Oophoropexy in Prepubertal Girl

Previous reports have described multiple different techniques for pre-pubertal oophoropexy of the ovary, with no specific procedure identified to have the best outcomes. This case illustrates a combination of uterosacral ligament fixation and pelvic side wall fixation to achieve successful laparoscopic oophoropexy in a pre-pubertal girl with recurrent ovarian torsion. The patient is a 7-year-old female who presented with severe abdominal pain and was diagnosed with right ovarian torsion. She was taken to the operating room and underwent laparoscopic detortion. Six months later, she presented with the same symptoms and was found to have recurrent right ovarian torsion. The right ovary was again untwisted laparoscopically. Otheropexy was not performed at the time of her second torsion due to edema and concerned that the increased weight of the adnexa would decrease the success of PEI. Her pain resolved and ultrasound was used for surveillance of the ovary, which appeared to return to normal size about 3 months after the second surgery. At that time, she presented for elective laparoscopic oophoropexy of the right ovary with the goal of preventing future torsion. Supine position was used as is typical for prepubertal patients. We placed a foley to decompress the bladder, critical to properly expose the pelvis in these young patients. Laparoscopic entry was performed through the umbilicus using a varis needle and a 5 millimeter port. A 2nd and 3rd port were placed in the left and right lower quadrants. In this patient, both ovaries appear larger in size than expected for age. However, as both episodes of torsion previously occurred on the right side, the decision was made to perform oophoropexy of the right ovary only. We inspect surrounding structures and elect to attach the ovary to the right uterosacral ligament, noting significant laxity. By elevating the right ovary, the medial aspect of the ovary is affixed to the uterosacral ligament, which situates the ovary in the orthotopic position. This is done with a 36-inch, 30 permanent prolene suture with SH needle and extra corporeal knot tying. A 2nd suture is similarly placed beside the 1st to ensure secure attachment to the ligament. Even with two well placed uterosacral sutures, the ovary still remains mobile in the pelvis and at risk for torsion. Therefore, we examine for another location for fixation. We consider shortening the utero ovarian ligament, affixing the ovary to the posterior aspect of the uterus, and attaching the ovary to the round ligament, which also appears lax. We proceed with fixation to the pelvic side wall to maintain orthotopic position of the ovary. We identify a portion of the lateral side wall medial to the ureter and elevate the ovary, allowing us to place a suture through this portion of the peritoneum. This same suture is passed through the lateral aspect of the ovary, allowing a second fixation point and resuming the typical positioning of the ovary. The ovary now rests securely in an orthotopic position with no evidence of kinking or obstruction of the ureter. The fimbria are free and in good communication to the ovary. In conclusion, laparoscopic oophoropexy was performed in this prepubertal patient using both fixation to the uterosacral ligament as well as to the peritoneum overlying the right pelvic side wall. This video highlights the surgical decisions that are made based on the patient's age, pubertal development, and individual anatomy. The use of two fixation points minimizes the possibility of future adnexal rotation within the pelvis. 6 months later, the patient continues to do well without any recurrence of ovarian torsion.