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ADNEXAL
TORSION

                  
Adnexal torsion, twisting of the ovary or tube is the fifth most common
gynaecological emergency with an incidence of 2.7% (1). Since it occurs more
commonly in adolescent girls and women of child bearing age, early diagnosis
and salvaging the ovary is very important. In adnexal torsion, venous and
lymphatic circulation is initially affected followed by occlusion of arterial
circulation. If unrelieved, it ultimately leads to gangrene. Hence, prompt
diagnosis and early intervention plays a major role in ovarian preservation.

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The standard option to treat twisted ischemic adnexa was adnexectomy
without untwisting until 1989
(2). Even though USG is diagnostic, laparoscopy has been the gold
standard in confirming adnexal torsion.
In
the recent years, laparoscopic detorsion followed by ovariopexy has been
successfully practised at our centre. Ovarian preservation has been done for
almost all of our cases including cases of severe ischaemic ovary. Various
procedures of ovariopexy are reported like fixing the ovaries to pelvic side
wall or uterus or uterosacral ligament or round ligament. Shortening of the utero-ovarian ligament and fixing its ovarian extremity to
the posterior surface of the broad ligament has been considered the gold
standard technique of ovariopexy.

 

ECTOPIC
PREGNANCY

               
The incidence of ectopic pregnancy has been on the rise over the last 20
years accounting for 0.6% to 2.1% of all pregnancies (3).
Laparoscopic management of ectopic pregnancy was first reported in 1980 (4). Even
though medical management is considered a safe alternative in cases of
unruptured tubal pregnancy, surgical treatment remains the main stay of
management (5).

                   
Laparoscopic management of ectopic pregnancy depends on the location,
size and nature of tubal pregnancy. In patients who are hemodynamically stable
and wish to preserve their fertility, tube preserving surgeries like
salpingotomy, salpingostomy, segmental tubal resection and reanastomosis, and
fimbrial milking can be performed. 
Laparoscopic salpingectomy is done in cases with uncontrolled bleeding,
severely damaged tubes, recurrent ectopic pregnancy in the same tube, failed
medical management and women who have completed family. In our centre, with
good surgical expertise, laparoscopic management is done even in cases of large
hemoperitoneum. There was no difference in fertility outcome following
salpingectomy and salpingostomy in patients with a healthy contralateral tube
(6).

 

 

CESAREAN
SCAR PREGNANCY

                 
Cesarean scar pregnancy is the implantation of gestational sac into the
myometrial scar of previous caesarean pregnancy. It is a rare case of
extrauterine pregnancy with an incidence of 1:1?800 to 1:2?200 pregnancies
(7). An unrecognised cesarean scar pregnancy can lead to catastrophic
complications like uterine rupture and uncontrollable haemorrhage. Laparoscopic
bilateral internal iliac artery artery ligation along with repair of the
uterine defect has been proved to be successful (8). The primary aim
of management should be preservation of fertility. Many such cases have been
successfully managed in our centre (9), thereby preventing the need for more
radical procedures like hysterectomy.

 

RUPTURED
OVARIAN CYST

                   
Although rupture and hemorrhage of an ovarian cyst may be physiologic
events and a self-limited process, conditions like haemorrhagic cyst, corpus
luteal cyst or endometriotic cyst may cause significant hemoperitoneum which
require surgical intervention. Laparoscopy has been the preferred surgical
approach in management of rupture of ovarian cysts (10). Care should
be taken in cases of rupture of dermoid cysts as it may cause chemical
peritonitis and rupture of endometriotic cysts might lead to adhesion formation
in addition to chemical peritonitis and sepsis and hence warrants immediate
surgical management. Laparoscopic ovarian cystectomy or oophorectomy should be
performed based on patient’s parity and thorough peritoneal lavage is mandatory
to prevent chemical peritonitis.

 

TUBO
OVARIAN ABSCESS

          
Tubo ovarian abscess is more commonly found in women of reproductive age
group with associated pelvic inflammatory disease. It affects around 18% of
women with pelvic inflammatory disease (11). If untreated, it might
rupture and lead to life threatening peritonitis and sepsis. Hence, prompt
diagnosis and inpatient medical management are required. Surgery should be
considered in cases with ruptured tubo ovarian abscess and which are not
responding to antibiotic treatment. Laparoscopy still remains the gold standard
for diagnosis and treatment of tubo ovarian abscess. The surgical procedure involves
drainage of the abscess cavity, aspiration of purulent fluid from the pelvis,
removal of necrosis and irrigation of the peritoneal cavity. In necessary
situations, salphingo oophorectomy is performed.

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