveals some tension in the muscles of the anterior abdominal wall and soreness in the lower parts. Frequent symptoms of irritation of the peritoneum. Peristaltic intestinal sounds are heard well.

Enlarged appendages can be palpated in approximately 1/3 of patients, in 70% of patients, soreness in the region of the uterine appendages is revealed. The soreness of the posterior vaginal vault is not characteristic, unlike endometriosis or ectopic pregnancy. There may be bilateral pain in the appendages area when the cervix is displaced.

Diagnostics of the torsion of the ovarian tumor

The diagnosis of torsion of the appendages of the uterus is rarely established before surgery. In a number of works it was shown that only 18% of the cases were correctly and timely diagnosed. Laboratory and hardware studies contribute little to clarifying the diagnosis. Leukocytosis often reaches 16 - 10 ⁶ / l, and exceeding these values - in about 20% of patients. Ultrasound examination does not provide additional diagnostic information if the appendages are palpable, but it helps to identify them in 80 % of patients in whom they were not identified in vaginal examination. Excretory pyelography may indicate a compression of the bladder or displacement of the ureter and is also used to exclude urolithiasis. Irrigoscopy can be used in tumoral formations to exclude primary pathology of the large intestine. The presence of serous bloody fluid with puncture of the posterior vaginal fornix usually does not provide additional information. Thus, we believe that when women enter a hospital with a picture of an acute abdomen and a tumor-like formation located in a small pelvis, ultrasound, radiology and puncture of the posterior vaginal vault, which delay the onset of surgical treatment, are hardly advisable.

[28], [29], [30], [31], [32]

Differential diagnosis

Differential diagnosis of torsion of the cyst or cystoma of the ovary is carried out with a broken tubal pregnancy, inflammation of the appendages, ovarian apoplexy, renal colic, appendicitis and acute intestinal obstruction.

For ectopic pregnancy characterized menses delay the appearance of dark bleeding from the genital tract; dominate the symptoms of internal bleeding and collapse, rather than the phenomenon of irritation of the peritoneum. Great value in the differential diagnosis is the nature of pain and their localization. When the tube is broken, they are usually sharp and strong, and with tubal abortion - cramping. Pain almost always irradiates into the rectum and external genital area, less often - in the shoulder and collarbone (frenicus-symptom). It is often useful in this case to conduct a pregnancy test.

Tubo-ovarian abscesses or salpingitis are usually characterized by more pronounced fever and leukocytosis, bilateral pain of the uterine appendages, as well as purulent secretions from the genital tract. In punctate from the abdominal cavity, pus or serous fluid is detected.

Apoplexy of the ovary is most often observed in the middle of the menstrual cycle (at the time of ovulation) or in phase II of the cycle. The clinical picture is not much different from the symptomatology of ectopic pregnancy.

With urolithiasis, pelvic masses are not found in the pelvic area, and erythrocytes can be found when examining urine. In renal colic, the pain is usually irradiated downward, dysuric disorders and soreness are observed in the lumbar region of the lumbar region. Excretory pyelography in this case is an effective diagnostic procedure.

Differential diagnostics of the torsion of the cyst leg or cystoma of the right ovary and acute appendicitis may present certain difficulties . It should be taken into account that with acute appendicitis, pain usually begins in the epigastric region; appendicular symptoms (rovzinga, Sitkovskogo, etc.) are positive, with vaginal examination of pathological changes from the uterus and appendages there.

In acute intestinal obstruction there are cramping pains in the abdomen, stool and gas retention, flatulence, a frequent, temperature-leading pulse, dry tongue. Clinical diagnosis is confirmed by X-ray examination of the patient (horizontal levels of fluid in the swollen intestinal loops).

Errors in the diagnosis of torsion of the appendages of the uterus can be explained by the comparative rarity of this pathology, and also by the fact that many other diseases have a similar clinical picture. Ultrasound examination and puncture of the posterior vaginal fornix should be used to exclude other pathological conditions in patients with unexpressed symptomatology. However, in the presence of tumoral formations in the area of the uterine appendages accompanied by pain, acute stomach phenomena or in the case of an unclear diagnosis, it is necessary to perform laparoscopy or laparotomy to clarify the nature of the disease.

[33], [34], [35], [36], [37]

Treatment of the torsion of the ovarian tumor

Patients with a diagnosis of torsion of the legs of the cyst or ovarian cysts are subject to urgent surgery. More preferable among other operative approaches is the longitudinal section, since it allows revision of the abdominal organs. After opening the abdominal cavity, before beginning further intervention, you should carefully examine the uterus, both ovaries, fallopian tubes, determine the condition of the peritoneum, the presence of adhesions, etc. It is necessary to get a clear idea of the formation originating from the ovary.

The main task of the doctor at the time of surgery is to determine the malignancy of the process, since the amount of surgical intervention primarily depends on this. For this, along with a thorough examination of the pelvic organs and abdominal cavity, it is necessary to examine the outer and inner surfaces of the tumor capsule, as well as its contents. The outer surface of the capsule can be smooth and do not cause doubts in the benign nature of the tumor, while on the incision to reveal signs of malignancy (brittle, easily bleeding "papillae", "marble" type of tumor, etc.). In the event of various complications, the ovarian tumor loses its characteristic appearance due to necrotic changes or the outflow of contents into the abdominal cavity. This significantly complicates the diagnosis and often leads to the selection of an inadequate volume of surgical intervention than with routine operations for an ovarian tumor with uncomplicated course.

When establishing the diagnosis of a malignant neoplasm of the ovary, the volume of surgical intervention, irrespective of the age of the patient, must be radical - pangysterectomy and resection of the large omentum. The exception may be elderly patients with severe chronic somatic diseases who undergo supravaginal amputation of the uterus with appendages and resection of the large omentum or removal of the appendages of the uterus from both sides and resection of the large omentum. Women of young age with malignant neoplasm of the ovary stage I can perform a conservative operation in the amount of removal of appendages from the affected ovary and resection of the second, visually unchanged, followed by careful monitoring of these patients for a number of years.

With a benign tumor, the surgeon's tactics depend on the structure of the tumor, the state of the second ovary and uterus. The age of the patient, etc. In the absence of confidence in the nature of the tumor during emergency intervention, the question of the scope of the operation is decided individually. In young women under 40 years with unilateral ovarian damage and normal size of the uterus, one-side removal of the uterine appendages and resection of the second ovary are performed to exclude the lesion by its tumor process. In patients older than 40 years, the volume of surgical intervention is expanding, since the risk of a tumor in the left ovaries in women of older age groups is particularly high.

When twisting the legs of a tumor, it should be cut off, not untwisting, as much as possible above the place of torsion. This tactic is due to the fact that blood clots form in the leg of the tumor, which, when unscrewed, can separate and enter the general bloodstream.

The unfavorable course of the postoperative period after the emergency intervention for an ovarian tumor is somewhat more frequent than after routine surgical interventions. This can be explained by the presence of inflammatory and degenerative changes in the complicated course of the ovarian tumor, as well as by the impossibility of a good preparation of the patient for surgery in emergency conditions.