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INDICATIONS

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Cervical conization is indicated for suspicious lesions of the uterine cervix to confirm or exclude the diagnosis of cervical cancer. It is also a therapeutic procedure for preinvasive lesions of the cervix. Certain outpatient procedures, such as colposcopy, usually precede conization and are useful in the investigation of cervical lesions and/or an abnormal pap smear. A grossly apparent lesion that is suspicious for neoplasia should be biopsied regardless of Pap smear results. A punch biopsy is the usual approach in this situation (figure 1). After exposure of the cervix, the punch biopsy forceps is introduced, and a piece of cervical tissue is removed with inclusion of a small bite of surrounding healthy tissue. Alternatively, many surgeons now stain the cervix with acetic acid and perform the biopsies via colposcopic guidance.

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A suspicious or positive Papanicolaou smear and/or positive punch biopsy may necessitate operation with cold knife conization, the definitive diagnostic procedure for malignant lesions of the cervix. Alternatively, a loop electrical excisional procedure (LEEP) can be performed in the office setting.

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PREOPERATIVE PREPARATION

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See Chapter 96. Douches are omitted.

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ANESTHESIA

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Either general or spinal anesthesia is given.

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POSITION

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The patient is placed in a dorsal lithotomy position.

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OPERATIVE PROCEDURE

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The usual preparation of the perineum and vagina is carried out. Following a pelvic examination under anesthesia, a speculum is inserted into the vagina and the anterior lip of the cervix is grasped with a single-toothed tenaculum. Dilatation and curettage is not performed before conization because it interferes with the lining of the endocervical canal and the squamocolumnar junction, making a pathologic diagnosis more difficult.

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DETAILS OF PROCEDURE

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The cervix may be sprayed with a 7% iodine solution for evidence of possible carcinoma. The cervix is circumferentially injected with a vasoconstrictive solution such as diluted Pitressin or lidocaine with epinephrine. The surgeon maintains traction on the tenaculum as an incision is made with a No. 11 triangular-shaped blade at a 45-degree angle toward the endocervical canal. The involved portion of the cervix is excised (figure 3A). The proximal 1.5 to 2.5 cm of the endocervix is also removed (figure 4). The removed tissue, which appears as a cone, is immediately placed in a fixative to avoid loss of diagnostic epithelium through contact with gauze and so forth. The length and width of the conization procedure can be tailored to the size and location of the lesion, and to the age of the patient. Alternatively, a CO2 laser or electrocautery wire (LEEP) may be used in place of the cold knife (figure 2 and 3).

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After the cone is removed, the conization bed may be coagulated with the electrosurgical unit to maintain hemostasis. ...

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