L

Figure 2

A Clear lateral margins B Profile of cone biopsy margins

The ball or other tip should then be held a few millimeters from the surface of the cone base to allow the current to arc across to the tissue requiring hemostasis. This cauterization produces thermal damage to a depth of 2-3 mm, further reducing the chances of recurrence but making the excision margins of the sample unreliable for determining prospects of recurrence. After the entire base has been cauterized in this manner, ferric subsulfate (Monsel's) solution should be applied. The patient should be instructed not place anything in the vagina for at least 2 weeks. A routine postoperative visit is not necessary.

Scalpel or 'cold knife' cone biopsy

Colposcopy should again be used to identify the lesion. The scalpel cone biopsy procedure does not require a special speculum with smoke evacuator. However, wall suction must be available since considerably more bleeding will be encountered. Since the procedure lasts longer than the LEEP and patient cooperation is necessary to deal with the intraoperative bleeding, either general or regional anesthesia is usually required.

Figure 3

1 Hemostat on drape

Knife Conization Suture

Figure 4

Cone to be excised

After positioning of the speculum, two lateral stay sutures are placed at approximately 3 o'clock and 9 o'clock. The sutures are placed in a figure-of-eight manner to help hold the cervix and reduce the blood supply by ligation of the cervical branch of the uterine artery. An absorbable suture of 0 or 00 is sufficient just at the level of the vagina fornices. The sutures are held with hemostats attached to the drapes to help draw the cervix down into the lower vagina (Figure 3). Starting posteriorly, using a large, curved knife handle, the colposcopically identified acetowhite lesion is excised (Figure 4). Again, for diagnostic cones, the entire

Figure 5

1 Ectocervix

2 Hemostatic absorbable packing filling cone base transformation zone should be removed. The base of the cone may be difficult to separate completely with the scalpel; instead, curved scissors may be used. A sample of the endocervical canal may be obtained at this point using an endocervical curette or brush. Active bleeding may be controlled with cautery or fine 000 absorbable sutures. Care must be taken not to occlude the os. A cotton-tipped swab, inserted in the os before any sutures are placed, will help in avoiding this complication. The remainder of the cone base should be cauterized and treated with Monsel's solution for prophylaxis. If bleeding is still a problem, a commercial hemostatic agent (such as sheets of oxidized cellulose) may be used to tamponade the bleeding base and held in place by the lateral stay sutures. These sutures can be brought together over the midline and tied together (Figure 5).

Complications

There is a small risk of primary hemorrhage and an approximately 5% risk of secondary hemorrhage and, although rare, infection. Cold knife cone biopsy and LETZ with 'top hat' techniques may increase the risks of future cervical stenosis and incompetence. The use of LETZ to a depth of no more than 1 cm may not affect cervical competence or cause stenosis.

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