What is the Torsion of the Legs of the Uterine Appendage Tumors?
In 15-25% of cases, torsion of the legs of the ovarian tumor is found, but torsion of the legs of any tumor (for example, the subserous node), the fallopian tube, the unchanged ovary and even the entire uterus or its appendages is possible. Movable mature teratomas, as well as paraovarial cysts, dense ovarian fibromas are susceptible to torsion.
Distinguish between the anatomical and surgical leg of an ovarian tumor. The anatomical leg of the tumor (cyst) of the ovary consists of stretched funnel and pelvic ligaments of the ovary and its mesentery. In the leg are vessels supplying the tumor and ovarian tissue (ovarian artery, branch of the ascending uterine artery), lymphatic vessels and nerves. In addition to the anatomical leg, an extended uterine tube enters the surgical leg resulting from torsion.
Causes of Torsion of the Legs of the Uterus Appendages Tumors
The reasons for the torsion of the legs of the tumors are not always clear. It is believed that for the occurrence of torsion, a sudden stop of the rotational movement of the body (gymnastic exercises, dances), physical activity, a sharp change in intra-abdominal pressure are important. In these cases, the rotation of the tumor around the leg continues by inertia, which leads to torsion. Torsion of the legs is facilitated by an asymmetric shape, uneven density of the tumor.
At the time of torsion, the branches of the uterine artery and ovarian artery that feed the ovary, along with the veins accompanying them, are bent. In the tumor, blood circulation is disturbed, then necrosis and aseptic inflammation occur, spreading to the peritoneum of the pelvis. Torsion can be full (more than 360 °) and partial (less than 360 °). Partial torsion of the legs of the tumor disrupts primarily the venous outflow with a relatively preserved arterial blood supply. All phenomena are not very pronounced and can disappear even without treatment. Secondary changes in the tumor (necrosis, hemorrhage) are detected in such patients during surgery.
Symptoms of Torsion of the Legs of the Uterus Appendages Tumors
The clinical picture of the disease is determined by malnutrition of the tumor. With a quick torsion of the legs of the tumor, the clinic is so characteristic that it immediately allows you to establish the correct diagnosis. The disease begins suddenly with the appearance of a sharp pain in the lower abdomen on the side of the lesion, nausea, vomiting, stool and gas retention (intestinal paresis). With a slow twist, the symptoms of the disease are less pronounced, they may periodically intensify or disappear.
Diagnosis of Torsion of the Legs of the Uterus Appendages Tumors
Diagnosis of the torsion of the leg of the tumor is based on complaints, anamnesis (an indication of a cyst or ovarian tumor), typical symptoms of the disease, data from an objective study. The skin becomes pale, cold sweat appears, the body temperature rises (usually up to 38 ° C), the pulse quickens. Tongue dry, coated with plaque. The abdomen is swollen, painful at the site of the projection of the tumor, the muscles of the anterior abdominal wall are tense, the symptom of Shchetkin-Blumberg is positive. In blood leukocytosis, ESR is increased.
Gynecological examination allows confirming the disease, which allows to identify a volumetric formation in the area of the uterine appendages, usually oval, with a tight-elastic consistency, limited mobility, sharply painful on palpation and attempted displacement. The uterus and appendages, on the other hand, are not changed. A two-handed gynecological examination is often difficult due to the sharp pain and tension of the muscles of the anterior abdominal wall, especially in girls, which forces them to be examined under anesthesia.
An important method for diagnosing the torsion of the tumor leg is ultrasound scanning, in which a volumetric formation with signs of a tumor or ovarian cyst is determined in the area of the uterine appendages. In girls, the diagnosis is often made untimely, as doctors do not always remember about the possibility of genital tumors in children and adolescents. The most accurate information can be obtained with laparoscopy. An endoscopic examination reveals a crimson-cyanotic mass in the pelvis — an ovary with torsion (Fig. 16.19), with or without signs of necrosis, as well as serous or serous-hemorrhagic effusion.
Differential diagnosis for torsion of the legs of the ovarian tumor should be carried out primarily with acute appendicitis (especially with the pelvic location of the appendix), renal colic. In this situation, additional research methods can help – an overview x-ray of the abdominal organs, ultrasound of the abdominal cavity and retroperitoneal space.
Treatment of Torsion of the Legs of the Uterus Appendages Tumors
Surgical treatment of torsion of the legs of the tumor (laparoscopic or laparotomy access). Procrastination with surgery leads to tumor necrosis, attachment of a secondary infection, fusion of the tumor with neighboring organs, and the development of peritonitis. After a visual examination of the macrodrug, and sometimes after an urgent histological examination, the volume of surgical intervention is finally determined.
Previously, during an operation, a tumor leg was strictly forbidden to unwind due to the risk of embolism by blood clots located in the blood vessels of the leg. Currently, medical tactics has been revised. In the absence of visual signs of necrosis, the formation leg is untwisted and the restoration of blood circulation in the tissues is observed. In the event of the disappearance of ischemia and venous stasis, instead of the previously accepted removal of the uterine appendages, you can limit yourself to ovarian resection (if the type of tumor or ovarian cyst allows). This is especially true for girls and adolescents, as it allows you to save an organ that is important for menstrual and reproductive functions.