When I was a student, the standard teaching was not to
remove the torsion of a twisted pedicle of an ovarian cyst or tumor. It was
recommended that the cyst/tumor be removed. It was stated that if the twist was
removed, thrombi and toxic materials would escape into circulation and harm the
patient.
Scientific thinking changed over time. Now we have Doppler
to help us decide preoperatively if the circulation through the ovarian vessels
is obstructed or not. It is believed that if ovarian circulation is not
interrupted, the ovary may be salvaged by removal of just the cyst in it. If it
is obstructed, removal of the cyst is recommended.
We had a 14 years old girl who presented with bilateral large
ovarian cysts, with features of torsion of one of them. Doppler studies
revealed absence of flow in its vessels. By standard teaching one would have to
remove the ovary. But we were reluctant to do so in view of her young age. Should we remove
one ovary and some time later even the other ovary had to be removed for a
similar reason, the girl would develop surgical menopause very early in her
life.
“Counsel the patient and her guardians/parents that we can
try to salvage the ovary” I told my Registrar on phone in the middle of the
night. “We will remove the twist and enucleate the cyst. If the raw tissues
bleed freely, the circulation can be presumed to be OK. Then we can reconstruct
the ovary. There is some risk that the vessels may get thrombosed due to
endothelial damage sustained due to the torsion, and she may need another
operation to get the ovary removed. If they agree, do as I have just described.”
Things went as I wished, and they saved her ovary. We still
need to wait and see, but the patient and her conserved ovary seem to be doing
well.
“Don’t always trust the Doppler report blindly” I told my
resident doctors. “Give the patient a fair chance. If the flow is indeed found
to be absent during dissection, you can always remove the ovary. If you just
clamp and cut the pedicle right away after opening the abdomen, there is no way
you can reverse it.”
I am sure they will carry this message into their own
practice when they qualify and go away.
