Diagnosis and management of isolated tubal torsion with a pa
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Isolated tubal torsion without ovarian involvement is an uncommon cause of emergency during pregnancy. Prompt surgical management is needed, otherwise necrotic tubal tissue may cause premature labor, even fetal loss, and maternal morbidity. However, since the clinical presentation of isolated tubal torsion is variable and often nonspecific, especially in the gravida abdomen at advanced gestational weeks, it is a diagnostic and therapeutic challenge for treating physicians.

Since imaging modalities including ultrasonography and magnetic resonance imaging (MRI),4 may not usually be enough to draw a conclusion, the traditional approach to diagnosing isolated tubal torsion is exploratory laparotomy, followed by detorsion or excision after making a correct diagnosis. However, especially in gravida with advanced gestation, a laparotomic approach can actually be invasive, as a long abdominal incision is usually required to achieve surgical success.

A 30-year-old nulliparous woman was transferred under suspicion of acute appendicitis, due to the sudden onset of severe right lower quadrant pain at 31 weeks and 4 days of gestation. Magnetic resonance imaging showed a cystic mass measuring 40 mm in diameter in the right lower abdomen. Because the right ovary without edematous swelling was noted adjacent to the cystic mass, isolated tubal torsion was strongly suspected.

Emergency gasless laparoendoscopic single-site surgery showed isolated torsion of the right fallopian tube with a paratubal cyst. The right ovary was not involved in this torsion. Because the color tone of the distal portion of the fallopian tube did not recover sufficiently after detorsion, right salpingectomy was performed. Postoperatively, the infusion of magnesium sulfate was initiated due to increased uterine contraction and continued until 36 weeks of gestation. At 38 weeks and 1 day of gestation, uneventful vaginal delivery yielded a healthy female infant.

When laparoscopic surgery is performed in gravida women, the potential negative effects on the fetus become the top priority. Pneumoperitoneum during pregnancy may decrease the venous return to the mother’s heart. The uteroplacental perfusion can also be disturbed. Furthermore, fetal acidosis may be induced by the absorption of carbon dioxide gas. Since gasless laparoscopy avoids risks arising from the insufflation of carbon dioxide gas, this approach may be a desirable option for the minimally invasive management of isolated tubal torsion in women with advanced gestation.

In conclusion, an MRI diagnosis followed by gasless LESS surgery for the management of isolated tubal torsion during pregnancy may be a feasible option with favorable pregnancy outcomes, even in cases of advanced gestation.

Source: https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/jog.14252
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