Conization of the Cervix

by the Loop Electrical Excision

Procedure (LEEP)

The indication for conization of the cervix are (1) the limits of the lesion in the cervix cannot be
completely defined by colposcopy and directed biopsy, or the lesion is noted to extend up into
the cervical canal and, therefore, is inaccessible to histologic examination by direct biopsy; (2)
there is severe cervical intraepithelial neoplasia (CIN) or carcinoma in situ in a young patient for
whom a hysterectomy is contraindicated because of age and desire for fertility; and (3) there is a
failure of agreement between cytology, colposcopy, and histology. The purpose of conization of
the cervix by the LEEP is to remove a cone-shaped piece of cervical tissue that will encompass
the squamocolumnar junction. The procedure can be diagnostic as well as therapeutic.

Physiologic Changes. This operation removes the endocervical glands and in some patients has
been associated with infertility because it reduces the production of cervical mucus. In addition,
it may weaken the internal os of the cervix and, therefore, can be associated with second-
trimester abortion.

Points of Caution. The surgical specimen should be adequate to provide an accurate diagnosis
and remove the entire lesion. Hemostasis after conization is essential. These patients should be
informed that there may be a small incidence of persistent cervical intraepithelial neoplasia
following conization by the LEEP. Therefore, follow-up cytology and colposcopy are essential to
this form of therapy.

Technique

The patient may be anesthetized with general or
local anesthesia. Local anesthesia consists of
paracervical injections of 1% lidocaine at the 3,
5, 7, and 9 o'clock positions around the cervix.
The cervix is stained with an iodine solution
such as Schiller's solution to demarcate zones of
With the lesion adequately stained with Schiller's
solution, the loop device with suction attached to
the rod removes the smoke or flume. The loop is
placed outside the lesion in the area of normal
cervix. The electrocoagulator is adjusted to a blend
between the cutting and the electrocoagulation
glycogen depletion and thus neoplasia. If the
patient is under general anesthesia, a solution of
Pitressin diluted with 10 international units to 30
mL of normal saline is injected around the entire
surface of the cervix. If the patient is under local
anesthesia, the Pitressin can be mixed with
lidocaine. Vascular constricture and blanching of
the cervix will be noted. The injection of
Pitressin solution is contraindicated in patients
with cardiovascular disease and /or hypertension.
A pursestring vascular cerclage to control the
bleeding is rarely indicated.
Electrocoagulation of any bleeding surfaces with
the ball cautery is performed.
Excessive lesion remains outside that removed
by the LEEP.
current. The loop device is inserted through the
cervical tissue to the depth of the available loop
and is slowly moved from one side of the portio of
the cervix to the other side. By inserting the loop to
the full depth of the cervix, the cone should contain
the entire lesion. When the surgeon has reached the
opposite limits of the lesion as noted by Schiller's
white area, the loop is lifted forward, and the
specimen is removed.
The lesion is larger than (extends outside the limits
of) the available steel loops and must be removed
in sections (see Figs. 5-8). The electric wire of the
loop is inserted and swept across the cervix in a
routine fashion as shown in Figures 1-3.
The cone is removed, but excessive lesion can still
be seen outside the excised area.
The remaining lesion can be removed by
repeating the standard procedure, moving the
electrical loop from one side to the other. The
lesion that was outside the original cone has
been removed.
The three cone specimens of the cervix are
removed by LEEP are (1) the original cone, (2)
the posterior portion, and (3) the anterior portion.
The lesion on the anterior lip of the cervix is
removed in a similar manner.
When the original lesion extends high into the
endocervical canal, the cone specimen of the cervix
is removed as shown here. Conization by the LEEP
is moved from the patient's right to the left in the
same technique as previously shown.
Most of the lesion has been removed by the
LEEP.
A smaller loop is placed up the canal. The
remaining portion of the endocervical canal is
removed by LEEP.
The exterior lesion on the portio is completely
removed, but neoplasia remains in the cervical
canal.
The two pathologic specimens, the cylinder and the
cone, are shown here. Hemostasis can be achieved
as shown in Figure 3 by the ball cautery. The
specimens are sent to pathology clearly marked as
upper cervical canal and lower squamous columnar
junction of the cervix.
We have found it advantageous to dip a tampon in
a ferrous sulfate solution such as Monsel's. The
tampon with the tip soaked in Monsel's solution is
placed in the cervical cone for additional
hemostasis.