User:Ekku2025/Cervical conization

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Prior to the introduction of the speculum, cervical cancer was only found once it was advanced. With the invention and use of a speculum, changes in the cervix could be appreciated. First, they were evaluated macroscopically and eventually were also assessed using a microscope. In 1927, H. Hinselmann discovered the transformation zone, where metaplastic squamous epithelium is found between the columnar epithelium of the endocervix and the squamous epithelium of the ectocervix. The transformation zone is clinically significant, as it is where almost all cervical cancers and precancerous lesions arise.

All current cervical conization methods can be traced back to amputation of the ectocervix which was developed by Marion Sims in 1861. Prior to this, any excisions of cervical carcinomas were mainly a palliative care treatment option. A. Sturmdorf was the first to describe an excision of a cone shape from the ectocervix, however he utilized this as a treatment for cervicitis. J. E. Ayre was the first to introduce cold knife conization in 1948 and stressed the importance of evaluating the excised tissue in serial sections to assess the extent of invasion. This method of cold knife conization has been utilized and eventually options for excisions using electrocautery were developed as well. Initially, excised tissue utilizing electrocuatery was not satisfactory for evaluation, but as the loops used have become finer, the quality of the surgical specimens have improved to rival those of cold knife conization. Presently, electrocuatery methods are often preferred to cold knife conization due to greater ease of procedure.

The decision to perform a cervical conization procedure is made with consideration of a patient's pap smear, colposcopy, and HPV test results. ACOG recommends that decisions regarding excision should be based on risk of CIN3+.

LEEPs can be performed in the office or in the operating room. The procedure will begin with the OBGYN placing the speculum to visualize the cervix. The loop is then passed through the speculum and used to excise a portion of the cervix. This tissue will be sent for further analysis to determine the depth of irregular cells. The OBGYN will ensure that there is no active bleeding prior to removing the speculum.

Immediate side effect from LEEPs to be aware of is heavy bleeding. This can occur within a few weeks of the procedure. Future pregnancies may be at risk for premature delivery or low birth weight, however the increase in risk of this due to the procedure is small.

After treatment, screenings will continue. HPV screening is recommended 6 months after conization. Regular cervical cancer screening will resume as well, with the schedule of screening being determined by the type of abnormal cells that were present in the cervix.

Conization is treatment for abnormal cervical cells. The results of a colposcopy are reported as CIN 1-3. CIN stands for cervical intraepithelial neoplasia and each grade represents varying levels of change present in the cells. CIN 1 is mild changes, CIN 2 is moderate changes, and CIN 3 is severe changes. CIN 1 can heal independently but CIN 2 & 3 can turn into cervical cancer. Often, changes in cervical cells are related to persistent infection with human papillomavirus (HPV). Thus, treatment for these changes can involve both conization and vaccination against HPV.

If all abnormal tissue is contained in the excised specimen, then conization is both a diagnostic and therapeutic procedure. If not all of the abnormal tissue is excised, then further treatment will be determined with the OBGYN. Both LEEP and CKC have shown equal effectiveness, so the decision for which procedure is often based on physician comfort with each procedure or other clinical considerations. CKC is performed with a scalpel and one advantage to this procedure is that the margins of the excised tissue will be free from thermal damage that would be present in the excised tissue from a LEEP.

Anatomy- The cervix connects the uterine cavity to the vagina. The cervix can be viewed by placing a speculum in the vagina. The part of the cervix that can be directly viewed upon placing a speculum in the vagina is the ectocervix. The beginning of the endocervix is called the cervical os. The endocervix leads from the vagina into the uterine cavity. The are where the columnar epithelium of the endocervix and the squamous epithelium of the ectocervix meet is called the transformation zone or the squamocolumnar junction (SCJ). This is the area of the cervix that is most susceptible to HPV infection and is where the vast majority of cervical precancers and cancers arise. This is the tissue that is sampled during a pap smear as a screening test to find abnormal cells or the presence of an HPV infection.

The cervix receives its blood supply from branches of the uterine arteries.

Contraindications- Severe inflammation of the cervix, termed cervicitis. Pelvic inflammatory disease. Anticoagulation. Pregnancy is a relative contraindication, meaning that decisions of whether to perform the procedure in pregnant patients would be made on an individual basis.

Procedure- speculum placed and vagina is prepped using antimicrobial scrub or iodine. Draping is placed to maintain a sterile surgical field. Some physicians may choose to drain the bladder using a catheter. The speculum will be placed and the cervix visualized. The tissue is then excised from the cervix. The tissue will include the transformation zone and will be shaped like a cone, as the procedure name suggests. The physician will ensure hemostasis has been achieved prior to removing the speculum and ending the procedure. Typically the physician will place a suture at the 12 o'clock region of the excised tissue to serve as a reference point during histological examination.

Complications- CKC procedure's most common complication is bleeding either during or within a few weeks after the procedure. Infection is a very rare complication. Cervical stenosis. Cervical insufficiency. The data regarding risk of preterm birth in future pregnancies is mixed, however it is generally accepted that for patients desiring to carry future pregnancies, limiting the amount of cervical tissue that is excised is best option to limit this risk. However, taking less tissue does produce increased risk that the margins of the excised specimen will be positive, so the decision on how aggressive of an excision is preformed must be discussed between patient and physician.

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