What is cervical surgery?
Cervical surgery can be investigative or definitive. In some cases cervical surgery can be both investigative and definitive.
- Cervical punch biopsy
- Cervical polypectomy
- Endocervical curettage
- Electosurgical coagulaton to cervical lesion
- Laser to cervical lesion
- Cervical dilatation
- Cervical cerclage
- Cervical cone biopsy
- LLETZ cervix procedure
- Excision biopsy of cervical lesion
- Cervical amputation
A special punch biopsy instrument is used to obtain a specimen or specimens from parts of the cervix. These will be areas thought to represent changes noted in the cervix. These samples are then sent for histological analysis.
Electrosurgery is a group of commonly used procedures that utilize the passage of high-frequency alternating electrical current. Depending on the setting, electrosurgery can be used to cut or to coagulate. Cervical electrosurgery is used to destroy, by coagulation, a previously identified abnormal area of the cervix. This is very effective treatment in appropriate circumstances, however there is no tissue obtained for analysis unless some is obtained through tissue biopsy beforehand.
Cone biopsy of cervix
Cone biopsy is a traditional method of excising a cone of cervix that includes the transformation zone. The technique is also know as ‘cold knife’ cone biopsy as it employs a surgical scalpel. The advantage is that a specimen is obtained for histological analysis and the margins can be examined to check if they are clear of pathology. Additional measures are required to stop bleeding including multiple sutures and electocoagulation.
A polyp sitting on the ectocervix (outer part of the cervix) or seen to be sitting in the endocervix can be removed by avulsion using polyp forceps. Where there is a concern that the polyp might arise from within the endometrial cavity, polypectomy may need to take place after visualisation using a hysteroscope.
Mid-infrared lasers are able to cut and cauterize the tissue at the same time, thus, they are preferred to lasers delivering shorter (better for cutting) wavelengths for areas prone to abundant bleeding such as the cervix. No tissue sample is obtained for histological analysis using this technique so all biopsies will need to have been obtained prior to treatment with the laser.
LLETZ stands for ‘large loop excision of the transformation zone.’ The transformation zone is the area of the cervix where cervical dysplasia (CIN) arises. This is an electrosurgical technique employing a loop of wire at the end of a thin, pencil-like instrument with an electrical current passing through it. The tissue is excised and the thermal energy seals blood vessels at the same time. A specimen is obtained which is then sent for histological analysis. An assessment of the involvement or otherwise of the margins of the specimen will determine whether or not excision of the abnormal area has been complete. Because of the electrocoagulation, there can be some thermal damage at the edges of the specimen.
A special spatula-like instrument called a curette is used to scatch cells from the endocervical area. The sample obtained is sent for histological analysis to screen for abnormal cells within the endocervix which might represent cervical disease or show the presence of endometrial cells being shed into the cervix.
Cervical dilatation is a very common gynaecological procedure performed to facilitate the passage of a hysteroscope through the cervix. In this context it is neither an investigative nor definitive procedure. However, cervical dilatation is performed as a definitive procedure in the much less common scenario of haemato colpos condition where, as a result of cervical stenosis (occurring naturally or after cervical surgery), menstrual blood is not released and thus builds up inside the uterus. The procedure aims to release the obstruction to the flow of menstrual blood out of the uterus via the cervix.
A cervical specimen is obtained in a targeted small area with the aim of biopsy of tissue that can be sent for histological analysis. Sometimes, either deliberately or simply as an outcome of the procedure, when histological analysis is obtained, it reveals that the lesion is fully contained within the biopsy and that the margins are clear. Whether or not further treatment is required is very much dependent on the nature of the lesion excised.
Cervical cerclage is a procedure performed when the cervix has been deemed to be incompetent (i.e likely to open under pressure during pregnancy and before labour begins – typically in the 2nd trimester). Sutures are used to close the cervix and the sutures can be placed through the vagina (transvaginal cervical cerclage) or through the abdomen (transabdominal cervical cerclage). Typically, the sutures are removed when a baby is considered full term — after week 36 of pregnancy. If necessary, the sutures can be removed earlier.
Cervical amputation is a more complex procedure than the LLETZ or cone biopsy procedures. The aim of surgery is to remove all of the cervix and this involves reflection of the bladder off the cervix and plication of the utero-sacral ligaments. Indications for cervical amputation include; elongation of the cervix presenting as a prolapse, part of a Manchester procedure for uterine prolapse and as a stand-alone procedure for very early stage cervical cancer where there is an intent to try and preserve fertility.