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Tabatabaei F, Hosseini STN, Hajiyar R. Laparoscopic management of ovarian cysts during pregnancy under urgent situations. J Minim Access Surg 2024; 20:30-36. [PMID: 37706405 PMCID: PMC10898641 DOI: 10.4103/jmas.jmas_192_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 01/16/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Majority of adnexal masses are incidental findings during pregnancy and resolve spontaneously. They may complicate pregnancy due to haemorrhage, cyst rupture and ovarian torsion. Laparoscopy is the preferred surgical intervention owing to shorter operative time, quicker recovery and lower post-operative pain. However, safety and feasibility of laparoscopic surgery in the management of ovarian cysts in pregnant women is challenging especially at advanced gestational ages and in urgent situations. METHODS In this retrospective study, a total of 48 cases of urgent laparoscopic surgeries were evaluated in the first and second trimesters of pregnancy between March 2018 and March 2021 in Al-Zahra Hospital, Tabriz, Iran. RESULTS The operations were ended in all patients successfully. The mean operation time was 45 min. There were no foetal maternal complications. All pregnancies had been terminated after 37 weeks of gestation. Oophorectomy had been performed in six patients and six other patients needed blood transfusion. Ovarian torsion was the most common reason for emergency surgery and mature teratoma was the most commonly reported pathology. Tocolytic therapy was required in six patients, and all of the patients were prescribed 50 mg of injectable progesterone twice daily for 10 days after surgery. The mean intra-abdominal pressure was equal to 15 mmHg and the mean end-expiratory carbon dioxide (CO 2 ) pressure was 36 mmHg. Intravenous paracetamol was used to relieve post-operative pain. The mean hospitalisation time was 1.63 days. CONCLUSION Most of the ovarian cysts can be managed laparoscopically with ensured safety and lower morbidity even in emergency situations at advanced gestational ages.
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Affiliation(s)
- Fatemeh Tabatabaei
- Women's Reproductive Health Research Center, Al-Zahra Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Obstetrics and Gynecology, Division of Gynecologic Laparoscopic Surgeries, Al-Zahra Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
- Endometriosis Research Center, Iranian Society of Minimally Invasive Gynecology, Iran University of Medical Sciences, Tehran, Iran
| | | | - Reza Hajiyar
- Women's Reproductive Health Research Center, Al-Zahra Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
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Didar H, Najafiarab H, Keyvanfar A, Hajikhani B, Ghotbi E, Kazemi SN. Adnexal torsion in pregnancy: A systematic review of case reports and case series. Am J Emerg Med 2023; 65:43-52. [PMID: 36584539 DOI: 10.1016/j.ajem.2022.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/16/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES This study aimed to investigate clinical presentations, surgical procedures and findings, complications, and predisposing factors of adnexal torsion in pregnant women. METHODS We searched PubMed/Medline, Embase, and Web of Science from January 2000 to March 2022. All case reports and case series with full-text English language reporting adnexal torsion in pregnant women were included. Medical history, clinical presentations, surgical procedures and findings, complications related to adnexal torsion, and predisposing factors were independently extracted by two investigators. RESULTS A total of 182 articles reporting 662 pregnant women with adnexal torsion were included. Most of the adnexal torsions occurred during the first trimester (54.63%), while others occurred during the second (26.36%) and third (19.00%) trimesters. The most common symptom of adnexal torsion was sudden-onset pain (80.60%). Enlargement of the adnexa was the most prevalent ultrasound finding in a twisted adnexa (95.20%). Additionally, about half of the patients had decreased blood flow in Doppler ultrasound (53.80%). Laparoscopic surgery was the favorite option (56.88%), while cystectomy and detorsion were the most commonly performed procedure (29.06%). Expectant management was reported in only 2.99% of the patients. In addition, the most common complications were preterm labor (27.58%) and emergent cesarean sections (25.28%). CONCLUSIONS Clinicians should think of adnexal torsion when pregnant women complain of sudden-onset pain. Then, using ultrasound, adnexal enlargement or masses should be explored seriously. They should take invasive and urgent therapy to preserve ovaries and prevent complications.
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Affiliation(s)
- Hamidreza Didar
- Preventative Gynecology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hanieh Najafiarab
- Preventative Gynecology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amirreza Keyvanfar
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Bahareh Hajikhani
- Department of Microbiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Elena Ghotbi
- Department of Obstetrics and Gynecology, School of Medicine, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyyedeh Neda Kazemi
- Clinical Research Development Center, Imam Hossein Educational Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Obstetrics and Gynecology and Female Infertility Unit, Tehran University of Medical Sciences, Tehran, Iran.
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Cathcart AM, Nezhat FR, Emerson J, Pejovic T, Nezhat CH, Nezhat CR. Adnexal masses during pregnancy: diagnosis, treatment, and prognosis. Am J Obstet Gynecol 2022:S0002-9378(22)02179-2. [PMID: 36410423 DOI: 10.1016/j.ajog.2022.11.1291] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/15/2022] [Accepted: 11/15/2022] [Indexed: 11/21/2022]
Abstract
Adnexal masses are identified in pregnant patients at a rate of 2 to 20 in 1000, approximately 2 to 20 times more frequently than in the age-matched general population. The most common types of adnexal masses in pregnancy requiring surgical management are dermoid cysts (32%), endometriomas (15%), functional cysts (12%), serous cystadenomas (11%), and mucinous cystadenomas (8%). Approximately 2% of adnexal masses in pregnancy are malignant. Although most adnexal masses in pregnancy can be safely observed and approximately 70% spontaneously resolve, a minority of cases warrant surgical intervention because of symptoms, risk of torsion, or suspicion of malignancy. Ultrasound is the mainstay of evaluation of adnexal masses in pregnancy because of accuracy, safety, and availability. Several ultrasound mass scoring systems, including the Sassone, Lerner, International Ovarian Tumor Analysis Simple Rules, and International Ovarian Tumor Analysis Assessment of Different NEoplasias in the adneXa scoring systems have been validated specifically in pregnant populations. Decisions regarding expectant vs surgical management of adnexal masses in pregnancy must balance the risks of torsion or malignancy with the likelihood of spontaneous resolution and the risks of surgery. Laparoscopic surgery is preferred over open surgery when possible because of consistently demonstrated shorter hospital length of stay and less postoperative pain and some data demonstrating shorter operative time, lower blood loss, and lower risks of fetal loss, preterm birth, and low birthweight. The best practices for laparoscopic surgery during pregnancy include left lateral decubitus positioning after the first trimester of pregnancy, port placement with respect to uterine size and pathology location, insufflation pressure of less than 12 to 15 mm Hg, intraoperative maternal capnography, pre- and postoperative fetal heart rate and contraction monitoring, and appropriate mechanical and chemical thromboprophylaxes. Although planning surgery for the second trimester of pregnancy generally affords time for mass resolution while optimizing visualization with regards to uterine size and pathology location, necessary surgery should not be delayed because of gestational age. When performed at a facility with appropriate obstetrical, anesthetic, and neonatal support, adnexal surgery in pregnancy generally results in excellent outcomes for pregnant patients and fetuses.
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Affiliation(s)
- Ann M Cathcart
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR
| | - Farr R Nezhat
- Weill Cornell Medical College, Cornell University, New York, NY; New York University Long Island School of Medicine, Mineola, NY.
| | - Jenna Emerson
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR; Division of Gynecologic Oncology, Oregon Health & Science University, Portland, OR
| | - Tanja Pejovic
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR; Division of Gynecologic Oncology, Oregon Health & Science University, Portland, OR
| | - Ceana H Nezhat
- Atlanta Center for Minimally Invasive Surgery and Reproductive Medicine, Atlanta, GA
| | - Camran R Nezhat
- Center for Special Minimally Invasive and Robotic Surgery, Palo Alto, CA; University of California San Francisco, San Francisco, CA; Stanford University Medical Center, Palo Alto, CA
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Effect of Two-Port Laparoscopic Surgery on Pregnancy Outcomes of Patients with Concurrent Adnexal Masses. J Clin Med 2022; 11:jcm11164697. [PMID: 36012938 PMCID: PMC9409682 DOI: 10.3390/jcm11164697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/29/2022] [Accepted: 08/09/2022] [Indexed: 11/25/2022] Open
Abstract
Adnexal masses are common in pregnancy, with 2–10% of pregnancies presenting with an ovarian mass and approximately 1–6% of these masses being malignant. For suspected malignancy or masses with symptoms, surgery must be performed as early as possible. We retrospectively investigated the effect of two-port laparoscopic surgery on the outcomes of patients with concurrent adnexal masses between 2012 and 2019 (including large mucinous tumor, large teratoma, serous borderline tumor, and heterotopic pregnancy). Laparoscopic right partial oophorectomy was performed for a 27 cm ovarian mucinous tumor at a gestational age (GA) of 21 weeks, laparoscopic right oophorocystectomy for an 18 cm teratoma at a GA of 10 weeks, and laparoscopic left salpingo-oophorectomy for a 7 cm serous borderline tumor at a GA of 7 weeks after ultrasonographic confirmation of an intrauterine gestational sac with a fetal heartbeat. Laparoscopic excision of a tubal pregnancy was performed in a heterotopic pregnancy at a GA of 12 weeks with massive internal bleeding. Laparoscopic surgery is easier and safe to perform during early pregnancy because a smaller uterus allows for superior visualization. All of these patients had optimal postoperative recovery and normal spontaneous delivery at term. We discussed several aspects of treatment and delivery, namely treatment option (expectant management or surgery), surgery timing (early or advanced pregnancy), surgery type (laparoscopy or laparotomy), and delivery route (normal spontaneous delivery or cesarean section), in patients with concurrent adnexal tumors and their effects on pregnancy outcomes.
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Wu WF, Wang ZH, Xiu YL, Xie X, Pan M. Characteristics and surgical invervention of ovarian torsion in pregnant compared with nonpregnant women. Medicine (Baltimore) 2020; 99:e20627. [PMID: 32541500 PMCID: PMC7302645 DOI: 10.1097/md.0000000000020627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of our study was to compare the clinical and surgical characteristics of pregnant and nonpregnant women with surgically verified ovarian torsion, as well as the differences among 3 trimesters during pregnancy.We conducted a retrospective study of patients diagnosed with surgically proven ovarian torsion in our hospital from January 2012 to June 2018. The clinical characteristics, surgical procedure, pathologic outcomes, and trimesters of pregnancy were analyzed.Thirty-three pregnant and 72 nonpregnant patients diagnosed with surgically proven ovarian torsion were assessed during the study period. The most common presenting symptom in both groups was abdominal pain (90.2% and 99.0%, respectively). The median time from admission to surgery was shorter in pregnant patients than nonpregnant patients (5.3 compared with 47.7 hours, P < .001). Pregnant patients had a higher number of twists than nonpregnant patients (median of 2 compared with 1, P < .01). Benign cyst was the most common cyst causing ovarian torsion in both groups, and luteum cyst was more common in the pregnant group. The mean size of ovarian cyst in pregnant patients was much smaller in the third trimester than the first and the second trimesters (6.6 ± 2.0, 8.4 ± 2.1and 8.1 ± 1.5 cm, respectively; P = .097). Cystectomy performed in the third trimester was more frequent compared with the other 2 trimesters (77.8%, 26.7%, and 22.2%, respectively; P = .021).Abdominal pain is the most common feature of ovarian torsion. Clinical presentation of ovarian torsion is relatively similar between pregnant and nonpregnant women, and among different trimesters. The tumor size was smaller in the third trimester of pregnancy than the other 2 trimesters of pregnancy. Cystectomy performed in pregnant patients is more during the third trimester compared with the other 2 trimesters.
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Ball E, Waters N, Cooper N, Talati C, Mallick R, Rabas S, Mukherjee A, Sri Ranjan Y, Thaha M, Doodia R, Keedwell R, Madhra M, Kuruba N, Malhas R, Gaughan E, Tompsett K, Gibson H, Wright H, Gnanachandran C, Hookaway T, Baker C, Murali K, Jurkovic D, Amso N, Clark J, Thangaratinam S, Chalhoub T, Kaloo P, Saridogan E. Evidence-Based Guideline on Laparoscopy in Pregnancy: Commissioned by the British Society for Gynaecological Endoscopy (BSGE) Endorsed by the Royal College of Obstetricians & Gynaecologists (RCOG). Facts Views Vis Obgyn 2019; 11:5-25. [PMID: 31695854 PMCID: PMC6822954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Laparoscopy is widely utilised to diagnose and treat acute and chronic, gynaecological and general surgical conditions. It has only been in recent years that laparoscopy has become an acceptable surgical alternative to open surgery in pregnancy. To date there is little clinical guidance pertaining to laparoscopic surgery in pregnancy. This is why the BSGE commissioned this guideline. MEDLINE, EMBASE, CINAHL and the Cochrane library were searched up to February 2017 and evidence was collated and graded following the NICE-approved process. The conditions included in this guideline are laparoscopic management of acute appendicitis, acute gall bladder disease and symptomatic benign adnexal tumours in pregnancy. The intended audience for this guideline is obstetricians and gynaecologists in secondary and tertiary care, general surgeons and anaesthetists. However, only laparoscopists who have adequate laparoscopic skills and who perform complex laparoscopic surgery regularly should undertake laparoscopy in pregnant women, since much of the evidence stems from specialised centres.
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Affiliation(s)
| | - N Waters
- Royal Surrey County Hospital NHS Trust
| | | | | | - R Mallick
- Brighton and Sussex University Hospitals NHS Trust
| | - S Rabas
- Queen’s Hospital London and King George Hospital
| | | | | | | | | | | | | | - N Kuruba
- Norfolk and Norwich University Hospital
| | | | | | | | - H Gibson
- Barking, Havering and Redbridge University Hospitals NHS Trust
| | - H Wright
- North Manchester General Hospital
| | | | | | | | - K Murali
- Salisbury District and General Hospital
| | | | - N Amso
- Cardiff University School of Medicine
| | | | | | | | - P Kaloo
- Gloucestershire Hospitals NHS Foundation Trust
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Yoon JR, Chung EY, Kim YS, Kim YH, Yeon JS, Kim TK. Retrospective anesthetic evaluation of non-obstetric surgery during pregnancy: single center experience. Anesth Pain Med (Seoul) 2018. [DOI: 10.17085/apm.2018.13.2.165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jun Rho Yoon
- Department of Anesthesiology and Pain Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eun Yong Chung
- Department of Anesthesiology and Pain Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yee-Suk Kim
- Department of Anesthesiology and Pain Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Hye Kim
- Department of Anesthesiology and Pain Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung Soo Yeon
- Department of Anesthesiology and Pain Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae Kwan Kim
- Department of Anesthesiology and Pain Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Chen Y, Luo Y, Han C, Tian W, Yang W, Wang Y, Xue F. Ovarian dysgerminoma in pregnancy: A case report and literature review. Cancer Biol Ther 2018; 19:649-658. [PMID: 29580145 DOI: 10.1080/15384047.2018.1450118] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Dysgerminoma is an uncommon malignant tumor arising from the germ cells of the ovary. Its association with pregnancy is extremely rare; the incidence is about 0.2-1 per 100,000 pregnancies. Because of its infrequency, there are few recommendations regarding its management in pregnancy; therefore, it is important to discuss and summarize the treatment strategy. CASE We presented a case of a 23-year-old pregnant woman with a large dysgerminoma originated from the right ovary, which had the unusual coincidence of being associated with an abdominal desmoid tumor simultaneously. We did not find any similar cases published in the PubMed database after 1947. A cesarean section was performed at 34 + 6 weeks gestation secondary to her abdominal pain worsening. The patient delivered a healthy boy and had fertility-preserving surgery, followed by 6 cycles of chemotherapy. This case is compared with 21 other reported cases of pure ovarian dysgerminoma in the literature to evaluate the clinical characteristics, feto-maternal compromise, treatment, long-term survival, and fertility outcome. CONCLUSION The treatment strategy in women with ovarian dysgerminoma should be discussed and structured on an individual basis. If pregnancy is desired, surgical intervention undertaken in the second trimester seems to be the first choice. When chemotherapy is indicated, unless delivery can be accomplished within a few weeks of diagnosis, it should not necessarily be delayed until after delivery. Good reproductive function and high survival rate can be achieved in patients treated with conservative surgery and adjuvant chemotherapy.
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Affiliation(s)
- Yuanyuan Chen
- a Obstetrics and Gynecology Department , Tianjin Medical University General Hospital , No.154, Anshan Road, Heping District , Tianjin , China
| | - Ying Luo
- a Obstetrics and Gynecology Department , Tianjin Medical University General Hospital , No.154, Anshan Road, Heping District , Tianjin , China
| | - Cha Han
- a Obstetrics and Gynecology Department , Tianjin Medical University General Hospital , No.154, Anshan Road, Heping District , Tianjin , China
| | - Wenyan Tian
- a Obstetrics and Gynecology Department , Tianjin Medical University General Hospital , No.154, Anshan Road, Heping District , Tianjin , China
| | - Wen Yang
- a Obstetrics and Gynecology Department , Tianjin Medical University General Hospital , No.154, Anshan Road, Heping District , Tianjin , China
| | - Yingmei Wang
- a Obstetrics and Gynecology Department , Tianjin Medical University General Hospital , No.154, Anshan Road, Heping District , Tianjin , China
| | - Fengxia Xue
- a Obstetrics and Gynecology Department , Tianjin Medical University General Hospital , No.154, Anshan Road, Heping District , Tianjin , China
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Fouedjio JH, Fouelifack FY, Nnang NA, Mbu RE. [Epidemiological, clinical and therapeutic aspects of supposed benign ovarian tumors at the Central Hospital of Yaoundé]. Pan Afr Med J 2017; 25:207. [PMID: 28270904 PMCID: PMC5326262 DOI: 10.11604/pamj.2016.25.207.9939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 10/18/2016] [Indexed: 12/04/2022] Open
Abstract
Introduction Les tumeurs ovariennes présumées bénignes (TOPB) constituent l'un des motifs les plus fréquents de consultation gynécologique, et l'une des indications les plus fréquentes en chirurgie gynécologique. Méthodes Nous avons mené une étude descriptive rétrospective dans le service de gynécologie-obstétrique de l'hôpital central de Yaoundé. La durée de l'étude était de 6 mois sur une période 5ans du 1er janvier 2010 au 31 décembre 2014. La population de l'étude était constituée de toutes les patientes opérées pour une tumeur ovarienne présumée bénigne pendant la période de l'étude. Résultats L'âge moyen était de 29,33± 6,83 avec un âge minimum de 20 ans et un âge maximum de 48ans. La tranche d'âge la plus représentée est celle de 21à 25 ans. Le motif de consultation était les douleurs pelviennes 93,90% des cas. Onze patientes avaient une grossesse soit 33,3% de notre population d'étude et 72,70% étaient au premier trimestre de la grossesse. Les TOPB répertoriés dans notre série étaient : la rupture de kyste (36,40%), la torsion d'annexe (27,30%), le volumineux kyste ovarien (21,20%), l'hémorragie intrakystique (15,20%). Le traitement était conservateur chez 26 (78,78%) patientes. Cependant, l'annexectomie a été réalisée chez 5 patientes sur 9 qui ont eu une torsion d'annexe. Conclusion Les TOPB compliquées sont présentes dans notre milieu surtout chez des patientes en âge de procréer. Le diagnostic tardif particulièrement en cas de torsion d'annexe oblige un traitement radical qui est délétère pour le patient. Le traitement chirurgical par laparoscopie est le plus recommandé si le plateau technique le permet car il diminue les risques de complications.
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Affiliation(s)
- Jeanne Hortence Fouedjio
- Unité de Gynécologie et Obstétrique de l'Hôpital Central de Yaoundé Cameroun; Département de Gynécologie et Obstétrique de la Faculté de Médecine et des Sciences Biomédicales de l'Université de Yaoundé I, Yaoundé, Cameroun
| | - Florent Ymele Fouelifack
- Unité de Gynécologie et Obstétrique de l'Hôpital Central de Yaoundé Cameroun; Département de Gynécologie et Obstétrique de l'Institut Supérieur de Technologies Médicales de Nkolondom, Yaoundé, Cameroun
| | | | - Robinson Enow Mbu
- Unité de Gynécologie et Obstétrique de l'Hôpital Central de Yaoundé Cameroun; Département de Gynécologie et Obstétrique de la Faculté de Médecine et des Sciences Biomédicales de l'Université de Yaoundé I, Yaoundé, Cameroun
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Cai ZH, Wang WM, Shi JR, Liang YJ, Ma YJ, Zhang JZ. Comparison of ultrasound interventional and laparoscopic surgeries for ovarian cyst pediculotorsion. JOURNAL OF ACUTE DISEASE 2016. [DOI: 10.1016/j.joad.2016.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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