Description of treatment procedures

LEEP

What does it mean?

LEEP are the initials for Loop Electrosurgical Excision Procedure. This procedure is also referred to as LLETZ (Large Loop Excision of the Transformation Zone). It is the excision of the transformation zone tissue by using an electrical loop. The Loop is made of a thin wire, with a high-frequency current running through it. Thanks to the current running through it, the wire loop cuts through the tissue and removes it.

Does the LEEP procedure require general anesthesia?

No general anesthesia is required normally, because the procedure is usually well-tolerated with local anesthesia. General anesthesia is administered when there are anatomical particularities (e.g. a displaced cervix), and access to the surgical field is difficult. Also, in cases where the lesions cover a large area and extend to the vaginal vaults or when curettage is also necessary.

How is the procedure performed?

• The patient lies in the gynecological examination position.
• The doctor inserts the speculum into the vagina (like when performing a Pap test) and opens the vaginal walls to have visual access to the surgical field. He cleans the vagina with normal saline and antiseptic solution.
• The doctor then inspects the cervix through the colposcope, after using an acetic acid solution, and if necessary, an iodine solution called lugol. He identifies the lesion areas and the transformation zone, i.e. the part of the tissue that must be removed.
• Local anesthesia is performed on the cervix, using a thin dental needle.
• The loop size is chosen, depending on the anatomical position of the lesions and the size of the transformation zone.
• The loop is connected with the electrodiathermy machine and the current is activated by the doctor as the loop moves, dissects and removes the tissue.
• The tissue with the lesions is usually removed in one go, i.e. by passing the loop once over it. However, in patients with extensive lesions, a second passage of the loop may be required.
• After the tissue is removed, the bleeding areas are identified and cauterized with electrodiathermy. The procedure does not require hospitalization of the patient. Hospitalization is required only in a few highrisk cases, when the doctor deems it necessary.

COLD-KNIFE CONIZATION

What is it?

It is the excision of a cone-shaped part of the cervix with a surgical scalpel.

When is it performed?

Cold-knife conization is very limited nowadays due to the wide-spread use of the LEEP procedure.

A cold-knife conization is performed:

• When there is suspicion of adenocarcinoma.
• In cases of high-risk lesions that extend high into the cervical canal.
• If smears of the cervical canal reveal serious lesions that were not detected by the colposcopy.

How is the procedure performed?

The patient is admitted to the hospital. The procedure is done under general anesthesia. The cervix is cut with a scalpel and a cone-shaped part is removed, including the transformation zone and part of the cervical canal. Hemostasis is performed, and sutures are placed for the anatomical restoration of the trauma.

What are the procedure's risks?

The risks from a conization are:

• Bleeding
• Inflammation
• Trauma to adjacent tissues and the vagina
• Fertility problems
• Stenosis of the cervical canal
• Increased chances of premature birth in future pregnancies

LASER CONIZATION

What is it and what are its advantages?

A focused laser beam is used in laser conization instead of a scalpel. The laser beam (carbon dioxide) dissects the cervical tissue, just like the scalpel. But it has the advantage that at the same time small vessels are cauterized and the bleeding is reduced. The beam is directed onto the tissue by a special control pad attached to the colposcope. The doctor views the surgical field through the colposcope. A significant advantage of this method is that it can be done under local anesthesia.

In which cases is it preferred?

First of all, the hospital must have the laser device available (which is very expensive). This procedure also requires training and experience of the doctor that will perform it.

With this technique, the doctor may remove with precision the part of the tissue with the lesions and modify the shape of the excision. For example, he may remove a part of the cervix that is not cone-shaped but cylindrical (this is done when the transformation zone extends high up into the cervical canal).