Plate 180

Cervical conization is indicated for suspicious lesions of the uterine cervix to confirm or exclude the diagnosis of cervical cancer. Certain outpatient procedures usually precede conization and are useful in the investigation of cervical lesions. The Papanicolaou smear taken with an Ayerst applicator is an efficient method of establishing the diagnosis of gross or microscopic lesions of the uterine cervix. In the event of a suspicious Papanicolaou smear or an obvious lesion of the cervix, the cervix is sprayed with Graham's 7% iodine solution. A punch biopsy is taken in the area, which does not stain in an otherwise deep-mahogany stained cervix (Figure 1). After exposure of the cervix, the punch biopsy forceps is introduced, and a piece of unstained 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 a culposcope.

A suspicious or positive Papanicolaou smear and/or positive punch biopsy necessitates operation with cold knife conization, the definitive diagnostic procedure for malignant lesions of the cervix.

(See Gynecologic System—Routine for Vaginal Procedures.) Douches are omitted.

Either general or spinal anesthesia is given.

The patient is placed in a dorsal lithotomy position.

The usual preparation of the perineum is carried out, but preparation of the vagina and cervix is avoided, lest loosely attached epithelium essential for diagnosis be destroyed. Even during the pelvic examination under anesthesia, the examiner's gloved fingers avoid the surface of the cervix. Following the pelvic examination, 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 evidence of possible carcinoma. A Garret retractor can be placed in the cervix for traction purposes. 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 2). The proximal 1.5 cm of the endocervix is also removed (Figure 3). 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. It is important to remove the endocervical canal, since carcinoma of the cervix is frequently of multicentric origin and over 50 percent of invasive lesions occur in the endocervical canal. It is advisable not to do too deep a conization, which would involve the internal os, because stenosis could result (Figure 3A). A laser may be used in place of the cold knife or electrocautery wire.

After the cone is removed, some prefer to smooth surgical margins by using the cutting current with the triangular wire loop completely encircling the coned area. This is often satisfactory in establishing hemostasis. The wire triangle is kept quite superficial. No effort is made to cut deeply into the body of the cervix. Individual points of hemorrhage are coagulated if necessary. The complete cone can be excised with the triangular wire loop (Figures 4 and 4A). Persistent bleeding after cold-knife conization is controlled by interrupted figure-of-eight fine sutures.

In the presence of extensive chronic cystic cervicitis, especially when the cervix is hypertrophied, a more extensive conization or amputation of the cervix should be considered. A rim of mucosa at least 1 cm wide should be mobilized from the entire margins of the amputated cervix. The mobilized mucosa will be necessary to reconstruct the new cervix. This can be accomplished by the placement of anterior and posterior Sturmdorf sutures (Figures 5 and 6).

The proper placement of the rather complicated Sturmdorf stitch can be enhanced if a moderate-size Hank's dilator is inserted into the cervical canal. A cervical cutting needle is introduced approximately 2 cm from the cervical margin in the midline anteriorly and directed out over the Hank's dilator (Figure 5). The mobilized mucosa in the midline anteriorly is grasped with forceps and a transverse bite is taken with the same needle (Figure 5). The Hank's dilator is reinserted in order to assist mechanically in the proper placement of the needle within the cervical canal and back out in the midline anteriorly.

The efficiency of this suture in inverting the anterior wall is tested by traction on the suture. Accuracy is essential, and the surgeon should not hesitate to replace the suture (Figure 7).

The patency of the reconstructed cervical canal is tested by the insertion of a Hank's dilator (Figure 7A). A similar Sturmdorf suture is placed in the mid-line posteriorly. Again, with the Hank's dilator in the cervical canal to ensure its patency, the lateral margins of raw surface are closed with interrupted absorbable sutures. These lateral sutures should include the margins of the mucosa and a bite in the underlying cervix. One or two sutures on either side are usually sufficient (Figure 8). It is preferred to leave no pack in the vagina, as good hemostasis should be obtained at the completion of the procedure.

The patency and direction of the cervical canal are determined by the passage of a uterine sound. The cervix is dilated gently with a series of lubricated, graduated Hegar dilators, and a systematic curettage is carried out (Figures 9 and 10). For diagnostic curettage dilatation up to a No. 8 or 10 Hegar is adequate. The largest sharp curette than can pass through the dilated cervix is gently inserted and passed to the fundus. The anterior wall is scraped until all endometrium is removed, then the posterior wall. Curettage is then repeated on the right and left walls, the fundus, and finally the uterine cornua. Following curettage of the uterus, persistent bleeding from the cold knife conization is controlled with figure-of-eight sutures. Diagnostic conizations are of such limited scope that plastic reconstruction of the cervix is not required.

Postoperative care in a cervical conization is most important. Wide and deep conizations of the internal os may be the source of cervical stenosis. Postconization stenosis may be associated with the development of dysmenorrhea as well as sterility. Postconization patients should be seen in the office in 6 weeks for dilatation of the cervix. Under no circumstances should a stem pessary be left in the cervix at the time of conization, since infection may supervene in the presence of a foreign body. On occasion, patients develop a perimetritis. This usually responds very well to antibiotics.