Cervical Conization (Cold Knife)

Published on 31/05/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

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Chapter 234 Cervical Conization (Cold Knife)

TECHNIQUE

Cold knife conizations are generally performed under regional or general anesthesia. After providing appropriate informed consent, the anesthetized patient is placed in the dorsal lithotomy position, the vagina and cervix are disinfected, and the cervix is visualized using retractors. If necessary, a colposcopic examination, facilitated by acetic acid or Lugol solution, may be performed to further characterize any abnormalities present.

The procedure begins with the placement of hemostatic sutures (simple loop or figure-of-eight) at the 3- and 9-o’clock positions on the cervix near the cervicovaginal reflections bilaterally. These are generally tied and held to stabilize the cervix until the end of the procedure. (The role of these sutures in actually reducing blood loss has been debated and they may be omitted.) Dilute vasopressin (one pressor unit per 20 mL saline) may be injected into the cervical parenchyma to further reduce blood loss. If desired, a blunt uterine probe or small cervical dilator is placed into the endocervical canal to guide the dissection.

A cone-shaped plug of cervical tissue is excised by sweeping the scalpel blade around the ectocervix with the blade angled inward to intersect the endocervical canal. The width and depth of the conization is determined by the anatomy of the cervix, the location of the transformation zone, and the lesion being treated; it must include the transformation zone and any specific lesion.

Hemostasis may be obtained through electrosurgical energy or the application of styptics such as Monsel solution. Some advocate general cautery of the cut surface of the cervix, although the resultant slough of damaged tissue may delay final healing. If desired, the ectocervical edges may be sewn with a running suture to provide hemostasis at the edge and to roll the edges inward. As an alternative, Sturmdorf stitches may be placed to partially reconstruct the external cervical os, although some argue that this may increase the risk of cervical stenosis. At the close of the procedure, the held tails of the hemostatic sutures may be either clipped (leaving the suture in place) or tied across the cervix to apply pressure or to hold a hemostatic pledget (oxidized regenerated cellulose [Surgicel, or similar]) in place. Pelvic rest (no tampons, douching, or sexual intercourse) is generally advised for 2 to 3 weeks following the procedure, and the patient is instructed to return for heavy bleeding or bleeding that lasts more than 2 weeks.

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