LEEP Technique

The cervix is first evaluated colposcopically with 5 percent acetic acid. Lugol's solution also may be applied to aid in visualizing the lesion, especially if intracervical anesthesia is used. A return electrode is attached to the patient, usually on the upper leg or under the buttocks.

Anesthesia may be obtained using a cartridge syringe system (Campion syringe or dental syringe), or a thumb syringe with needle extender, spinal needle, or Pototchy needle. Use a 26 to 32 gauge needle (the smaller the better) with 2% Xylocaine with 1/100,000 epinephrine. The infiltration of the lidocaine solution should be very superficial, and is usually applied at the 12, 3, 6, and 9 o'clock positions or into the center of each quadrant. Consider applying 20% benzocaine solution before injection and adding between 1:1 and 1:4 of a 8.3% sodium bicarbonate solution to the lidocaine to decrease the amount of pain with injection.

For treatment of SIL lesions, a loop should be chosen that allows excision of the entire transformation zone in one or two passes without major risk of contact to the vaginal side wall. Ring forceps held against the cervix may be a useful size referent. The amount of current used depends on the generator and the loop size. The relative cutting power needed is proportional to the amount of wire that comes into contact with the cervix. As the surface area of the cut increases, the amount of power needed to make the cut also increases. Therefore, larger or deeper cuts and larger loops require higher current settings. Drier or more keratinized skin also requires higher current settings. Setting the current too high results in increased thermal damage and increased risk of unintentional burns. A blend 1 mode is most commonly used for cutting, with a setting of around 35 to 65 watts. A coagulation setting of around 40 to 55 watts is typical.

The loop is attached to a pencil-like base that is controlled with a finger switch or foot switch. To excise tissue, the loop is placed a few millimeters above the cervix and about 5 mm lateral to the lesion or edge of the transformation zone. Current is applied before the loop contacts the cervix. If current is applied after contact is made, significant thermal injury will occur and the quality of the cut will be poor. The loop is pushed into the tissue to a depth of 5 to 8 mm since maximal crypt involvement by CIN is approximately 5 mm. 26 Then it is drawn slowly through the tissue until the loop is approximately 5mm past the edge of the transformation zone. It is then removed perpendicularly (see Figure). The average cutting time is approximately 5 to 10 seconds. The excision should be done in a single smooth motion with continuous current. Stopping the cutting current before the excision is completed causes extensive thermal injury and may damage the loop. An endocervical curettage is recommended by most experts at this point. 4 Superficial fulguration is applied to the entire crater. Monsel's solution is also applied to the bed and may reduce late bleeding. 27

LEEP conization (also known as the "cowboy hat" procedure) can be used when a lesion extends into the endocervical canal. The cervix is anesthetized as above except that if intracervical anesthesia is used, an additional 0.5 to 2cc of Lidocaine is infiltrated at 6 and 12 o'clock around the os to a depth of approximately 1 cm. The external os and distal endocervical canal can be excised to 9 to 10 mm, usually with a 10 mm x 10 mm loop or square electrode. Orientation of the specimen is unnecessary since the deep os margin will be lined with columnar epithelium and the shallow margin with squamious epithelium. The rest of the transformation zone then can be excised in the usual manner. Some physicians advocate removing the external transformation zone first and then excising the os. When using this method, the orientation of the central os cut must be carefully marked or the pathologist will be unable to tell which end is from the deep margin and whether or not the deep margin is involved with dysplasia. With either method, the end result is similar to a cold knife conization performed in the operating room.

Patient instructions should include prohibition of sexual intercourse, douching, and tampon use for two to four weeks. A discharge is expected for two to three weeks, but may last up to six weeks. The patient should report any significant bleeding or malodorous vaginal discharge. Follow-up pap smear with or without colposcopy should be scheduled for 4 to 6 months.

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