A 22-year-old woman presents with acute, severe, stabbing right lower quadrant pain associated with nausea and two episodes of vomiting for 4 hours. She has a history of a known 6 cm right ovarian dermoid cyst. On examination, she is in acute distress with marked tenderness and voluntary guarding in the right iliac fossa. Transvaginal Doppler ultrasound reveals an enlarged right ovary (volume 48 mL) with peripheralized follicles and absent venous and arterial blood flow. What is the definitive management?
Answer and explanation
Correct answer: C. Emergent diagnostic laparoscopy with detorsion and ovarian preservation
- Step 1: The patient has Ovarian Torsion, a gynecologic emergency resulting from the twisting of the ovary and fallopian tube on its vascular pedicle.
- Step 2: Dermoid cysts (mature cystic teratomas) are common benign lead points due to their weight and mobility.
- Step 3: Emergent laparoscopy is the procedure of choice. Modern standard practice prioritizes untwisting (detorsion) and preserving the ovary even if dark or ischemic in appearance, as substantial functional ovarian tissue frequently recovers viable folliculogenesis.
Answer
Emergent diagnostic laparoscopy with detorsion and ovarian preservation.
Why not the others: 'Radical oophorectomy' is unnecessarily aggressive in young women desiring fertility; 'Conservative observation' leads to complete hemorrhagic infarction and irreversible ovarian necrosis; 'Percutaneous drainage' of a dermoid cyst risks severe chemical peritonitis from sebum spillage.
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