Adnexal torsion during pregnancy is rare and is complicated by ambiguous symptoms and often nonspecific imaging findings. Differential diagnoses of torsion include a ruptured ovarian cyst, tubo-ovarian abscess, and appendicitis. A low threshold for the recommended surgical laparoscopy is necessary to avoid delayed diagnosis and fetal or maternal complications. We present a case of a 30-year-old woman at 10 weeks gestation as a surrogate carrier, admitted for progressive, sharp lower right quadrant abdominal pain. On presentation, she was afebrile and vitally stable, with moderate leukocytosis and elevated inflammatory markers. Transvaginal ultrasound showed a 6 x 6 cm adnexal mass/cyst, without ovarian vascular compromise, in addition to a tubular structure indicating possible hydrosalpinx. Initially, her presenting symptoms partially resolved following antibiotics and analgesics, which led us to consider a tubo-ovarian abscess as the culprit. However, upon a recurrence of pain, we proceeded with a diagnostic laparoscopy, with a high suspicion of ovarian torsion. A right adnexal torsion and paratubal cyst were identified; detorsion with preservation of adnexa and cystectomy was performed, with resolution of the pain in the postoperative period. This case underscores the importance of identifying multiple risk factors and complex clinical scenarios for ovarian torsion in premenopausal patients in the context of surrogate pregnancies following tubal ligation. Our findings contribute to the existing literature by emphasizing the need for a high index of suspicion for adnexal torsion, as it is imperative to prevent complications and ensure prompt surgical intervention.

Acute appendicitis and adnexal torsion are leading causes of acute surgical abdomen in female patients. However, the simultaneous occurrence of these 2 conditions is extremely rare. Here, we present an extraordinary case of a woman radiologically diagnosed with ovarian dermoid torsion coexisting with acute appendicitis. The patient was managed operatively by surgeons from the respective fields in a single setting, thereby meeting the patient\'s standard of care. This case provides valuable insight into the possible coexistence of acute adnexal pathology with acute bowel pathology and vice versa, emphasizing that radiologists should avoid satisfaction of search after a single possible explanation of the condition.

BACKGROUND: Tubal mesosalpinx cysts are paratubal cysts, that account for approximately 10% of adnexal masses, and the presence of these cysts combined with adnexal torsion is a rare acute abdominal condition, with few cases reported in the literature. We reported two cases of adolescent tubal mesosalpinx cysts combined with adnexal torsion and reviewed the literature to help improve the diagnosis of the disease.
METHODS: The first patient was an 11-year-old girl with left lower abdominal pain for 5 days and fever with nausea and vomiting for 3 days, who was found to have a cystic pelvic mass on preoperative imaging and was diagnosed intraoperatively and postoperatively on pathology as having a left tubal mesosalpinx cyst combined with adnexal torsion. The second patient was a 13-year-old girl with right lower abdominal pain for 16 h and a palpable mass in the lower and middle abdomen on examination, which was hard and tender to palpate. Preoperative imaging revealed a large cystic mass in the right adnexal region, and intraoperative and postoperative pathology revealed a right tubal mesosalpinx cyst combined with adnexal torsion.
CONCLUSIONS: Tubal mesosalpinx cysts combined with adnexal torsion are rare causes of acute lower abdominal pain. Early diagnosis and timely surgery are necessary to ensure ovarian and tubal function. Accurate preoperative imaging diagnosis is challenging, and MRI is a beneficial supplement to ultrasound and CT examinations, providing more objective imaging information and reducing the incidence of adverse outcomes.

Adnexal cyst torsion in late preterm pregnancies is rare, but it frequently causes secondary uterine contractions. Thus, deciding on performing a simultaneous cesarean section due to the potential for early postoperative labor onset is crucial despite no obstetric indications. Here, we report a case of adnexal torsion at 34 weeks of gestation treated with emergency surgery, followed by a full-term vaginal delivery, along with a literature review. A 31-year-old primigravida at 34 weeks and four days of gestation presented to the emergency department with right lower abdominal pain. An emergency laparotomy was performed to achieve term delivery, suspecting right ovarian cyst torsion without signs of fetal distress. General anesthesia with sevoflurane was selected over spinal anesthesia, considering the incision height. The patient was placed in the left lateral decubitus position on the operating table to ensure proper visualization and maintain uterine circulation. A 4-cm transverse skin incision was made under ultrasound guidance, revealing the twisted right paratubal cyst immediately beneath. The cyst was excised, and the torsion was relieved. The postoperative course was uneventful, and spontaneous labor occurred at 39 weeks and six days of gestation, resulting in a vaginal delivery at 40 weeks. This case demonstrates that even late preterm adnexal torsion can be managed safely with appropriate surgical techniques, allowing for a subsequent term vaginal delivery.

We report four cases of isolated fallopian tube torsion (IFTT) successfully treated with laparoscopic surgery over the past 10 years. Two young women (each 19 years old) were IFTT with paraovarian cyst (POC) and tubal preservation was possible with detorsion and cystectomy. The other two patients (a 41-year-old woman with hydrosalpinx and a 50-year-old woman with hematosalpinx) underwent salpingectomy and adnexectomy, respectively, because there was no desire for tubal preservation. One patient had emergency surgery due to severe abdominal pain, one had semi-emergency surgery due to mild abdominal pain, and the other two were diagnosed during scheduled surgery without symptoms.Although IFTT was considered a very rare disease, our case series and recent reports suggest that it may have been underestimated, as it accounts for approximately 10% of adnexal torsion cases. Preoperative diagnosis of IFTT may be more difficult than for adnexal torsion because of its infrequency and nonspecific, vague clinical symptoms.　Since the prevalent age for this disease is young, as in our first 2 patients, early surgical intervention to preserve the fallopian tubes should be chosen when necessary, and it seems to be important for gynecologists to be aware of this disease for earlier diagnosis and appropriate surgical intervention.

A 41-year-old woman presented with acute, severe left-sided abdominal pain and vomiting at 37 weeks\' gestation. Her symptoms were attributed to renal colic, and she was admitted for supportive treatment. During her admission, she went into spontaneous labour. Due to other obstetric indications, the team proceeded with delivery by emergency caesarean section. Intra-operatively, a necrotic left fallopian tube and ovary were identified, and a diagnosis of adnexal torsion (AT) was recognised. There was no return of tissue perfusion on de-torsion, and a left salpingo-oopherectomy was performed. AT in pregnancy is unusual, with only a minority of cases occurring in the third trimester. This is a challenging diagnosis to establish and requires a high index of suspicion. Ultrasound and magnetic resonance imaging can be helpful in establishing a diagnosis but should not delay definitive treatment. Prompt surgical intervention is paramount to prevent irreversible damage to ovarian tissue.

UNASSIGNED: This study aimed to evaluate the effectiveness of prophylactic laparoscopic surgery for avoiding adnexal torsion in pregnant women with benign adnexal masses.
UNASSIGNED: This report contains two analyses, each for a different group of patients. Analysis 1: Surgical and pregnancy outcomes were examined among the 126 cases who underwent laparoscopic assisted cystectomy for adnexal masses during pregnancy in our hospital between January 2001 and December 2020. Analysis 2: The incidence of adnexal torsion during pregnancy was evaluated among the cases with adnexal masses ≥5 cm who opted for conservative follow-up in our hospital between January 2011 and December 2020.
UNASSIGNED: In analysis 1, the most common pathological diagnosis was a mature cystic teratoma (76.2%). The mean gestational age at surgery was 13.1 ± 1.3 weeks. No cases were converted to laparotomy and oophorectomy. Regarding delivery outcomes, 97.4% of cases went on to have full-term deliveries. In Analysis 2, the incidence of adnexal mass ≥5 cm that did not resolve spontaneously during pregnancy was 89 cases (0.8%). The frequency of malignancy was 3 cases (0.03%). In 28 cases who opted for conservative treatment, 5 (17.9%) underwent emergency surgery for adnexal torsion.
UNASSIGNED: Prophylactic surgery for benign adnexal masses during pregnancy can be performed laparoscopically and preserved ovarian functions. In pregnant women with adnexal masses that do not resolve spontaneously, planning laparoscopic surgery is considered beneficial for complications, such as adnexal torsion.

UNASSIGNED: Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is an emerging minimally invasive approach increasingly applied to perform many gynecological procedures. Despite a still limited level of evidence, compared to conventional laparoscopy, vNOTES seems to be associated with reduced blood loss, shorter operative time, less postoperative pain, shorter hospitalization time, better cosmetic results and decreased postoperative morbidity. Although growing evidence supports the effectiveness of vNOTES for elective adnexal surgeries, there is still limited knowledge regarding its feasibility and safety in emergency settings. In the present study, we report our experience performing vNOTES in gynecological emergency cases.
UNASSIGNED: We prospectively collected and analyzed data from patients who underwent vNOTES for gynecological emergencies between November 2021 and June 2023. Demographic and perioperative characteristics were collected and analyzed.
UNASSIGNED: Seventeen patients were included. Interventions were realized for suspicion of ectopic pregnancy in 7 cases (41.2%), for suspicion of adnexal torsion in 7 cases (41.2%), for post-hysterectomy hemoperitoneum in 2 cases (11.8%), and for uncontrollable uterine bleeding in 1 case (5.9%). Emergency procedures included unilateral salpingectomy (35.3%), ovarian cystectomy (23.5%), ovarian cystotomy (17.6%), adnexal detorsion (11.8%), hemoperitoneum drainage (11.8%), hysterectomy (5.9%), and appendectomy (5.9%). The overall median operative time was 38 [18-72] minutes. The median estimated intraoperative blood loss was 30 [5-150] mL, and no intraoperative complications occurred. Conversion to conventional laparoscopy or laparotomy was never needed. Patients stayed hospitalized for a median time of 30 [4-144] hours after the intervention. The median visual analog scale value for postoperative pain evaluation was 2 [0-5] at 12, 24, and 48 postoperative hours. No complications associated with the procedure occurred.
UNASSIGNED: This study demonstrated the feasibility of performing vNOTES procedures for managing gynecological emergencies such as tubal ectopic pregnancy, adnexal torsion, painful ovarian lesions, post-hysterectomy hemoperitoneum, and uncontrollable uterine bleeding. Associated with data reported in the available literature, our results suggest potential benefits in treating gynecological emergencies by vNOTES over conventional laparoscopy. However, stronger evidence from larger studies is needed to confirm it.

UNASSIGNED: Isolated utero-ovarian torsion poses a challenge to diagnosing adnexal torsion, as it may not present with imaging findings. Clinicians with high suspicion for torsion but lack of evidence on ultrasonography should proceed to diagnostic laparoscopy.
UNASSIGNED: Adnexal torsion occurs when the ovary rotates around its supporting ligaments, the infundibulopelvic and utero-ovarian (UO) ligaments, often causing disruption of blood supply. This pathology often presents with acute pelvic pain and is a gynecologic surgical emergency. Diagnosis is typically made with Doppler ultrasound, although dual blood supply to the ovary poses additional diagnostic challenges and sensitivity of this tool is debated. In this case study, we present a case of missed torsion due to isolated compromise of UO ligament.

BACKGROUND: Early management for adnexal torsion increases likelihood of ovarian/tubal salvage. The Coronavirus disease of 2019 (COVID-19) pandemic poses delays from symptom-onset to intervention. The primary objective was to evaluate rates of ovarian salvage and tubal salvage following ovarian torsion and adnexal torsion during the COVID-19 pandemic in a pediatric and adolescent gynecology population.
METHODS: This was a retrospective quality improvement cohort study of pediatric and adolescent gynecology patients at a single children\'s hospital who underwent laparoscopy for suspected ovarian torsion/adnexal torsion between March 2020 to March 2021. Descriptive statistics and t-tests were utilized.
RESULTS: There were 50 suspected adnexal cases in 47 patients. All underwent laparoscopy, revealing 39 adnexal torsion occurrences in 36 patients and 1 patient with recurrent adnexal torsion three times. All underwent pre-operative COVID-19 testing. Mean age was 13.9 ± 2.6 years for adnexal torsion cohort. Menarche was achieved in 88% (n = 44) and 12% (n = 6) were pre-menarchal. The primary outcome was ovarian salvage and tubal salvage rates, which were 97.4% (n = 38) and 89.7% (n = 35), respectively. Secondary outcomes assessed factors contributing to the primary outcome or operative delays. The mean age of menarche was 11.2 years (salvaged) and 12.5 years (non-salvaged) (p = 0.04). There were no differences in mean pain duration or mean COVID-19 testing time between groups. Left, right and bilateral adnexal torsion occurred in 42% (n = 21), 32% (n = 16), and 4% (n = 2) respectively. The most common pathologies were paratubal cyst (n = 17, 34%) and benign ovarian cyst (n = 16, 32%).
CONCLUSIONS: Ovarian salvage and tubal salvage rates were 97.4% and 89.7%, respectively during the time frame studied. These salvage rates during the study period are comparable to previous rates in a pre-COVID cohort at our institution. Institutional and departmental quality and safety initiatives likely contributed to this outcome.