Laparoscopic Management of Isolated Fallopian Tube Torsion in the Adolescent Patient

Isolated torsion of the fallopian tube is a rare occurrence necessitating surgical management. The condition closely mimics other abdominal disease processes and is therefore most often diagnosed during surgical intervention. Although a recent case of a salvaged fallopian tube has been reported, the majority of cases have been treated via surgical excision of the involved tube. Case Report A 12-year-old G 0 presented to the emergency room with acute onset of right lower quadrant pain with nausea and vomiting over the last day. She now had nonnal bowel movements, denied urinary symptoms, and reported no fever or chills. The patient had had an appendectomy 3 1/2 weeks prior to this visit after a similar presentation. After her surgery, she bad been discharged from the hospital following an uneventful post-operative course and had been resuming her normal activities. Histology of her appendix was unremarkable. Ms. A. had experienced menarche at age 11, with menses every 4 to 6 weeks, the last being 2 weeks prior to admission, and denied sexual activity. Examination revealed a temperature of 37.6° C with a pulse rate of 120. An abdominal exam revealed generalized tenderness with localization to the right lower quadrant. Pelvic exam revealed an intact hymen with no discharge. A pregnancy test was negative, a white cell count showed 11 000/mm 3 , and her hematocrit was 37 %. A roentgenogram of the abdomen revealed no evidence of small bowel obstruction. A sonogram revealed a cystic right adnexal mass confumed on CT to be 3 cm × 4 cm × 4 cm. At this point the patient was taken to surgery for a diagnostic laparoscopy with the provisional diagnosis of right ovarian cyst and possible torsion of the right adnexa. At laparoscopy the ileum and cecunt were adhesed to the right adnexa which was dissected free. Torsion was noted to have occured at this position of the tube and the distal tube appeared necrotic. The right ovary contained a corpus luteum and was not torsed. The left tube and ovary were normal to gross inspection A laparoscopic partial right salpingectomy was performed. Histology revealed an edematous tube. The patient was discharged on post-operative day two. Discussion Since first reponed in 1890 the incidence of isolated torsion of the fallopian tube has been reported to be from 1 in 50,000 to 1 in 1,500,000. The presenting symptoms, examination. laboratory, and radiologic fmdings, which are similar if not identical to other abdominal processes, makes tubal torsion nearly impossible to diagnose preoperatively despite a recent report of sonographic characteristics. The mechanisms postulated for torsion of the tube include: excess mobility, hematosalpinx, hydrosalpinx, an unusually long mesosalpinx, hydatids of morgagni, jarring movements of the body/trauma, and prior pelvic surgery and its aftereffects. The management of torsion, once diagnosed, is more straight forward. When possible, salvage of the tube should be undertaken. Unfortunately, the diagnosis and intervention may not occur until the affected tube is infarcted and excision of the tube may then be necessary. However, just as detorsion or removal of the adnexa can be managed laparoscopically, similar management can be accomplished laparoscopically. This case demonstrates the previously documented difficulty in diagnosing tubal torsion. Additionally, establishing the etiology of this torsion is complicated by our patient's prior surgery. It is unclear whether she was experiencing intermittent torsion causing her acute pain prior to the appendectomy; or, if the sequelae of that surgery may have caused the torsion. This case also demonstrates the unfortunate consequences of an albeit difficult, but delayed, diagnosis, in the loss of a young woman's fallopian tube. While a laparotomy was avoided, the ideal management would be detorsion of the fallopian tube by way of laparoscopy.