Ovarian Torsion with Dr. Jennifer Dietrich

Stay Current is a multimedia publication designed to keep healthcare professionals up to date with standards of care and new emerging ideas. Stay Current is created and edited by Todd Ponsky, Nicholas Bruns, and Ian Glenn in partnership with Globalcast MD and is recorded and produced at Akron Children's Hospital in Akron, Ohio. Welcome to Stay Current in Pediatric Surgery. This is Todd Ponsky from Akron Children's Hospital, and today we're going to be talking about ovarian torsion. This is certainly something that we have to deal with quite a bit, and I know that the management of this has changed over the years. So we have thankfully an expert in the field, Dr. Jennifer Dietrich, who is chief of pediatric and adolescent gynecology at Texas Children's Hospital. And has a lot of titles at Baylor College of Medicine. She's the division director of pediatric and adolescent gynecology. She's the CME director. She's the fellowship director, and she's associate professor department of obstetrics and gynecology and Department of Pediatrics at Baylor College of Medicine. That's a mouthful. Jennifer, thanks for joining us today. Absolutely, thank you for having me. I'm happy to discuss this topic. I think it's really important. Well, we're looking forward for your answers. I know that I have a lot of questions and so let's dig right into it, OK, so. Jennifer, you've got a 13 year old female who comes to the emerging emergency department with lower abdominal pain. Let's just start with that. How do you evaluate a thirteen-year-old girl with lower abdominal pain? Well, I think first and foremost it's really important to get a thorough history, you know, even though we hope that most young teenagers are not engaging in sexual activity, it is important to ask. And so definitely no matter what, in all reproductive age females, we are going to check a pregnancy tests. Very helpful to gather that information ahead of time nonetheless. Certainly we are going to ask questions about kind of the characteristics of the pain. Was it something that she's been experiencing for just a short period of time? Is it something that she's experienced for a whole month? Is it related to any certain activities or things like that that she may have participated in? With regard to sports, and so certainly some of those things can help us gauge whether or not this could be an acute source of pain or a chronic source of pain, and you know an ultrasound is going to be a very helpful tool to us as gynecologists to evaluate the ovaries and the uterus. How good is the ultrasound in an overweight female? Still better than a CAT scan, right? Yeah, I mean, really, an ultrasound is going to give us some kind of real-time pictures in addition to still pictures, and, you know, with the capability of ultrasound nowadays there's, there's a lot better penetration regardless if a female is, you know, has a lower BMI or a higher BMI. And so I think that we have the ability to take a look as long as that female has a full bladder. OK, so they get the ultrasound. And what is it that you want to hear about the ultrasound? What are you looking for? Yeah, well, I think the important things that I want to hear about is whether or not there's some evidence of asymmetry between the two ovaries. Now we know that there is some anatomic variability between the right and left ovary, and sometimes the right ovary is a bit larger than the left, but we want to know about significant asymmetry. Sometimes that makes us more worried that specifically on the side in which the patient. is experiencing pain. If it's significantly enlarged on that side compared to the other, we may be more worried about a twisting event of the adnexa on that side. We'd also like to know about the characteristics of the ovary. And so does it look like it's a normal ovary with normal sized follicles? Does it look like all of the follicles are kind of at the periphery? Um, does it look like there's, there's an adnexal lesion or mass that is coming from the ovary or next to the ovary, in which case we might worry about the tube itself being torsed rather than the actual ovary. We'd like to know about the presence or absence of blood flow. And really interestingly, the complete absence of blood flow is the most concerning and is more reliable. The presence of blood flow is actually less reliable, believe it or not, on an ultrasound. And so really if a patient has that clinical picture, you know, is in significant pain, has, you know, a good story for an acute onset of pain that's really kind of been. Um, progressively worsening and certainly perhaps with nausea or vomiting, fever, those types of things, in addition to finding abnormalities on the side she's experiencing pain on the ultrasound, we're going to be much, much more worried about a torsion, whether or not they report that there's presence of blood flow because it could be just a torsd tube, in which case we would still see flow to the ovary. And I know, I really want to stress this point because I know that I've been fortunate enough to have been taught that, I think, by our pediatric gynecologist when I was back in Washington DC, but I know some still really love to hear that there's good flow and they go back to sleep, and I know that that's, I want to reinforce what you just said, that blood flow does not mean they don't have torsion, and you had explained to me in the past that The reason for this is, and I think this is right, so I may be stating it wrong, but that Just because it's at the moment you did the ultrasound, it's, it could be twisted but not completely cutting off the blood flow. Is that that's the reason why? Well, absolutely. I mean that's, that's another variation of what could occur and so certainly intermittent torsion occurs and sometimes, you know, if if it's difficult to make a call in this situation and maybe perhaps the ovary looks entirely normal. Sometimes you might choose to observe a patient and decide if they kind of declare themselves. And so in that situation, if their pain worsens, then I would reorder an ultrasound and see if anything has changed. And if something has changed, it could be that their intermittent torsion has just become a full torsion and or maybe they were loosely torsed and it became tighter to the point where their pain. Has worsened, you're able to declare it at that point. It's just unfortunately ultrasound has not gotten to that point where it can make a difference in helping us determine who's a loose or a tight torsion. Got it. That's a great explanation. I want to ask you more about you had mentioned the finding about where the follicles are located peripherally or centrally. What, what did you mean by that? Yeah, well, sometimes if the ovary is edematous and some of the blood blood supply has been cut off, some of the the middle of the ovary where most of that blood supply is going to be close to, there's a lot of vascular congestion, and so many of the follicles just kind of get peripheralized to the periphery of the ovary. Wow, OK, so I know that we had had a couple of cases where there was concern for torsion. We went in and there was not torsion. And we were all sort of wondering what kind of findings other than just the, the seeing a twist or seeing lack of blood flow, what other findings are there, and I think those are what you're alluding to, which is the edema, the um the location of the follicles, uh, and can you repeat what else you said they might find? Yeah, so I mean you might find a lesion, so there could be an ovarian or a peritubal lesion, and then certainly we've seen cases where they present like a torsion but maybe perhaps have had a surgical history in the past and instead it's really more of a strangulation of the adnexa related to adhesions. And so that can certainly occur and not necessarily be a torsion, but more of a strangulation. OK, so that's interesting. What is the The cyst size that would make you concerned. So you get the ultrasound, maybe you don't see all of those things that are concerned for torsion, good blood flow, but there's a cyst that's 6 centimeters. What do you do with that? Yeah, so I mean definitely, you know, in the literature, you know, any, any time something gets up around 5 or 6 centimeters in terms of the size of a lesion, we get more worried about a risk for a torsion in the setting of symptoms. It's not that every single patient who has a cyst greater than that size definitely has a torsion. But it just, it heightens your suspicion a little bit in the setting of those clinical symptoms because, you know, it tends to make the ovary and tube heavy enough in which it can twist in the pelvis. Now that's not always the case because, you know, we've actually had a Paper just recently come out looking at various laparoscopic outcomes for pelvic pathology in children and adolescents, um, you know, among those presenting to our service specifically, and in fact in prepubertal girls, sometimes it was a normal ovary that was tors and the the most. Often the reason that those little girls actually went to surgery for a gynecologic reason was because we found a torsd ovary in a prepubertal child. And so I think it's really important to think about those symptoms in the prepubertal female because it's more often related to a torsion than other pathologies. Wow, OK, yeah, I have not seen that yet and I'm sure I will at some point. And is, what is your size cut off? Do you have one? Is it, is it 6 centimeters? Is it 5 centimeters? No, I mean, really, we don't. It's all based on clinical diagnosis and certainly, you know, once again I'll bring up the example of a prepubertal child. You know, their ovaries are very tiny and so may only be 1 centimeter, 1.5 cm in total size, but normal ovaries can twist. And you know this is one thing that we're trying to actually determine why do some people torse and others don't. Maybe it's just how their ligaments are supported within their pelvis. Maybe it's related to how their connective tissues develop. Maybe it's just around the time of puberty. I think all of those are potential factors to consider. But you know, definitely if, if a child has a 2 or 3 centimeter cyst and you're dealing with a 33 year old child who has already a very small ovary, it doesn't take much to twist it. Yeah, you mentioned, you alluded earlier to some findings that may suggest malignancy. Can we hit on that again? What would you look for that would make you more concerned that there's a malignancy there? Sure. Well, certainly if we see a lot of complexity on ultrasound, you know, frequently it's easy for us to determine if something is purely simple and cystic and has a, you know, nice thin cyst wall that is all contained within one sphere. Um, versus if it has a lot of complex features where it's partly partly cystic and partly solid. In addition, sometimes ultrasound, if they're able to put Doppler flow in the middle of that cyst and that complex cyst in this situation, sometimes they're able to. Determine if there's more hypervascular flow within that lesion, and that makes us more worried about a malignancy again with just neovascularization occurring with tumors. And then finally elevated tumor markers would heighten our suspicion, right. OK, any role for CT or MRI at all? You know, um, certainly a CT may be beneficial if we need to distinguish a lesion from something like an abscess or if we're concerned, um, that it could be related to the appendix versus, um, the adnexa, um, so infection in that setting is very helpful to us. Um, an MRI is really very useful if we need to distinguish someone who kind of has that picture of torsion. Um and pain symptoms, but may in fact have a malarian anomaly and so we see that too and really they may be having significant pain, but it could be that they have an outflow tract problem and what is being seen on ultrasound is the hematosalpinx, in which case there's not going to be good blood flow to that. It ends up being very similar to like a hemorrhagic cyst in the ovary where it's essentially a blood clot within a distended tube, right, right, OK. Um, when do you start doing pelvic exams? So you know, really there is no time in particular that a pelvic exam needs to occur, and in fact in adolescence we tend to delay that until much later in their teenage years, if not until the time of their first Pap smear at age 21. So really until that, you know, time dictates either they've become sexually active and they're they're having a specific concern, or, you know, from a congenital standpoint there may be a need to perform a little bit of a perineal exam. Um, you know, or, or rectal vaginal exam. Sometimes we don't put them through a full pelvic exam per se when they're young. Got it. So Jennifer, you've got this girl, she's saying she's had pain, let's say for maybe 12 hours. It's mostly in the right lower quadrant, not sexually active. You're getting the ultrasound. They're, they're, they're ordering it. Do you, do you need to get any labs on her? Yeah, so I mean, you know, certainly there are some labs that can help us a little bit and certainly in the right lower quadrant we're also going to be interested in what they see in the area of the appendix since that's going to be in the same location. And so, you know, we'd want to know if the patient has an elevated white count or, or, you know, an elevated neutrophil count. And sometimes that can be helpful in determining that they have an ongoing inflammatory process but may not necessarily tell us it's the ovary or the appendix. And then, you know, certainly if the ultrasound were suggestive of a cyst complex in nature, then we might add some tumor markers. OK, well, let's talk to you. Let's talk about that now. So what tumor markers would you send? So in our population we tend to send alpha fetoprotein. We send a serum beta HCG quant, and so we don't want to just know that a pregnancy test is negative, but we want to know kind of the specific number. We'd like to know about lactate dehydrogenase and then finally a CA 125. All of those things can tell us about various, um, you know, ovarian or a. So pathologies that the patient may have whether it's a benign or a malignant germ cell tumor or other type of tumor or if we're dealing with just kind of a benign ovarian or peritubal cyst and so I'm assuming most or all of those are send out labs or at least take several days, is that right? You know at our institution we are fortunate in that 3 out of the 4 we will get within the time that we would post to go to the OR. So generally they're pretty quick about turning around within an hour, hour and a half or so. And so a lot of times if we are consulted on the ER side they have maybe perhaps gotten. In a preliminary read from the radiologist who, you know, may see a cyst or a complex adnexal mass and so we might, as we are making our way into the hospital, have them go ahead and send those labs so that perhaps by the time we get a chance to see the patient and determine if the patient needs to go to the operating room, we also have that information. OK, that's great. And that's, you know, that's, I guess that depends on the hospital. Some people would go with or without those labs depending on their situation. Yes, absolutely. All right, so Jennifer, now I think for whatever reason the patients with ovarian torsion tend to group up, gang up on us and try to come in at 1 in the morning. So now it's 1 in the morning. You get a phone call that says that there's a patient with a 6 centimeter cyst. Uh, has great normal arterial and venous blood flow. What do you do? When do you operate? Do you go in at one in the morning? Can you wait till the morning? What are your thoughts on that? Yeah, so I mean ideally you'd like to try to address it as soon as possible once you've made that diagnosis. I mean it's definitely a clinical diagnosis, but certainly there are some studies from Boston Children's that, you know, really kind of go over the time to onset of abdominal pain and the salvage rates. And so certainly, you know, within the 1st 24 to 72 hours your salvage rates are higher as opposed to the patient who may have come in and have abdominal pain for one week. You're going to have a lesser chance of being able to salvage that ovary, but you know, the one thing you just can't predict sometimes unfortunately is who has a loose torsion and has a bit more time versus who has a really tight torsion and is really going to have ischemia develop quickly. And so ideally if you've made that diagnosis, you know, you try to address it as soon as you can. So I'm just summarizing here where the general thing that I'm hearing is we can't wiggle our way way out of this one, that if there's a child that has a suspicion for possible torsion. The ultrasound's not going to get you out of it. The time of waiting is not really reasonable. This needs to be dealt with whenever it comes in and and showing blood flow is not going to get you out of it. Is that a good statement there, or is that? Yeah, yeah, absolutely. I mean, if really your clinical suspicion is high, it is a clinical diagnosis, and you should act on that. If you're uncertain or, you know, there's there's still. Some question in your mind. I mean, it's also a patient you could observe and you might be able to, you know, determine within a few hours because it could be a patient with intermittent torsion who will declare herself. So I like that that's an interesting new concept for me that If there's a questionable history that it's not so clear cut, it's not unreasonable, if it's not so clear to wait a few hours, maybe get another repeat ultrasound to see if things have changed, right? OK, right. So I mean, don't hesitate to observe a patient if it's, if it's unclear. I mean, I wouldn't just send them home, right, right, right, got it. I understand what you're saying, but if, but any degree of suspicion, I think, needs for me, I'm pretty aggressive. I go in if there's any chance. So I'm going to beat a dead horse here and ask you this, I think for the 3rd time now. Sorry, can you tell me the classic story of a patient that would make you concerned for torsion? Yeah sure So you know, let's say that you know you have a gymnast who has been, you know, doing a bunch of different cartwheels and all kinds of new activities in her gym class, and you know, after she gets home right after dinner, has acute onset of abdominal pain, develops some nausea and vomiting. Her parents bring her to the ER. Her pain is persistent, hasn't really responded to any over the counter measures. And an ultrasound demonstrates that one ovary is larger than the other and on the side that she is experiencing pain, and it's a pretty good story. And so that would heighten my clinical suspicion. That's a, that was actually a great summary. I never knew that there really was a correlation to being topsy-turvy the day before, but it makes sense. Yeah, absolutely. I mean, we've actually even had a situation when someone was on a banana boat just boating for the day and bouncing all around and then developed. Some symptoms after that. And so I think sometimes it's maybe related to activities, but a lot of times it's not, and it just happens spontaneously. But the thing that always confuses me is differentiating a patient who you might have torsion versus someone who's got a painful ovarian cyst. Yes, and the difference in those two patients. Yeah, well, certainly, you know, if we're worried about a hemorrhagic cyst, we would be more likely to see that in a female who's already menstruating. And so in a patient who has a hemorrhagic cyst, it's, it's really important for us as we're taking the history to know kind of about their menstrual cycles. Are they regular? Are they irregular, when their last cycle was, because that can help us determine if they were at risk for having a hemorrhagic ovarian cyst or a corpus luteum cyst. Because those are the ones I went in incorrectly on where I went in thinking it might be a torsion and they were hemorrhagic cysts, and I guess that's the hardest thing is you don't want to over operate on everyone who's got a hemorrhagic cyst. So um I guess taking that history is helpful. Yeah, so that's beneficial and certainly sometimes it's it's a matter of just um. Doppler can be helpful in this situation where in within the cyst itself you don't see flow and so there can be a concern called as a result of that, but peripheral to the cyst there is flow and so I know our radiologists are very good about looking in both locations and so that can be a helpful adjunct. OK, that's that is helpful. OK. All right, so you take the person, it's now 3 a.m., you go into the operating room and you see a non-ischemic torsion. What do you do for that patient? Well, so if we go to the operating room, we are going to detour the ovary, obviously, and you know if we see a lesion such as a peritubal cyst or an ovarian cyst, we are going to take it out. So it is typically in that situation the lesion has made the entire adnexa more heavy and apt to twist and so. Taking care of the lesion itself eliminates the problem, the heaviness of the of the adnexa, and so you know you can address that and you know, certainly we want to try to avoid an oophorectomy and a salpingo oophorectomy at all times. And so we really try to save it, you know, once you untwist it, give it time, and You'd be surprised how many, many purple, black and blue ovaries recover over time. I want to get into that in more detail because I know that's another controversy, but on this patient who's non-ischemic and in the ovary, you actually don't just drain the cyst, you actually do a cystectomy. You take out the cyst. We take out the cyst, yeah, unless it's clear, clearly like a functional cyst. We make sure that we can kind of resect the cyst so that it doesn't recur, and that's particularly important for a perubal cyst because the peritubal cyst will recur. OK, so technically now for the perubal cyst, you just, uh, what's the technique on how to remove that? Well, you just basically open up the mesal cell pink, so that's kind of the supporting tissue just beneath the fallopian tube itself, and you usually can determine that that's what it is because you can see the fallopian tube splayed on top of the cyst. And so you just, you want to get underneath that mesosalpinx cortex so that you can expose the cyst wall beneath and then shell it out, OK? And doing the and just a hemorrhagic ovarian cyst, same thing, you score the outside and sort of shell it out. Yeah, I mean some of these you can actually, you know, if it's an expansive problem, you definitely want to try to remove the cyst and then coagulate any areas that might still be bleeding and certainly that would be another reason to go to the operating room and the. of an expanding hemorrhagic cyst, but you know, it's the funny thing about a hemorrhagic cyst is that sometimes if you don't get all of the cyst wall, it continues to bleed. Wow. So I can tell you that in my practice I've been draining these for the last 10 years and I've never done a cystectomy at the time. So this is really helpful for me to learn from you today. Well, that's why we're doing this, yeah, yeah, and some of these will resolve. I mean, obviously you've got to make a judgment call, and in the situation where it's determined to just be a hemorrhagic cyst, with time and a follow-up ultrasound, the cyst will resolve on its own, right, which is what I usually do. I just sort of drain it and get follow-up ultrasounds, but this sounds like a Taking out the cyst might be the safer option. Now you go in and let's say I want to get back to what you alluded to before is that you go in and it is purple. It is a, and it looks like a necrotic tourists ovary. What do you do? Well, I would still try to save it. And so, you know, detourse it, give it some time, try to address an ovarian or peritubal lesion if you see one, and you know, we attempt to leave it. And so really unless that ovary and or tube are kind of just literally as you're trying to untwist the adnexa, it's just kind of falling apart. We, we try to salvage it. And remarkably, even at our own institution we've done some follow-up studies on just a small subset of patients who've had an ovarian torsion, and you know, people have return of ovarian function, those that were already pubertal, and evidence of follicles. And so sometimes it just takes a few months for things to kind of get back to normalcy. And I think that's the two points that I want to address. One was your explanation that Blood flow doesn't make you assured that it's not torsion, and the second one is this that we shouldn't be taking out these ovaries, that we should be leaving them in even if they don't look survivable unless it is mush, um, and when you do take out the mush, you leave the fallopian tube, correct? Well, it just sort of depends if it's involved in the torsion event itself and if it's also devitalized completely or if it's salvageable and so that'll be sort of a judgment call at the time. Got it. What is the ovarian bivalve procedure? Does that have any role here? Yeah, so this is also a really well described technique at Boston Children's. You know, really remarkably, sometimes after an ovary has been tightly torsed, you know, you just, you have a lot of change in vascular pressures going to the ovary and trying to come out of the ovary, and sometimes, Um, you know, it's almost like a compartment syndrome event for the, for the ovary. And so sometimes if you can make a little incision into the ovarian cortex, once you've untwisted the adnexa, it will help blood supply kind of come to the periphery a bit better. It's almost like releasing the pressure. Mhm. So do you, but you're going to be mostly taking out. You're going to be doing a cystectomy most of the times, no, so then does that have any relevance? It certainly does in the case of an ovary that may be still so edematous after being twisted that you might need to kind of debulk the ovary. Um, there might be still a risk or a concern that perhaps the adnexa could could twist again, even if it was a peritubal cyst that you address. And then in the situation of a normal ovary, if it's a completely normal ovary that torso and it's still a big bulky ovary and there's simply no lesion to take out, sometimes you do have to bivalve, release some of the pressure in order to. Kind of release some of the edematous fluid that's backed up and then if that, if that is not good enough in terms of its decompression, then sometimes you can debulk the ovary with with a biopsy to remove some of that extra bulky tissue that would otherwise make it twist again. That's fascinating. I have not done that before. When you do that, do you use an energy device so it doesn't bleed like crazy? Or how do you do it? Yeah, so I'm, you know, as, as a gynecologist, we tend to love the harmonic, and so I love the harmonic, but you know, definitely many of my pediatric surgery colleagues also like the hook device and so sometimes we will use the monopolar hook. That's also an acceptable option, but you know, whichever energy device you have at your institution, got it. So, so I'll actually ask you right now. I know that we're, you've sent us a couple, but um I'm, uh, for anyone out there listening, if you are watching, listening to this through the stay current app, we will have associated videos with this, and I know we have some of Dr. Dietrich's videos, and we will try to find other videos as well that may demonstrate the bivalve procedure or Jennifer, if you have that so that people can watch these videos. I know I want to watch that. Um, talk to me about Pepsi. Who do you Pepsi and how do you Pepsi? Yeah. Well, so an oophoropexy, you know, again it's sort of a judgment call, and there's no kind of hard and fast rule, although definitely in the situation where, let's say a child has lost an ovary, whether it's due to a tumor in the past and then now. Presents with a torsion, we might kind of aim toward pexing that ovary just simply so that that ovary has every chance to survive. Now anytime you PEI, there's always that potential that you're changing the fertility potential of a young woman in the future. Now certainly changing the position of the ovary is, is, is a better option than losing the ovary, and it's, you know, still potentially. You know, with in vitro technologies is an option to retrieve eggs and kind of place them within the uterus one day, um, and so, you know, sometimes we'll make that call in that situation if someone has a recurrent torsion, we'll decide to PEI. And you know, again, sometimes it is a judgment call at the time where maybe perhaps you feel like if you could peck the ovary while the inflammation is kind of resolving, you might choose to use an absorbable material that will hold the adnexa still for 4 to 6 weeks, allow that swelling to go down, and then minimize the risk for torsion again. That's a great in the near future. That's cool, yeah. Um, but yeah, otherwise you could use a permanent option if you're, if you want to stay put. So, um, two points. One, let's address this first. What about clipping the utero ovarian ligament? So it doesn't always prevent the torsion in that situation. And so if you, if you think about it, it could be either torsion of the uter ovarian ligament or torsion of the infandibular pelvic ligament, and both of those are kind of helping to stabilize the adnexa in one position or another. And so there's still an ability for the ovary to twist on one pedicle or another, OK. So when you PEXi, what do you sew it to the lateral side wall of the pelvis? So you can use a variety of different locations and so you can decide to shorten the utero ovarian ligaments. You're not cutting that ligament, but you're actually shortening the ligament by clipping it or by by by kind of, well, not really clipping it, but sort of sewing. It closer together so you're you're shortening the actual length of it, so the adnexa ends up being closer to the uterus, right? So that's interesting. I was taught to clip it to shorten it, but it's basically the same thing. It's accordioning the thing so you sort of bleed it together. You can use suture. Got it. What about, OK, so but then if you were to Pexi though, where do you Pexi to? Mhm, yeah, so either you can shorten that ligament, you can actually some people just depending on the anatomy of the patient, it can be Pexi to the side wall if again you're well away from the ureters, and then sometimes you can Pexy it to the back of the uterus, and I talked to one colleague who said that. Uh, he, I think this is Mark Wilkin down in Atlanta. He, he said that he actually sews the two ovaries together under the uterus. Have you ever heard of someone doing that? That's an interesting way to do it, and you know it would make sense if both were at risk for torsion or both had had a torsion event in the past, you know, again, it's probably going to be a judgment call dependent on one's anatomy, right? But now you're potentially putting both sides at risk for infertility because you're putting them both in an unusual location. Plus I, I, it scared me. I think we discussed this on one of our global casts. It worried me that it's almost a potential space for an internal hernia too, um, yeah, that's a good point. Alright, so, um. The, if I, if you go in and I don't know, I've been fortunate that this hasn't happened to me, but if you go in you find a tubal ovarian abscess, uh, what do you do there? wash it out and get out, or is there more to it? Well, I mean, really, if you find a tubal ovarian abscess, really, it's good to kind of just add antibiotics and let those antibiotics begin to work. Unless that patient is really crashing and requires a washout, it's best to try to not disturb that. Section so as not to spread it further because it can seed other pelvic structures and then it's more difficult to treat, right? So I guess that's something that usually you would know preoperatively. You would rarely go in and find that as a surprise. Yeah, rarely would we find something like that as a surprise, right, right, that's, yeah, OK, um, and what about does pregnancy change your approach? I mean, no, still there may be a need to kind of look in the adnexa and still, I mean there could be a concern for an ectopic pregnancy and so, you know, definitely this is something that we would proceed to the OR for and you know. It's, it's going to present very similarly with acute onset pain, um, you know, in a nexal mass or a lesion, maybe with flow, maybe not, and you may not be able to tell on ultrasound if it's a tortud Nexa or not, um, just depending on on. The quality of the ultrasound that day and so you know, despite pregnancy, if there's a concern for a ruptured or an unstable ectopic, it's it's worth a scope, yeah, yeah. Um What is, well, actually, let me ask you that. I mean, I wasn't planning on asking this, but if you go in, let's say they're, they're, the, um, quantitative HCG is high, they, they have evidence of them being pregnant, and you, you usually can tell that preoperatively right by the ultrasound or is that you're saying sometimes you might find that operatively. Yeah, well, sometimes on ultrasounds, you know, depending on the type of ultrasound that is performed, there's a certain level of pregnancy hormone in which you can actually see a pregnancy within the uterus or outside the uterus with a transabdominal probe. And then there's a certain level which is, which is a little bit more sensitive if you're able to do a transvaginal probe, but many of these patients are not able to undergo a transvaginal probe, and most children's hospitals will not do that or may not have access to that probe. And so, you know, if they are early in pregnancy, it may not show up on ultrasound, OK. And if you go in and you, what do you see that it, is it pretty, I've actually never seen one. What does it look like when you get in there? Is it big bulge? Yeah, I mean it looks like a bulge, and it can be in any location of the tube, more commonly, more rarely it can be kind of in the area of the cervix or in the area of the ovary or completely outside the pelvic structures within the abdominal cavity. But if it's in the fallopian tube, if it's a, if it's in the fallopian tube, you I go ahead and make an incision along the fallopian tube lengthwise and it comes right out. Yep, that's what you do. So you just make a salpingostomy and you remove the pregnancy, the ectopic pregnancy from the tube, ensure hemostasis, and just submit for pathology. You don't suture close the salpingotomy. No, we don't actually. And remarkably these pelvic structures heal pretty well. And so one of the things again that we always worry about whether you are considering making an incision on the ovary or the tube is that. You know, any manipulation is potential effects down the road with scar tissue formation, and that includes suturing in these areas sometimes. And so it does require fine suturing, obviously if it has to be done for for reasons of tubal reimplantation that our reproductive endocrine colleagues would take care of. Um, versus, you know, if it's just a small alboostomy that you've made, these heal very well and tend to have less stricture than if you put several stitches in it. Wow, that's great. OK, since we're talking about unexpected findings, what about, what does endometriosis look like and what should we do if we go in and we see it? Yeah, well, I mean, endometriosis can be elusive, and an elusive diagnosis in a younger adolescent female, they tend to have earlier lesions that don't look classic, like the bigger kind of blue or blackish lesions that adult women have, which is, you know, significant for more advanced. Endometriosis, but young girls may have kind of clear lesions that you can't necessarily see very easily just looking with a camera traditionally, or they might have red lesions that almost make it look like the peritoneal tissue is just hyperemic. Wow, OK. Uh, I, I have to see pictures of that because, you know, I tell you, we go in and do these negative laparoscopies for for when we think it might be appendicitis. I wonder how many of us are really good at looking for endometriosis. Um, so it's, it's great that you're saying that. Where, where should we be looking? Well, a good place to start looking is in the cul-de-sac, and one little trick to look for clear lesions that almost look like little blebs that are kind of pulling away from the peritoneum is to fill up the pelvis with a little bit of crystalloid fluid and then take your camera and dive under, and you can see things a little bit closer. Wow, OK, that's a great trick. You know, I would argue that that should be part of the standard laparoscopy whenever we find a negative appendix, because I don't think most people do that. Yep, that's, that's what we like to do if we don't find anything. Yeah, I know that I spoke with Senna Najat who was asking if we could do a combined study to get a better understanding of what pediatric surgeons do when we find a negative appendix, and I think that's one thing that we should be looking at. Are they looking for endometriosis. So, uh, OK, and then when we find it, we just burn the lesions. Well, so depending on where they're located and so sometimes you might want to excise the lesion and specifically if it's kind of in an area where it might be directly overlying the ureter or the bowel or something like that, you might want to use, you know, cold scissors to excise it. OK, OK. Um, so, OK, so now you've operated on this patient. Can they go home the next day? Any particular postoperative plans for them? Yeah, I mean, very frequently, as long as everything has been addressed through the camera, you know, we tend to send our patients home very quickly unless, you know, maybe perhaps there's a concern for additional inflammation or, you know, I've, I've definitely had the situation where I have found not only a torsion but, you know, an appendicitis, and so it will be both our service's call and the pediatric surgeon's call in terms of when they will allow that patient to go home, but Certainly after recovering in our postoperative anesthesia care area, many patients, if they've met milestones, can go home within a few hours, and we just, you know, recommend they limit their activity for 4 to 6 weeks to allow incisions to heal and avoid hernia formation. And many patients will transition to over the counter medications within a few days. That's, uh, that's really, you know, Jennifer, we're sending our appendectomies home the same day at some locations, so it sounds like you guys are following the same direction with your discharge, um, anything to, uh, do to prevent this from coming back? Do you start oral contraceptives? Well, obviously in the pubertal female that is an option, and we certainly discussed that as an option if it happens to have been a functional cyst that resulted in this in the first place. And unfortunately though, if we found something like a dermoid cyst or a peritubal cyst, oral contraceptive pills or other combined hormonal options won't make a difference. And so it's really sort of dependent on the underlying pathology in the prepubertal female, you know, we tend to provide surveillance ultrasounds in both groups regardless, and so we kind of follow them. And in the female who's had a recurrence or only has one ovary, then one of the ways we minimize that is decide to do an oophoropexy, OK. And just to hit more on that was going to be my next question to you, the surveillance. So you finish the case, they go home. When and if at all, do you have them come back and get a repeat ultrasound? So usually it's going to take a few months for a lot of that inflammation to go down, so we try to get the ultrasound within about 3 months of their surgery, and then, you know, if there are still signs that the ovary is recovering, we may do another one in 3 to 6 months following that, and then we try to do it annually, OK, so you don't get a baseline immediately post-op to make sure that it's gone down, no, because it's going to take a little bit of time for a lot of that inflammation to resolve, right? But I mean, I guess I'm trying to figure out how you would know if you didn't have a baseline postoperatively to know that it's improving. I guess the answer is that you would compare it to the other ovary. You want symmetry after 3 months, is that right? Well, and to keep in mind though that sometimes there is known baseline asymmetry between the two ovaries, but it's all about clinical picture. It's all about clinical signs. And so if the patient looks well, feels well, has no pain. It's, it's not a torsion. Got it, OK. Um, and I think Jennifer, you have answered all my questions. Um, do, I don't know if you have, if there's anything I missed that you wanted to hit on, or did we cover pretty much everything? No, I think that we covered everything. Well, Jennifer, I will tell you that you have become my go to person. I'm sorry about that, but when Mary Brandt introduced me to you years ago, you know that I always keep calling on you, and I appreciate you sort of being our pediatric adolescent gynecologist to the pediatric surgeons, and I'm sure that uh if people have more specific questions or have patients they want to send to you they could find you uh online. I know I found you easily uh all your information on the website so um uh that's I don't know if there's any partic particular way other than just calling Texas Children's Hospital. Yeah, no, or, or send me an email at J E D I E T R I at BCM.edu. Perfect, um, that's great and uh I I think you'll be getting some, some questions and some, some referrals from that. I know that others have when we've done these, so I, so I appreciate you being available for that. Jennifer, thank you so much for taking the time to do this, um. And uh I'm sure I'll be calling you again in the next couple of years for for more of these so thanks so much and I hope you have a great day. All right, you as well thanks so much. OK bye bye bye. We hope you enjoyed this episode of Stay Current in Pediatric Surgery. You can listen, watch, or read all content by downloading the Stay Current and Surgery app. Please send questions or comments to us at staycurrent podcast@gmail.com. We'll see you next time.