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Biopsy of the Cervix

Directed Biopsy of the Cervix at Colposcopy

Endocervical Curettage
at Colposcopy

Conization of the
Cervix by the Loop Electrical Excision Procedure (LEEP)

Cryosurgery of Cervix

Conization of Cervix

Abdominal Excision
of the Cervix Stump

Correction of an Incompetent Cervix
by the Shirodkar

Correction of an Incompetent Cervix
by the McDonald

Correction of an Incompetent Cervix
by the Lash Operation

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.   


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 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.

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 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.

Electrocoagulation of any bleeding surfaces with the ball cautery is performed.

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.

Excessive lesion remains outside that removed by the LEEP.

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 lesion on the anterior lip of the cervix is removed in a similar manner.

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.

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.

The exterior lesion on the portio is completely removed, but neoplasia remains in the cervical canal.

A smaller loop is placed up the canal. The remaining portion of the endocervical canal is removed by LEEP.

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.

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