Laser cervix conization
Last updated date: 18-Oct-2022
Originally Written in English
Laser cervix conization
Cervical conization is the surgical removal of part of the cervix. The cervix is the uterus's bottom section. The cervix is accessed via the vagina in this operation.
Conization of the cervix refers to the removal of a cone-shaped or cylindrical wedge from the cervix uteri that includes the transformation zone and all or part of the endocervical canal. It is used to provide a definitive diagnosis of squamous or glandular intraepithelial lesions, to rule out microinvasive carcinomas, and to treat cervical intraepithelial neoplasia conservatively (CIN).
What is Cervix conization?
Conization of the cervix is a surgical treatment used to detect and treat cervical dysplasia or early cervical cancer. It entails removing a cervical lesion as well as the complete transformation zone by excising a cone-shaped piece of the cervix. This technique has several indications. It can be utilized when pap smear and biopsy findings are contradictory, when histology results are much less severe than cytology results, when there is evidence of severe dysplasia, and even when there is stage A1 squamous cell cervical carcinoma.
Conization can be done with a scalpel (cold-knife conization), a laser, or an electrosurgical loop. The loop electrosurgical excision procedure (LEEP) or large loop excision of the transformation zone (LLETZ)is the latter. A combined conization method is one that begins with a laser and ends with a cold-knife approach. Excisional or destructive laser conization is possible (by vaporization). Diagnostic and therapeutic conization techniques are nearly comparable. Individual requirements must be considered while determining the extent of excision.
A cone biopsy involves the removal of a cone-shaped piece of tissue from the cervix. The cone is made by removing the cervix closest to the vagina as well as a portion of the route from the uterus to the vagina (called the endocervical canal). Cervical conization is another term for a cone biopsy.
A cone biopsy is often performed in the hospital as an outpatient treatment. This implies you will not be required to remain overnight. You will be given either a local anesthetic (freezing) or a general anesthetic (you will be unconscious). It depends on how the cone biopsy is done. You may be given pain medication by oral or IV if you are given a local anesthetic.
You will be laying on your back with your feet up in stirrups during a cone biopsy, much like you would for a Pap test. To keep the vagina open, the doctor will use a speculum (the same device used during a Pap test). The doctor next examines the vagina and cervix with a colposcope (a lighted magnification equipment) and guides the instruments needed to do the cone biopsy.
There are 3 ways to do a cone biopsy:
- Loop electrosurgical excision procedure (LEEP) uses a thin wire loop heated by electricity to remove the cervical tissue.
- Cold-knife excision uses a surgical knife (scalpel) to remove the cervical tissue.
- Laser surgery uses a laser (an intense, narrow beam of light) to remove the cervical tissue. Laser surgery is also called laser excision.
The excised cervical tissue is submitted to a lab to be examined under a microscope. If you receive a general anesthesia, you will be transported to the recovery room immediately following surgery and will remain there until you are ready to be discharged.
Most women are able to resume most of their routine activities within a week of having a cone biopsy. You will be instructed to abstain from sexual activity, douching, and the use of tampons for 3 to 4 weeks.
A Pap test will be performed every 4 to 6 months. After a few normal Pap test results, you and your doctor will decide how frequently you should get the test.
Anatomy and Physiology
The cervix is the connecting structure between the uterus and the vagina. It is divided into two sections: the ectocervix and the endocervical canal. The ectocervix is the part of the cervix that protrudes into the vagina. It is lined with a stratified squamous non-keratinized epithelium. The external os is the orifice in the ectocervix that marks the transition from the ectocervix to the endocervical canal. The endocervical canal connects the endometrial cavity to the vagina and runs the length of the cervix. It is covered by glandular epithelium.
The squamocolumnar junction is found in the ectocervix (SCJ). It is a transition zone when the epithelium transforms from glandular to squamous, and it is this zone that is most vulnerable to human papillomavirus attachment, which can lead to dysplasia and malignant transformation. When contemplating surgical choices for a conization operation, keep in mind that the cervix's major vascular supply is at three and nine o'clock, with the descending branches of the uterine artery and vein.
Laser cervix conization
When performed by skilled surgeons using cutting-edge technology, laser conization is as good as or better than knife cone or Lietz cone. The risk of premature birth increases with the volume and height of the cone, like with previous conization treatments. The laser conization height should never be more than 20 minutes.
Indications of Cervix Conization
Cervical conization is recommended for a variety of reasons. Excisional operations are necessary for diagnosis and therapy. If a lesion on the cervix is suspected for invasive cancer or an adenocarcinoma in situ, a surgeon should undertake a diagnostic excisional operation. A diagnostic cone is advised if there is a histological discordance with the cytological screening test and the histology results are less severe. Unsatisfactory colposcopic assessment with dysplasia present or unexplained high grade or unusual glandular cell cytology necessitates an excisional cone, or if the whole lesion is not visible on colposcopy.
The cone technique has minimal contraindications. A cold knife cone may not be performed if there is insufficient cervix to excise due to past excisions. If a patient is not a good surgical candidate, an office procedure that does not require general anesthesia is indicated. Pregnancy is a relative contraindication to the cold knife cone, which should only be used if there is a high suspicion of invasive malignancy. The cone is contraindicated in patients with severe cervicitis or those on anticoagulant medication.
The patient will be sedated and intubated by the anesthesiologist. The patient is put in the dorsal lithotomy position, with her legs supported by candy cane stirrups or Allen stirrups. Depending on the surgeon's inclination and capacity to examine the cervical lesion, colposcopy with 5% acetic acid or Lugol's solution can be done in the operating room. The vagina is prepared and draped in the normal sterile manner, including bladder drainage. For vaginal prep, surgical scrub solutions of Hibiclens antibacterial scrub or Betadine are sufficient.
This treatment does not necessitate the use of any antibiotics. A vasoconstrictor solution has been prepared. Before the surgery, vasopressin is normally diluted with 50cc saline. To give simultaneous local anesthesia, epinephrine-free lidocaine can be added to the solution.
A weighted speculum is inserted into the vagina; a right angle retractor is utilized to see the cervix; and a tenaculum is used to hold the anterior lip of the cervix. If stay sutures are utilized, they are put at the cervicovaginal junction at three and nine o'clock. Because current research shows no reduction in bleeding or hemorrhage, it is a surgeon's preference.
At 2 o'clock, 4 o'clock, 8 o'clock, and 10 o'clock, 10 cc to 15 cc of dilute vasopressin is injected into the cervix. Blanching will be seen. Starting at two o'clock outside the transformation zone, an angled blade is used to cut the cervix. Circumferential jigsaw cutting is used to incorporate the lesion and the transformation zone. To give countertraction and raise the cone bed, use toothed forceps or an Allis clamp, taking care not to harm the epithelium.
The cone specimen is created with an angled blade, and the base of the cone is excised with Mayo scissors following circumferential excision. A Kevorkian curette is used to curettage the remnant endocervical canal, and the specimen is caught on a Telfa pad. The bleeding is then stopped with Bovie cautery at a 40 W ball electrode, or some surgeons will use interrupted suture at the cone bed edges.
If stay sutures were used, a narrow piece of oxidized cellulose (surgicel) might be put in the cone bed and fastened in place with the stay sutures. The patient should be informed that she will be passing this packing in the coming weeks. Following the removal of the cone, a suture is put at the twelve o'clock position to mark the area for the pathologist.
A hemorrhage is the most serious consequence of a cold knife cone. This can occur during surgery or be delayed by up to two weeks. Intraoperative bleeding can be controlled using a variety of suturing procedures, and hysterectomy is a last resort. Although post-operative bleeding occurs in 5% to 15% of patients, conservative procedures in the office such as Monsel's paste, silver nitrate, or packing usually treat the majority of these patients. To achieve hemostasis, the surgeon may need to return to the operating room and recauterize or suture the cone bed. Infections caused by cold knife cones are uncommon and may be treated with medicines.
Late consequences of this operation include cervical stenosis and insufficiency. Stenosis can be treated with dilatation, and if vigorous Bovie cauterization of the endocervical canal or a deep cone bed specimen was obtained, it should be reviewed post-operatively. There is conflicting evidence about the risk of preterm birth and perinatal death linked with excisional surgeries.
There are no randomized controlled trials in existence. The majority of research demonstrate that cold knife cone is linked to a higher risk of preterm birth and perinatal death, whereas LEEP is not. A deeper excision appears to enhance the risk of PPROM and premature delivery. An increase in the number of operations has been associated to an increased risk of premature delivery.
- At the Care Center
You will be placed in a recovery area to rest while the anaesthetic wears off. You will be able to return home once you are awake and alert.
- At Home
It will take approximately a week to go back to normal. It will take 4 to 6 weeks for the region to recover completely. A follow-up exam in 6 weeks is possible.
- Call Your Doctor
After arriving home, contact your doctor if any of the following occur:
- Signs of infection, including fever, chills, or foul-smelling discharge from vagina
- Heavy vaginal bleeding (can happen a week after procedure)
- Belly or pelvic pain that is getting worse
If you think you have an emergency, call for emergency medical services right away.
Laser Conization Treatment of Cervical Intra-Epithelial Neoplasia
In a randomized trial of 123 women with CIN, 59 were treated with laser conization under colposcope without further hemostatic treatment, and 64 were treated with cold knife conization guided by Schiller's iodine dyeing, supported by side sutures, vaginal packing, and postoperative oral administration of tranexamic acid. Colposcopy and cytology were performed three and twelve weeks after surgery, and then every six months.
The average time of follow-up was 36 months. The laser group experienced reduced postoperative hemorrhage. However, postoperative bleeding was substantially less prevalent in the laser group (5%) than in the cold knife group (17%).
The rate of CIN recurrence was 7% in the laser group and 10% in the knife group. Cervical canal stenosis occurred in 7% of participants in the laser group and 3.5% in the knife group. After 12 weeks, the squamocolumnar junction was visible in its entirety in 66% of laser-treated patients vs 38% of cold-knife-treated patients. It is determined that laser conization is a safe treatment even when no hemostatic methods are applied, other than the coagulation properties of the laser beam itself.
Conization of the cervix is often done by a gynecologist, but a cytopathologist must be present to evaluate the sample. The primary care clinician and nurse practitioner should educate the patient on cervical cancer prevention by emphasizing the need of safe sex and condom usage during sexual intercourse. The HPV vaccination, which may help prevent or reduce the risk of cervical cancer, should be made available to both men and women.