Infertility and IVF Unit, Assaf Harofeh Medical Center, Sackler Faculty of Medicine, Zerifin 70300, Tel-Aviv University, Israel
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Abstract |
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Key words: adnexa/Fallopian tube/laparoscopic detorsion/torsion
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Introduction |
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To the best of our knowledge this is the first reported case concerning recurrent torsion of the right Fallopian tube that occurred within an interval of 2 years.
The dilemma of how to manage such an uncommon condition and the options on how to prevent the recurrence of Fallopian tube torsion after it is first encountered are discussed.
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Case report |
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This time, on admission, she was pale, tachycardic, without fever, with severe tenderness of the right lower quadrant of the abdomen but with no guarding signs or rebound tenderness. The right adnexa was tender on vaginal examination. Vaginal ultrasonic examination revealed a normal uterus surrounded by a relatively large amount of pelvic fluid. Dilated tubular structures with thickened echogenic walls and internal debris between the uterus and the right ovary were demonstrated. Haemoglobin and white blood cell values were within normal limits and the urinary ß-human chorionic gonadotrophin (HCG) measurement was negative. At this stage emergency diagnostic laparoscopy disclosed a normal left adnexa. The right ovary was normal but the adjacent tube was longer than usual, twisted four times on its distal part, which was dilated, oedematous and dark red. The fimbrial portion of the tube was still red. No pelvic adhesions or endometriotic lesions were seen. Laparoscopic detorsion was successfully performed and the tube gradually regained its pink colour within 20 min. The postoperative course was uneventful and the woman was discharged the next day.
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Discussion |
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At the first episode of torsion of the Fallopian tube, tubal preservation must be the rule, unless the tube is totally necrotic. Pregnancy has been reported after detorsion of the tube (Blair, 1962). After a second episode of tubal torsion the question as to whether the tube remains functional is not yet clear. Salvage of the tube in order to preserve future fertility, especially in a young nulligravid patient, is crucial. However, if tubal function has been compromised, then leaving it in place exposes the patient to the risk of ectopic pregnancy and to the possibility of a third episode of tubal torsion, including the risks of anaesthesia and laparoscopy.
Operative fixation of the Fallopian tube in order to prevent a recurrent episode of torsion is logical and technically possible but it may change the normal anatomy of the pelvis either moving the adnexa outside from the pelvis or distorting the important close relationship between the ovary and the fimbrial portion of the tube. Branches of both the uterine and the ovarian arteries provide circulation to the Fallopian tube. Shortening of a `billowing' mesosalpinx may potentially reduce the mobility and hence prevent recurrent torsion of the tube; this was not performed in the case reported here since it may have impaired the blood supply to the adjacent ovary.
Although isolated torsion of the tube is rare and recurrent torsion is even more rare, it should be considered in the evaluation of a woman with acute onset of lower abdominal pain. Sonographic features of isolated torsion of the tube (Propeck and Scanlan, 1998) may help to establish a preoperative diagnosis which may lead to timely laparoscopy before irreversible necrosis occurs.
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Notes |
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References |
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Submitted on July 22, 1999; accepted on September 14, 1999.