Box 26-1 Master Surgeon's Corner
A cervical conization refers to the surgical excision of the squamous-columnar junction. The indications are both therapeutic and diagnostic. It is a therapeutic procedure in cases of cervical intraepithelial neoplasia grade 2 or 3 and microinvasive carcinoma of the cervix (negative margins). Diagnostic indications include unsatisfactory colposcopy, positive endocervical curettage, persistent positive cytology for dysplasia in the presence of a normal colposcopy, and a cervical biopsy positive for microinvasion. The full management paradigm has been discussed in previous chapters and will not be reviewed here (see Chapters 4 and 5). A knife cone biopsy is the gold standard and has the advantage of proper evaluation of the margins because no thermal energy is used; however, for the most part, a loop electrosurgical excision procedure (LEEP) is sufficient. The exception is in cases in which a precise margin is essential. LEEP is usually performed as an outpatient procedure under local anesthesia, whereas in cases of knife cone biopsy, general or regional anesthesia is used.
Preoperatively a colposcopic evaluation of the cervix is performed to evaluate the extent of disease. Biopsies from appropriate areas are sent, and if a conization is indicated, formal informed consent is obtained with emphasis on possible complications including cervical incompetence, bleeding, and infection. The patient is admitted to the hospital on the day of surgery.
Box 26-2 Caution Points
Optimal visualization is important in order to properly evaluate the extent of the lesion and thus minimize the need for repeat procedures.
The size of the excision should be suffi cient to remove the entire lesion; however, it should be kept in mind that the deeper the conization, the greater is the likelihood of future cervical incompetence.
The use of relatively large loop electrodes can lead inadvertently to removal of large amounts of the cervix.
The procedure is performed under general or regional anesthesia. The patient is put in the semilithotomy position, and a bimanual examination is performed. The patient is then prepped and draped and the bladder emptied via a catheter. A speculum is inserted into the vagina for maximum visualization. Lugol's stain may be used to help delineate the dysplasia. A single-tooth tenaculum is used to grasp the anterior aspect of the cervix. Bleeding from the cervix can be minimized by injecting a dilute solution of vasopressin in lidocaine into the 4 quadrants of the cervical stroma. Figure-of-eight "stay" stitches of 1-0 delayed-absorbable suture can be placed at the 3 o'clock and 9 o'clock positions on the cervix just below the cervicovaginal junction. These stitches will aid in hemostasis ...