Ovarian accidents that may be encountered at laparotomy include: haemorrhage, rupture, torsion, infection, and degeneration. These complications usually involve ovaries that are enlarged, but haemorrhage and, rarely, torsion may also occur with ovaries of normal size, and are therefore especially likely to be misdiagnosed preoperatively. All of these ovarian complications are associated with pain and should ideally be distinguished from other causes of acute pelvic pain before embarking on a laparotomy. These include ectopic pregnancy, spontaneous abortion, salpingitis, appendicitis, diverticulitis, ileitis, ureteric colic, intestinal obstruction, torsion of other pelvic organs, and retroplacental haemorrhage or red degeneration of a fibroid during pregnancy.

The nature and timing of the pain will frequently be helpful in establishing the correct diagnosis. Pain caused by ovulatory bleeding will usually be at midcycle and is commonly unilateral, (so-called mittelschmerz). It may also follow ovarian hyperstimulation, especially in women undergoing gonadotropin treatment. Pain due to the rupture of a corpus luteum cyst will usually occur during early pregnancy, but may also occur late in the menstrual cycle, while intraperitoneal bleeding due to rupture of other functional ovarian cysts may occur at any time and cause confusion. Although most cysts rupture spontaneously, this may also occur during intercourse, labour, or pelvic examination. The pain is of acute onset and may be associated with a feeling that something has ‘given way’. It is usually followed by signs of peritonism, such as vomiting and diarrhoea. Shoulder-tip pain due to fluid under the diaphragm may also occur. Rupture of a dermoid cyst, although rare, releases extremely irritant sebaceous material into the peritoneal cavity, causing an acute abdomen. Bleeding into the pelvic cavity is generally of sudden onset and causes a constant ache of variable severity. Large haemorrhages may cause widespread abdominal pain and referred diaphragmatic pain in one or both shoulders, together with shock, which may be profound.

If the ovary is enlarged, torsion or bleeding into an ovarian cyst are more likely than haemorrhage, but intraperitoneal bleeding may also occur with the rupture of an endometriotic or neoplastic cyst. Torsion typically causes severe pain of sudden onset, to one or other side of the midline. There may also be a history of intermittent episodes of similar pain. Vomiting and irritability of the adjacent bowel or bladder may occur. Shock is rarely present and, although there may be a tachycardia, the woman is usually afebrile.

Small ovarian tumours lying in the pelvis can only be palpated on vaginal or rectal examination, and may be impossible to feel if there is guarding due to peritoneal irritation. Most lie posterior to the uterus, except for dermoid cysts (benign teratomas) which are typically found in the uterovesical pouch.

Ovarian tumours that are large enough to be palpable through the abdominal wall tend to displace the bowel above and laterally and to lie centrally above the uterus. As a result, an ovarian tumour can easily be distinguished from ascites by the absence of flank dullness. The position of the tumour is, however, of little value in distinguishing it from an enlarged uterus or distended bladder. It is also difficult to be certain from which side of the pelvis the tumour arises, as even when an ovarian tumour is lying to one side, it may still be found to arise from the opposite ovary.

Before embarking on a laparotomy for a suspected ovarian accident, it is important to exclude other pelvic and abdominal tumours for which surgery is not required, such as a gravid uterus, distended bladder, or pelvic kidney. Rarely, an enlarged liver or spleen, or simply obesity, may also cause confusion. If necessary, empty the bladder with a catheter. Always consider the possibility of pregnancy and perform a pregnancy test on urine, if necessary, using a sensitive monoclonal &bgr;-human chorionic gonadotropin kit. A placental souffle, identified with a portable Doppler ultrasound transducer, is also suggestive of pregnancy, while detection of fetal heart sounds is diagnostic.

Careful pelvic examination will indicate whether the mass is attached to, or a part of, the uterus. In addition, always bear in mind the possibility of a pelvic kidney.

Abdominal or pelvic ultrasound should be performed whenever possible, and will usually give clear evidence of an ovarian cyst, but cannot, even in experienced hands, be relied upon to distinguish between solid ovarian and uterine tumours, or to identify very early intrauterine or ectopic pregnancies. Radiographs of the abdomen and pelvis are seldom helpful but may, rarely, reveal calcification due to teeth in a dermoid cyst. If the tumour is not large and the diagnosis remains in doubt, then a diagnostic laparoscopy should always be performed.

The surgical procedure adopted depends on the nature of the ovarian accident, the age of the patient, and, if a tumour is present, whether or not this appears to be malignant.

Haemorrhage into a functional ovarian cyst of less than 5 to 6 cm in diameter, diagnosed laparoscopically, is self-limiting and should be managed conservatively. If there is active intraperitoneal bleeding from a ruptured functional cyst or corpus luteum, haemostasis may be achieved laparoscopically using bipolar diathermy or, if available, the ‘cold coagulator’ or contact Nd-YAG laser. If laparoscopic techniques fail, or are not feasible because of heavy bleeding, then a laparotomy should be performed to control the haemorrhage by oversewing the bleeding points, or by removing the cyst or, if necessary, the whole ovary.

Rupture of benign ovarian cysts usually occurs at the site of previous ischaemic degeneration, but may also occur if the cyst is endometriotic, papilliferous in nature, or malignant. If the cyst is of benign appearance and a plane of cleavage can be identified between the cyst and normal ovarian tissue, then an ovarian cystectomy should be performed and the ovary reformed. If normal ovarian tissue cannot be identified and the tumour is unilateral, a salpingo-oophorectomy is preferable. In women of childbearing years, ovarian tissue should be conserved whenever possible. However, in those rare circumstances where bilateral benign ovarian tumours are found and a bilateral salpingo-oophorectomy is necessary, because no normal ovarian tissue can be identified in either ovary, the uterus should always be conserved so that the woman may subsequently consider in vitro fertilization using ‘ovum donation’. If the cyst is endometriotic in nature, additional pelvic endometriotic tissue may be present, especially around the uterosacral ligaments. An effort should be made to excise or cauterize this tissue, taking great care to avoid ureteric damage, especially when using diathermy cautery.

Features suggesting malignancy, which may be noted at the time of laparotomy, include solidity, or solid areas in a cystic tumour, areas of haemorrhage in the tumour, large surface blood vessels, tissue fungating through the surface of the ovary, free peritoneal fluid, a bilateral distribution, and metastases on the peritoneum or in the omentum or liver. When the tumour is clearly malignant, bilateral salpingo-oophorectomy is usually necessary, especially in peri- or postmenopausal women. Ideally, the tumour should, if possible, be removed intact to prevent contamination of the peritoneal cavity with the cyst contents. If there is free peritoneal fluid, this should always be sampled and sent for cytological examination. It is usual to perform a total abdominal hysterectomy at the same time in women who have completed their family, but if there is doubt about the diagnosis, and the tumour is confined to one ovary, then the uterus should be conserved. All large tumour nodules of more than 1 cm in diameter should be excised if possible, to ‘debulk’ the tumour and make it more amenable to subsequent chemo- and/or radiotherapy. The greater omentum should also be excised to reduce the risk of subsequent large-bowel obstruction. If there is any doubt about the diagnosis, especially in younger women who wish to conserve their fertility, a frozen section biopsy examination should be arranged whenever possible.

Thorough peritoneal lavage using warm isotonic saline solution should be performed at the end of the procedure, to remove blood and potentially irritant cyst fluid from the peritoneal cavity. This practice will reduce the incidence of postoperative ileus and adhesion formation, and is especially important if the tumour is a mucinous cystadenoma as it may lessen the risk of subsequent pseudomyxoma peritonei.

If tubo-ovarian torsion is suspected or diagnosed laparoscopically, then an immediate laparotomy is indicated. If the torsion is recent or incomplete, the ovary and tube may be viable and can be conserved, using a suture to stabilize them and prevent a recurrence. If the ovary contains a cyst, an ovarian cystectomy should be performed. More commonly, the ovary and tube have suffered irreversible ischaemic damage and are gangrenous, necessitating salpingo-oophorectomy.

Tubo-ovarian infection (see also Section 30.1 206) may occasionally be identified during a laparotomy performed for suspected appendicitis or inflammatory bowel disease. If the infection is unilateral, it may be appropriate to perform a salpingo-oophorectomy. Pelvic inflammatory disease is, however, more commonly bilateral and usually occurs in young women of childbearing age. The temptation to perform a bilateral salpingo-oophorectomy must therefore be resisted. Obvious pus should be drained and conservative management with intravenous antibiotics should be instituted in an attempt to conserve fertility.

Degeneration of ovarian tumours may be identified as a coincidental finding at laparotomy. Most large, solid, ovarian tumours display necrosis or haemorrhage in their centres. These tumours should be treated by salpingo-oophorectomy.

Primary ovarian tumours. In: Tindall VR. Jeffcoate's principles of gynaecology. 5th edn. London: Butterworths, 1987: 471–81.

Peel KR. Benign and malignant tumours of the ovary. In: Whitfield CR, ed. Dewhurst's Textbook of obstetrics and gynaecology for postgraduates. Oxford: Blackwell Scientific, 1986: 733–54.