The chart review identified 142 cases in 119 patients who underwent diagnostic laparoscopy from March 2020 to March 2021. Ninety-two non-torsion laparoscopic cases were excluded from the analysis. There were 50 suspected ovarian/adnexal torsion cases in 47 patients. The mean age was 13.9 ± 2.6 years (range 8–18 years) and 88% (n = 44) were post-menarchal, and 12% (n = 6) were pre-menarchal. All underwent diagnostic laparoscopy which revealed 39 laparoscopically-confirmed ovarian/adnexal torsion cases in 36 patients with one subject having three episodes of torsion (Fig. 2).

Flow diagram of included patients. *One patient with recurrent torsion 3 times

Among the 50 suspected ovarian/adnexal torsion patients, left ovarian/adnexal torsion was confirmed in 42% (n = 21/50), right ovarian/adnexal torsion in 32% (n = 16/50), bilateral ovarian/adnexal torsion in 4% (n = 2/50), and no torsion in 22% of cases (n = 11/50). One case involving both adnexa was in a premenarchal patient and the other case was in a menarchal girl who both presented within one day of symptom onset and were found to have paratubal cysts on pathology. The recurrent case was a menarchal patient who experienced 3 recurrences within 3 months involving left side, with spontaneous torsion with no lesion identified on tissue exam.

Among the 39 laparoscopically-confirmed ovarian/adnexal torsion cases, ovarian salvage was accomplished in 97.4% (n = 38/39) and tubal salvage in 89.7% (n = 35/39), with 1 oophorectomy and 3 salpingectomies in the non-salvaged group, which was the primary outcome of interest. There was one case of autoamputation of the fallopian tube from an old torsion. The mean age of menarche was slightly younger in the salvaged group compared to non-salvaged group (11.2 vs. 12.5 years, p = 0.037) (Table 1).

Of the 4 patients with tubal torsion, 3 underwent salpingectomy of the affected tube (Table 2). The one case who underwent oophorectomy was a menarchal girl noted to have the ipsilateral (right) tube encased in adhesion intraoperatively, suggestive of autoamputation, and thus salpingectomy was not pursued

Secondary outcomes assessed factors that could have contributed to a delay or a risk for non-salvage. Overall, among the 50 suspected ovarian/adnexal torsion cases, presentation was within 24 h of symptom onset in 52% (n = 26), after 24 h but within 72 h for 26% (n = 13/50), after 72 h but within one week for 16% (n = 8/50), and greater than one week for 6% (n = 3/50). Among the 39 laparoscopically-confirmed ovarian/adnexal torsion cases, mean pain duration prior to presentation was 61.3 h (salvaged) and 56 h (non-salvaged) (p = 0.47) (Table 1). A pre-operative COVID-19 test prior to surgery was collected from all 50 suspected ovarian/adnexal torsion cases prior to surgery, and results were negative in 96% (n = 48/50). While all 50 suspected ovarian/adnexal torsion cases received COVID-19 testing, 6% (n = 3/50) did not result pre-operatively, with a range of 4–7 medical personnel in the operating room at risk for COVID-19 exposure. The average turnaround time from COVID-19 sample collection to a result was 143+/- 122 min. The mean length of COVID-19 testing was 158 and 173 min for the ovarian/adnexal torsion salvaged and non-salvaged groups respectively (p = 0.42) (Table 1). COVID-19 tests resulted within an hour of collection in 18% (n = 9/50), within two hours of collection for 42% (n = 21/50), within three hours of collection for 22% (n = 11/50), within four hours of collection for 10% (n = 5/50), and over four hours of collection for 10% (n = 5/50).

Regarding the 4 patients who underwent surgical removal (Table 2), all were menarchal, and length of presentation was approximately within 72 h for half (with symptoms for 1 day and 2 days) and after 1 week for the other half (with symptoms for 7 days and 10 days). For the 2 patients who presented to the emergency room (ER) within 72 h of symptom onset, additional delay to the operating room (OR) due to pre-operative COVID-19 testing was 93 min (for the patient who presented within 1 day) and 367 min (for the patient who presented within 2 days). The patient who presented within one day of symptom onset was the case with autoamputation of the right adnexa, with right oophorectomy but no salpingectomy of the encased right tube. For the 2 patients who presented to the ER after 1 week of symptom onset, the patient who presented after 10 days proceeded to the OR urgently; the patient who presented after 7 days had additional delay to the OR due to pre-operative COVID-19 testing that resulted after 154 min.

Regarding the 2 patients whose pre-operative COVID-19 test result was positive, one menarchal patient presented within 2 days of symptom onset was taken to the OR emergently due to severe pain and a large adnexal cyst on ultrasound, despite being incidentally COVID-19 positive and asymptomatic on presentation. Post-operatively, she was transferred to recover in the main campus med-surg COVID-19 unit. The menarchal patient with 3 recurrences had tested positive for COVID-19 on her second recurrence. For the second occurrence, she presented to the ER within 3 days of symptom onset, after her 10-day quarantine from testing positive for COVID-19. For the first and third occurrences, she presented within one day of acute left lower quadrant pain.

Regarding the 3 patients who proceeded to the OR prior to their pre-operative COVID-19 test result, one patient presented after 10-days of symptom onset and proceeded to the OR based on the urgent nature of the case (severe, unresponsive pain and vomiting), and this decision was communicated with the chief of the service. The test result was ultimately negative, resulting after 81 min. The second patient was transferred from an outside hospital, where she tested negative. The third was the patient with 3 episodes of recurrent torsion on her second presentation where she presented after a 10-day quarantine, described above. Her pre-operative COVID-19 test was positive, resulting after 155 min.

Pathology specimens were available for 48 of the 50 suspected ovarian/adnexal torsion cases, with the most common pathology noted to be paratubal cyst (n = 17/48, 35.4%), followed by ovarian (n = 16/48, 33.3%), tubal/ovarian (n = 4/48, 8.3%), and no lesion was identified in 33.3% (n = 8/48) (Table 3).