Overview of Cold Knife Conization of the Cervix
Cervical conization is a surgery that doctors use to find and sometimes treat a condition called cervical dysplasia, where abnormal cells are found on the cervix. During a cervical conization or ‘cone biopsy,’ a cone-shaped part of the cervix that includes the area where abnormal cells are found (the transformation zone) and any suspicious lesions is removed. This sample is studied later in a lab.
If all the abnormal cells are found and removed during this process, the procedure can be considered both a way to diagnose and treat the issue. There are different ways to perform a cervical conization, such as using a scalpel in a cold knife cone (CKC), using a laser, or using an electric wire loop in what’s called loop electrosurgical excision procedure (LEEP) or loop excision of the transformation zone (LLETZ).
Doctors usually perform this kind of surgery when they need a tissue sample to study in a lab. This is often the case when there are conflicting results from a cervical screening and biopsy, severe cervical dysplasia, or when the transformation zone can’t be seen completely. Out of the different ways to perform cervical conization, LEEP and CKC are the most common, and both are effective at both diagnosing and treating the issue. It’s up to the doctors to choose the right method based on each patient’s situation. CKC is done with a scalpel and usually requires general or local anesthesia. It’s often thought to provide a bigger sample and cause less thermal damage to the edges of the sample than other methods.
Doctors need to understand the right cases to consider using CKC in, and they also need to understand the risks, benefits, and potential complications of the procedure. They also need to know the right way to perform it. These doctors need to work with a team of other healthcare professionals to care for patients who have cervical dysplasia and who are having a CKC procedure. This team-based approach can lead to better outcomes for patients.
Anatomy and Physiology of Cold Knife Conization of the Cervix
The cervix is a small, cylinder-shaped part of the lower uterus, linking the uterus to the upper part of the vagina. The part of the cervix that extends into the vagina is called the ectocervix, and its surface is covered in squamous epithelium, which is a kind of tissue. The entrance from the vaginal canal into the ectocervix is known as the external cervical os.
On the inside, the cervix has a passageway called the endocervical canal, connecting the uterus to the vagina. This canal is lined with columnar glandular epithelium, another type of tissue. The area where the squamous and glandular tissues meet is called the squamocolumnar junction, or transformation zone.
Because the ectocervix is exposed to the acidic environment of the vagina, the glandular tissue is continually replaced by squamous tissue. This replacement area, the transformation zone, is important because it’s where changes can occur that may lead to cancer. This region is particularly prone to infection by the human papillomavirus or HPV, a common sexually transmitted infection that can lead to changes in cervical tissue.
The cervix receives its primary blood supply from branches of the uterine vessels, entering the cervix on either side. It is controlled both by the sympathetic nerves, which prepare your body for intense physical activity, and the parasympathetic nerves, which relax your body and slow many high energy functions. Interestingly, the cervix doesn’t feel pain from cutting or burning, and minor procedures can often be performed with minimal anesthesia. However, it is sensitive to stretching.
Why do People Need Cold Knife Conization of the Cervix
Cone biopsy (CKC) is a type of surgery that doctors usually carry out when they need a tissue sample to study under a microscope. This procedure is often done when:
- The squamocolumnar junction (SCJ) of the cervix cannot be adequately seen.
- Cell test results show abnormalities (like cervical intraepithelial neoplasia or CIN 2+, CIN 3+ or adenocarcinoma in situ or AIS).
- There seems to be a disagreement between the initial cell test and the tissue biopsy results.
- The examination of the cervix using a special microscope, called a colposcope, reveals an abnormal tissue (dysplastic lesion) extending into the cervical canal that can’t all be seen.
In addition, women over 25 years may have this surgery in certain situations:
- Persistent abnormal but not yet cancerous cells (atypical squamous cells) that can’t rule out serious abnormalities or CIN 1 on a cell test for 2 years.
- Persistent serious abnormalities on a cell test for 1 to 2 years.
- Results from a previous tissue inspection show these abnormal cells (CIN 2+) on the edges of the tissue sample.
- An instrument used to scrape the inner surface of the cervix (endocervical curettage) demonstrates these CIN 2+ cells.
A CKC procedure might be favored over other treatments for patients with a high risk of cervical cancer, where it’s important to keep the sample margins intact. Fragmenting a sample is to be avoided, as it’s been related to higher rates of unclear margins, i.e., edges of the tissue sample where the abnormal cells are found. Recent data suggest that abnormal cells extending to the edges of the tissue sample are linked with an increased risk of recurrence. So, it is recommended to have follow-up tests like cytology, HPV testing, and colposcopy for such cases.
There is some evidence that for patients wishing to preserve their fertility, a cervical cone biopsy may be used to treat early-stage cervical cancer (Stage IA1 squamous cell carcinoma), along with checking for cancer in the lymph nodes.
When a Person Should Avoid Cold Knife Conization of the Cervix
There are several reasons why a person may not be able to undergo a CKC, which stands for Cold Knife Conization, a surgical procedure to remove a small, cone-shaped part of the cervix:
- If a person has severe inflammation of the cervix, also known as cervicitis.
- If a person has Pelvic Inflammatory Disease, which is an infection of the reproductive organs.
- If a person is taking blood thinning medication and it can’t be safely adjusted. This condition is referred to as uncorrected anticoagulation.
Pregnancy also complicates the CKC procedure and is therefore considered a relative contraindication. A doctor might only consider this procedure if there’s a strong suspicion of invasive cervical cancer. But, this should only be performed by an experienced clinician because of the increased risk of bleeding and pregnancy problems. If for any reason there’s not enough cervix to remove, the CKC procedure might not be possible. Alternately, for those who are not good candidates for surgery, the doctor might recommend a procedure performed in the clinic that does not require general anesthesia.
Equipment used for Cold Knife Conization of the Cervix
The CKC procedure, also known as a cone biopsy, is a surgery that happens in an operating room. You’ll likely be put to sleep for the surgery, but it’s possible you’ll instead get medicine that numbs only part of your body. The tools your doctor might use include:
* Candy cane or Allen stirrups, which help keep your legs in the right position.
* A colposcope, which uses a special vinegar mixture or Lugol solution to make abnormal cells on your cervix more visible.
* A straight catheter to empty your bladder.
* A weighted speculum and a right-angle retractor that help your doctor see your cervix more clearly.
* A single-tooth tenaculum, which is a clamp to hold your cervix steady.
* A vasoconstrictive solution, like vasopressin, which narrows blood vessels to reduce bleeding, but not used in people with conditions like heart disease.
* A scalpel on an angled handle or a long knife to make the incision.
* Long-handled or Allis forceps, which are clamps to hold tissue.
* Long-handled scissors, for cutting tissue.
* A special type of suture, a medical “thread”, that is slow to be absorbed by your body. It’s used with a Heaney needle driver, a tool to help handle the needle during suturing.
* A Bovie cautery tool, to stop bleeding by burning and sealing the blood vessels.
* Monsel’s solution, a medication to help stop bleeding.
And if needed, an endocervical curette, a tool to scrape the inside of the cervical canal.
Who is needed to perform Cold Knife Conization of the Cervix?
In a Closed Kinetic Chain (CKC) procedure, there is a team of professionals involved.
The first person is the primary surgeon, who is the main doctor in charge of the surgery. They are the ones who will perform the operation itself.
Next, we have the anesthesia personnel. These are the professionals who are in charge of making sure you are comfortably asleep and don’t feel any pain during the surgery.
Apart from these, there is the operating room surgical technician. This person is in charge of preparing the necessary tools and supplies for the surgery.
Finally, there is the operating room nurse circulator. The nurse circulator takes care of you before and after the operation. They also assist the surgeon and help ensure everything goes smoothly during the surgery itself. All these people work together to make sure the procedure goes as safely and smoothly as possible.
Preparing for Cold Knife Conization of the Cervix
CKC surgeries are often done while the patient is asleep from anesthesia, or the area being operated on is numbed, so they don’t feel any pain. After this, the patient is positioned with their legs raised and supported by specially designed supports, often referred to as candy cane or Allen stirrups. The vagina area is cleaned using a special soap, called Hibiclens, or a solution called povidone-iodine, to prevent any infection.
The patient is then covered with sterile drapes, or cloths, to maintain cleanliness during the surgery. Sometimes the bladder is emptied using a small tube, but some doctors prefer to leave it full, depending on the circumstances.
According to the American College of Obstetricians and Gynecologists, it’s common practice to give a patient a single dose of antibiotics before the procedure to prevent any infection. However, some research indicates that these antibiotics might not always be beneficial for certain types of procedures.
In some cases, a procedure called colposcopy may be performed in the operating room to help the doctor see any abnormal areas in the cervix. This involves using a special solution that highlights these areas. Additionally, a drug called Vasopressin may be injected into the cervix to help reduce bleeding during the surgery as it causes the blood vessels to contract or tighten.
How is Cold Knife Conization of the Cervix performed
A CKC, or cone biopsy, is a medical procedure used for diagnosis or treatment by removing a cone-shaped piece of tissue from the cervix. Your doctor firstly needs a clear view of the cervix, which is the lower part of your uterus. They do this by placing a special device called a speculum into your vagina. To see the cervix clearly, a tool called a right-angle retractor is used to lift the front wall of your vagina.
Your doctor may then use a tool to gently hold the front lip of your cervix still. In order to control bleeding during the procedure, stitches can be placed at the spots where the cervix connects to the vagina. These are sometimes referred to as stay sutures. However, some research suggests these stitches may not always be necessary. Your doctor might also choose to inject a solution that helps to limit bleeding into specific points around your cervix.
Next, the doctor cuts around the cervix, starting from the back part to prevent blood from blocking the view of the surgical area. A specific technique is used to remove the cone-shaped piece of the cervix. This piece includes the entire abnormal area and the surrounding tissue. Special tools are used to lift the area that is cut, while taking care not to damage surrounding tissues. Eventually, the base of the cone is cut off with precise scissors.
Your doctor may then scrape the remaining part of your cervix to ensure no abnormal tissue is left behind. This step isn’t always necessary and depends on the individual’s condition or risk factors, such as being past menopause or experiencing abnormal bleeding. It’s important to stop any bleeding after the procedure, so your doctor might use a heating device called a cautery, stitches, or a solution that helps clotting.
Last but not least, a reference mark will be placed on the tissue sample by using a stitch at the top position so that it can be easily examined by a pathologist later.
Possible Complications of Cold Knife Conization of the Cervix
The biggest potential issue after you have a CKC (cold knife conization) procedure, which is a type of operation used to remove abnormal tissue from the cervix, is bleeding. This could happen during the surgery or in the first 2 weeks after. Different techniques can be employed in case bleeding happens during the operation, such as applying a special paste called Monsel paste, using a chemical known as silver nitrate, packing the area, or sewing up the site. After the surgery, severe bleeding may occur for some patients, the range is broad, 2% to 17%, which depends on the study referred to. In rare cases, the patient may need to return to the operating room so that the surgical site can be cauterized (burned to stop blood flow) or stitched up again to stop the bleeding.
Post surgical infections are pretty rare after a CKC procedure, only happening in about 1% of patients. If that happens, the usual treatment is to take oral antibiotics. A couple of more delayed complications that might happen after this operation are cervical stenosis, which is a narrowing of the cervical canal, and cervical insufficiency, which is when the cervix is weaker than normal. If the surgery involves cauterization or removal of a large portion of the cervix, cervical stenosis should be monitored after the operation. Cervical stenosis can be managed by a procedure that widens the endocervical canal. Usually, postmenopausal women are those who tend to have cervical stenosis more often.
Information is varied when it comes to the link between having an excisional conization procedure, such as a CKC, and the risk of preterm delivery and death around the time your baby is born. Formal trials haven’t been conducted yet. However, most studies suggest that a CKC procedure might lead to a greater risk of preterm delivery and possible infection in the water sac surrounding the baby compared to the LEEP (Loop Electrosurgical Excision Procedure), mainly because more cervix is cut out in the CKC. A recent study found that if the amount of cervix cut out was 18 mm or more, there was an increased risk for early-onset neonatal sepsis (an infection in the newborn) and water sac infection. However, most other studies made the same conclusion that the larger the amount of cervical tissue removed, the higher the chance of early labor. Having more than one conization procedure also raises the risk of preterm birth. Because of that, If you’re planning to get pregnant in the future, it’s really important that your doctor tries to keep as much of the cervical tissue as possible during the conization procedure.
What Else Should I Know About Cold Knife Conization of the Cervix?
Cervical Intraepithelial Neoplasia (CIN) 2 or 3 is a condition involving abnormal cell changes in the cervix. The Cold Knife Cone (CKC) is a type of surgical treatment for this condition, which exhibits different recurrence rates based on factors such as age, initial disease severity and the status of the tissue margins (edges) removed during surgery. On average, this rate is about 1.4%.
Among other surgical techniques used to treat CIN, the CKC method is associated with the lowest rate of the disease coming back. This procedure, which requires an operating room, provides the most complete tissue sample for laboratory analysis. Cleaner and well-defined tissue margins are important as positive margin status—when there are still abnormal cells at the edge of the removed tissue—is linked to higher rates of disease recurrence.
One way to prevent CIN from recurring is by vaccination against the Human Papillomavirus (HPV), which is known to cause this condition. A 2020 study showed significantly lower rates of recurrent or persistent high-grade squamous intraepithelial lesions (HSIL), another term for severe cervical cell abnormalities, in those who received HPV vaccination after surgery.