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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

Correction of an Incompetent Cervix by the Shirodkar Technique

Patients who have habitually experienced second-trimester abortions may have an incompetent cervical os. Of the several surgical alternatives available to correct this problem, the Shirodkar technique, with fascia lata used, is an excellent choice for patients in the nonpregnant state.

The purpose of the operation is to restore competence to the cervix and thereby prevent the cervix from dilation during the second-trimester pregnancy.

Physiologic Changes. The restoration of appropriate strength to the internal cervical os prevents sudden dilation as the pregnancy progresses.

Points of Caution. Patients having this operation should be delivered at term by cesarean section.

Care must be taken to adequately mobilize the bladder to prevent injury from application of the fascia strap.

If the tunnel made on the lateral side of the cervix is made too high, the uterine vessels may be perforated, and copious hemorrhage may result.


The patient is placed in the dorsal lithotomy position. The vulva and vagina are prepped with a surgical soap solution. A weighted posterior retractor is placed in the vagina, and the cervix is grasped with a wide-mouthed tenaculum on the anterior lip. A transverse incision approximately 2-3 cm wide is made at the junction of the vaginal mucosa and the portio of the cervix. The incised edge of the vagina is picked up with an Allis clamp or thumb forceps.

Allis clamps are applied to the lateral edge of the transverse incision, and a gloved finger is used to dissect the bladder off the cervix. The bladder should be dissected up to the vesicouterine peritoneal fold, thus avoiding injury when the strap is placed.

The posterior vaginal epithelium overlying the cul-de-sac is exposed. A transverse incision is made approximately 2-3 cm at the junction of the posterior vaginal mucosa and the cervical portio. With Metzenbaum scissors, the peritoneum of the cul-de-sac is dissected from the posterior cervix.

A piece of fascia lata that has been previously taken from the lateral thigh (see Vagina and Urethra, for the Goebell-Stoeckel fascia lata sling procedure including the technique for obtaining the strip of fascia lata) is used for the Shirodkar strap. An aneurysm needle is maneuvered under the vaginal mucosa from the anterior incision into the posterior incision. A suture of 2-0 Prolene is placed in the end of the fascia lata strap and tied to the aneurysm needle.

The fascia strap is pulled from the posterior transverse incision into the anterior transverse incision. In a similar manner, the other aneurysm needle is used to dissect under the left side of the remaining vaginal mucosa and likewise is attached to the opposite end of the fascia strip with 2-0 Prolene.

The fascia lata strap is fixed to the posterior surface of the cervix with a single interrupted 2-0 synthetic absorbable suture.

A right-angle retractor lifts the bladder up and away from the anterior cervix; the fascia lata strap is trimmed to fit snugly around the cervix at the level of the internal os. The fascia strap is anchored to the anterior cervical tissue with several interrupted 2-0 Prolene sutures.

The anterior vaginal mucosa is returned to position and resutured with interrupted 3-0 synthetic absorbable suture.

This illustrates the results of the operation in the midplane. The internal os is closed enough to admit only a uterine sound or a 4-mm Hegar dilator. Thus, it becomes obvious that cesarean section will have to be performed to accommodate delivery.


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