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Case Report

Laparoscopic Management of Fallopian Tube Torsion


at 35 Weeks of Gestation: Case Report
Lubna Chohan, MD, Mildred M. Ramirez, MD, Curtis J. Wray, MD,
and Charles C. Kilpatrick, MD*
From the Departments of Obstetrics and Gynecology (Drs. Chohan, Ramirez, and Kilpatrick) and Surgery (Dr. Wray), University of Texas Health Science
Center at Houston, Houston, Texas.

ABSTRACT Isolated fallopian tube torsion requiring surgical intervention in pregnancy is rare. Herein is reported a case of fallopian tube
torsion that was managed laparoscopically at 35 weeks of gestation. Journal of Minimally Invasive Gynecology (2011) 18,
390–392 Ó 2011 AAGL. All rights reserved.

During pregnancy, laparoscopy is comparable to laparot- that time, she had no symptoms. She came to the obstetric
omy in terms of safety [1,2]. Laparoscopy has the added service at 35 weeks 4 days with symptoms of acute-onset
advantages of decreased length of stay, less postoperative right lower quadrant pain 8/10, nausea and vomiting, and
pain, quicker return to ambulation, and a smaller chance of uterine contractions. At examination, she was afebrile,
wound infection and incisional hernia [3]. The most com- with normal vital signs. Fundal height was 32 cm. Physical
mon nonobstetric surgery performed in pregnancy is appen- examination of the abdomen revealed positive bowel sounds
dectomy, and in many hospitals the laparoscopic approach is and tenderness over the right lower quadrant and suprapubic
becoming the standard [4]. Ovarian torsion is increasingly area without evidence of peritoneal symptoms. The patient
more often managed laparoscopically [5]. Data from case re- was admitted for observation and given intravenous pain
ports and series list the incidence of ovarian torsion in preg- medication. She experienced contractions regularly without
nancy as from less than 1% to 22% [6]. Fallopian tube cervical change, and the fetal heart rate tracing was within
torsion due to a paraovarian or paratubal cyst in pregnancy normal limits. Complete white blood cell count, electrolyte
is even less common, with only case reports in the literature concentrations, and urinalysis were within normal limits.
[7]. Herein is described a successful case of laparoscopic Ultrasonography performed to evaluate the right adnexa
drainage of a paratubal cyst, with untwisting of the fallopian and appendix revealed a 9.2 ! 5.8 ! 4.2-cm right adnexal
tube, at 35 weeks of gestation. cyst, 3.1 ! 1.6 ! 2.1-cm right ovary, and normal duplex
Doppler flow (Fig. 1). It could not be determined whether
the mass was arising from or adjacent to the right ovary,
Case Report and the appendix could not be visualized. No free peritoneal
A 33-year-old woman, gravida 5, para 4, was noted to fluid was visualized.
have a simple-appearing right ovarian cyst measuring 6.7 Because of concern for ovarian torsion, surgical manage-
! 6.3 ! 4.6 cm when she was evaluated at ultrasound at ment was recommended. The patient was counseled about
30 weeks of gestation due to size and date discrepancy. At the diagnosis and treatment options, and informed consent
was obtained. Laparoscopy was performed with the patient
under general endotracheal anesthesia. A single dose of
The authors have no commercial, proprietary, or financial interest in the
ephedrine, 20 mg IV, was required after induction to main-
products or companies described in this article.
Corresponding author: Charles C. Kilpatrick, MD, Department of Obstetrics tain blood pressure within 20% of baseline, and maternal
and Gynecology, University of Texas Health Science Center at Houston, end-tidal carbon dioxide (CO2) was maintained at 32 to 34
Lyndon Baines Johnson Hospital, 5656 Kelley St, Houston TX, 77026. mm Hg throughout the procedure. In the left upper quadrant,
E-mail: [email protected] inferior to the costal margin, superior to the gravid uterus,
Submitted December 15, 2010. Accepted for publication January 26, 2011. and medial to the Palmer point, a Veress needle was intro-
Available at www.sciencedirect.com and www.jmig.org duced, and intraperitoneal placement was confirmed with
1553-4650/$ - see front matter Ó 2011 AAGL. All rights reserved.
doi:10.1016/j.jmig.2011.01.017
Chohan et al. Laparoscopic Paratubal Cyst Management at 35 Weeks’ Gestation 391

Fig. 1 Fig. 3
Ultrasound image of right paratubal cyst abutting the right ovary. Laparoscopic view of right fallopian tube after untwisting.

without symptoms. She went into labor 18 days later at 38


weeks of gestation, and delivered a vigorous female infant
weighing 2810 g without complication, and was discharged
to home the next day. Three months after the surgery, repeat
an opening pressure of 6 mm Hg and visual confirmation pelvic examination and transvaginal ultrasound revealed
with a 5-mm, 0-degree Optiview (Ethicon Endo-Surgery, no evidence of cyst reaccumulation. The patient remains
Inc, Cincinnati, OH) using the same location. Intraperitoneal symptom-free.
pressure was maintained at 15 mm Hg throughout the
procedure, and the patient was placed in a left lateral tilt Discussion
position. Inspection of the fundus of the uterus revealed no
trauma. The camera was changed to a 30-degree scope to Isolated torsion of the fallopian tube in pregnancy requir-
visualize around the gravid uterus, and revealed a normal ing operative intervention is rare; only 19 cases have been
appearing right ovary, a large right paratubal cyst (Fig. 2), reported in the literature to date [7]. As in our patient,
and the right fallopian tube twisted 360 degrees. Two addi- most often it occurs on the right side with symptoms of
tional 5-mm ports, right lower quadrant and right upper nausea, vomiting, and lower abdominal pain. Physical ex-
quadrant, were placed under direct visualization, and the amination reveals lower abdominal tenderness and rarely
cyst was drained and the fallopian tube untwisted (Fig. 3). symptoms of peritoneal irritation. Abnormal laboratory
Because of increased vascularity of the mesosalpinx, exci- test results are rare. Predisposing factors are anatomic abnor-
sion of the cyst wall was not attempted, and the procedure malities such as hydatid cysts of Morgagni, pyosalpinx, and
was ended. hydrosalpinx. Differential diagnosis includes acute appendi-
The patient had an uneventful recovery. She was observed citis, ovarian torsion or a symptomatic ovarian cyst, nephro-
after surgery using tocodynamometry and fetal heart rate lithiasis, pyelonephritis, leiomyoma pain or degeneration,
monitoring. She was discharged to home the next morning, and small bowel obstruction. Imaging may aid in narrowing
and at follow-up in the clinic a week later was doing well the differential diagnosis; however, it is difficult to differen-
tiate a paratubal cyst from an ovarian cyst [8]. The appendix
is not always visible at ultrasound, especially later in gesta-
Fig. 2 tion [9]. Surgical management is necessary if torsion of the
Laparoscopic view of the uterus, right ovary, and twisted fallopian tube, tube or ovary is clinically suspected. At many institutions,
next to a large paratubal cyst. laparoscopic management of ovarian torsion in the nonpreg-
nant state is the standard of care [5].
To our knowledge, this is the first case report of laparo-
scopic management of fallopian tubal torsion in pregnancy.
A PubMed search of articles from 1966 to 2010 using the
keywords ‘‘Tubal torsion,’’ ‘‘Pregnancy,’’ ‘‘Adnexal torsion,’’
‘‘Laparoscopy,’’ and ‘‘Surgery’’ did not yield another case.
Under ideal circumstances, cystectomy would have been
performed to prevent recurrence and to enable complete
pathologic characterization. However, because of the techni-
cal challenges of the gravid uterus, the increased vascularity
of the mesosalpinx, and the extremely low incidence of
borderline paratubal cysts [10,11], the cyst was drained
392 Journal of Minimally Invasive Gynecology, Vol 18, No 3, May/June 2011

rather than excised. In this clinical scenario, we believe the References


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