Risk of Ovarian Torsion After Hysterectomy
Post-hysterectomy ovarian torsion is a rare but serious complication that occurs significantly more frequently after laparoscopic hysterectomy compared to other surgical approaches, with an estimated incidence of 1-8% overall but substantially higher risk following laparoscopic procedures. 1, 2
Incidence and Risk by Surgical Approach
The risk of adnexal torsion varies dramatically based on the hysterectomy technique used:
Laparoscopic hysterectomy carries the highest risk of post-operative adnexal torsion compared to abdominal or vaginal approaches, with statistically significant increased prevalence (P < 0.05). 2
In one retrospective cohort study, 7 out of 8 cases (87.5%) of post-hysterectomy adnexal torsion occurred after laparoscopic hysterectomy, with only 1 case following vaginal hysterectomy and zero after abdominal hysterectomy. 2
Among 705 patients who underwent laparoscopic hysterectomy with ovarian preservation, the prevalence was significantly elevated compared to other approaches. 2
General estimates place post-hysterectomy adnexal torsion between 1-8% of cases when ovaries are preserved. 1
Timing of Occurrence
Post-hysterectomy ovarian torsion does not occur immediately but develops months to years after the initial surgery:
Mean time to torsion is approximately 27 months (range 3-60 months) after hysterectomy. 2
Cases have been reported occurring 2-3 years post-operatively, demonstrating this is not just an early post-operative complication. 3, 4
Clinical Presentation
When post-hysterectomy ovarian torsion occurs, patients present with characteristic symptoms:
Acute onset pelvic or abdominal pain is universal (100% of cases), often unilateral. 2
Nausea and vomiting occur in approximately 62.5% of cases. 2
Gastrointestinal symptoms like diarrhea may be present but are less common. 2
The diagnosis is challenging because symptoms are nonspecific and clinicians may not consider torsion in patients who have undergone hysterectomy. 3
Why Laparoscopic Approach Increases Risk
The mechanism behind increased torsion risk after laparoscopic hysterectomy relates to anatomical changes:
Removal of the uterus creates increased mobility of the adnexa within the pelvis. 2
The laparoscopic approach may result in different peritoneal healing patterns or adhesion formation compared to open surgery. 2
Even when prophylactic oophoropexy (ovarian suspension) is performed during the initial surgery, torsion can still occur, as the suspension sutures may fail or the ovary may tort despite fixation. 1, 4
Critical Diagnostic Considerations
Maintain a high index of suspicion for adnexal torsion in any patient with acute pelvic pain and history of hysterectomy with ovarian preservation, especially if the hysterectomy was performed laparoscopically. 3, 2
Pelvic ultrasound with Doppler is the initial imaging modality, though normal Doppler flow does not exclude torsion (38-60% of torsion cases in pregnancy showed normal flow, and similar limitations apply post-hysterectomy). 5
CT and MRI can aid diagnosis, particularly in identifying the displaced ovarian position. 4
Diagnostic laparoscopy remains the gold standard when clinical suspicion is high, as imaging may be equivocal. 6
Management Implications
Once diagnosed, immediate surgical intervention is required:
Emergency laparoscopic detorsion is the treatment of choice if the ovary appears viable. 1
Oophorectomy is performed if the ovary shows hemorrhagic infarction or is non-viable. 4
Early surgical intervention is critical to preserve ovarian function and prevent severe morbidity. 6
Prevention Strategies
Surgeons should consider preventive measures during the primary laparoscopic hysterectomy when ovarian preservation is planned:
Prophylactic oophoropexy can be performed but does not eliminate torsion risk entirely. 1, 4
The decision to preserve ovaries must weigh the benefits of hormonal function against the 1-8% risk of subsequent torsion requiring emergency surgery. 1
Patients undergoing laparoscopic hysterectomy with ovarian preservation should be counseled about this specific complication and instructed to seek immediate evaluation for acute pelvic pain. 2