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 with colposcopic guidance.
A suspicious or positive Pap 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.
See Chapter 100. Douches are omitted.
Either general or spinal anesthesia is given.
Patients are placed in a dorsal lithotomy position.
The usual preparation of the perineum and vagina is carried out. Then a time-out is performed. 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.
The cervix may be sprayed with a 7% iodine solution for visual evidence of possible carcinoma. The cervix is circumferentially injected with a vasoconstrictive solution such as diluted vasopressin or lidocaine with epinephrine. The surgeon maintains traction on the tenaculum as an incision is made with an 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 1.5–2.5 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 in place of the cold knife, a Loop Electrosurgical Excision Procedure (LEEP) may be performed with an electrosurgical wire (FIGURES 2 and 3). Laser treatment is also an option.