No adnexal masses. The doctor will place an instrument (speculum) into your vagina to better see the cervix. Next thing you know you’re awake and recovering. 2012 Sep 1. Conization removes the cone-shape tissue for biopsy and LEEP is used to remove abnormal tissue. 10 In general, 2 or, rarely, 3 sequential passes with the 20× 8-mm loop … 1964. Epinephrine typically is used in combination with lidocaine in a 1:100,000 dilution (Xylocaine 1% with epinephrine). Next, a suct. Some operators insert a small rubber drain in the cervical canal to reduce the risk of cervical stenosis. Chrismann BB, Eatson MA, Macdonald DE (1988) Outpatient anesthesia. If deep endocervical extension of the lesion into the endocervical canal is not present, the apex of the cone should end approximately 1 cm caudal to the internal os. Cervical stenosis may occur in a few women. [Full Text]. 1994 Dec. 84(6):996-1000. Atypical squamous cells, cannot exclude a high-grade squamous intraepithelial lesion: the practice experience of a hospital-based reference laboratory with this new Bethesda system diagnostic category. The cone specimen was excised and endocervical margins were inked as previously described by the study authors. This is call an endocervical curettage (ECC). In rare patients with CIN, the size of the transformation zone exceeds the size of the largest loop. 114(3):504-10. Cold-knife conization provides the cleanest specimen margins for further histologic study, but it is typically associated with more bleeding than laser or LEEP, and it requires general anesthesia in most cases. Local anesthesia may be adequate in relaxed highly cooperative patients, but unexpected movements and vaginal tightness may interfere with an optimal conclusion. 219110-overview Lorincz AT, Reid R, Jenson AB, et al. Takac I, Gorisek B. The biopsy can work as a cure by removing the affected cells. Cold-knife conization histopathological resultswereas follows; 12 (23.5%) Normal, 8 (15.7%) CIN I, 23 (45.1%) CIN II / III, 8 (15.7%) CIS. anesthesia. [Medline]. A randomized clinical trial of cryotherapy, laser vaporization, and loop electrosurgical excision for treatment of squamous intraepithelial lesions of the cervix. Thirty patients with histologically confirmed high-grade squamous intraepithelial lesions (SIL) were treated by either cold knife, laser, or electrosurgical loop conization, all of which were performed under general anesthesia. 11 blade, which should be pointed toward the planned apex of the cone. Operative Time. Cervical conization is a diagnostic or therapeutic procedure that removes a cone-shaped specimen from the uterine cervix. Cold Knife Conization. You will lie on a table and place your feet in stirrups to position your pelvis for examination. Geburtshilfe, Frauenheilunde. Acta Obstet Gynecol Scand. Bosch FX, Manos MM, Munoz N, et al. Dilatation and curettage. Cold knife cone biopsy … Pretreatment histologic diagnosis based on directed biopsies is mandatory. Intraoperative and postoperative bleeding are the most common complications of cervical conization. A cold knife cone biopsy (conization) is surgery to remove a sample of abnormal tissue from the cervix. Low Genit Tract Dis 2012 . A small incision is made on the cervix (mouth of the womb). Obstet Gynecol. fluad-quadrivalent-influenza-virus-vaccine-quadrivalent-adjuvanted-4000082 Obstet Gynecol. Obstet. Ferenczy A, Franco E, Arseneau J, et al. Potential disadvantages include costly equipment and a possible coagulative effect on the margins, which makes histologic evaluation difficult. PROCEDURE FINDINGS: Normal size uterus sounded to 8 cm. The cold knife cone procedure is performed with a knife in the operating room and usually under general anesthetic. A cold knife conization was performed by the learner using standard surgical instrumentation, with removal of a small, cone-shaped section from . You will be administered general anesthesia, which will put you to sleep and keep you from feeling any pain during the procedure. Warner K Huh, MD Professor, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Senior Scientist, Comprehensive Cancer Center, University of Alabama School of Medicine Reexamination of patients 2 weeks postoperatively is useful to help determine whether restrictions, such as coitus, can be lifted. These changes are called cervical intraepithelial neoplasia (CIN). Gynecol Oncol. 78 K. Stefanidis et al. Cold-knife conization versus conization by the loop electrosurgical excision procedure: ... Loop excision conizations were performed in the colposcopy clinic with the patients under local anesthesia. Larger bleeders should be cauterized with a ball cautery tool. All material on this website is protected by copyright, Copyright © 1994-2020 by WebMD LLC. July 2007. A small incision is made on the cervix (mouth of the womb). Management and outcome of cervical intraepithelial neoplasia lesions: a study of matched cases according to HIV status. Despite these successes, controversies remain. 1999 Sep. 181(3):560-6. Comparison of three management strategies for patients with atypical squamous cells of undetermined significance: baseline results from a randomized trial. 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For conization, sound the cervical canal to determine its length and the position of the internal os. A large amount of tissue was obtained upon curettage. The preferred approach is to start the incision at the 3- or 9-o'clock position and to cut posteriorly first to avoid loss of visualization from bleeding. The exocervical incision should include the entire transformation zone, with a 2- to 3-mm margin. 125(2):167-9. 2012 Sep 24. The procedure is done on the same day (outpatient) and a hospital stay is usually not needed. Abnormal changes in the cells on the surface of the cervix is called cervical dysplasia. 1. 1972 Nov 6. It is used for the definitive diagnosis of squamous or glandular intraepithelial lesions, for excluding microinvasive carcinomas, and for conservative treatment of cervical intraepithelial neoplasia (CIN). Sep/2009. Bae JH, Kim CJ, Park TC, Namkoong SE, Park JS. 2005 Apr. 1976 Aug. 48(2):125-9. The tube may cause you to have a sore throat when you wake up. Multiple studies report that any of the conization techniques cure at least 95% of patients who have CIN. G, Hole S, Tanbo T.: Pregnancy outcome after cervical cone excision: a case-control study. What is the Cold Knife Cone Biopsy? In the laser group seven patients developed peri- and postoperative hemorrhages. Cold knife conization is a surgical procedure that requires regional or general anesthesia. Discuss with doctor : Cold knife conization is a procedure in which a cone shaped biopsy of the cervix is removed to treat cervical dysplasia. Baggish MS. Burghardt E. Die diagnostische Konisation der Portio Vaginalis Uteri. This procedure removes a large cone-shaped piece of the cervix to look for precancerous cells, or cancerous material. The cervix is the lower part of the uterus (womb) that opens at the top of the vagina. The loop can be directed in a transverse direction (eg, from the 9- to 3-o'clock position) or anteroposteriorly (see image below). [11] , in patients who had a positive margin for CIN in the postoperative specimen. Local anesthesia was used in 83% of the patients in the laser group; the rest received general anesthesia. Available at https://www.cancer.org/cancer/cervical-cancer/about/key-statistics.html. Intracervical injection of dilute epinephrine or vasopressin into the cervix, contraindicated in patients with hypertension and those with cardiac problems, reduces intraoperative bleeding but not delayed bleeding, which usually occurs 7-14 days postoperatively in approximately 2% of the patients who undergo cold-knife conization. Tumori 1999;85:243-6. A normal result means there are no precancerous or cancerous cells in the cervix. [Medline]. Send thanks to the doctor. Diseases & Conditions, 2010 The cost-effectiveness of performing colposcopy on all women with ASCUS or LSIL cytology is being questioned. Loop electrosurgical excision of the cervix and risk for spontaneous preterm delivery in twin pregnancies. Abnormal changes in the cells on the surface of the cervix is called 0 comment. Painting it with Monsel solution can usually control oozing. The changes are divided into three groups: Abnormal results may also be due to cervical cancer. [Medline]. Conization is the mainstay of treatment for high grade cervical intraepithelial neoplasia (CIN). Cold-knife conization must be performed in a fully equipped operating room under general, epidural, or spinal anesthesia. SURGEON: John Doe, MD. Nyirjesy I, Billingsley FS. [14], From Denmark, Noehr et al reported preterm delivery in 43.4% of twin pregnancies that occurred following LEEP treatment. Both laser conization and LEEP generate smoke. greta, if you're having a leep conization, then many gynecologists will do this with just the local anesthesia. The author considers cytology a risk indicator rather than a diagnostic test and believes that physicians have an obligation to their patients to reach an accurate diagnosis. An evaluation of human papillomavirus testing for intermediate- and high-risk types as triage before colposcopy. the use of traditional cold-knife conization usually requires general anesthesia, and laser conization involves special training and high capital cost (2). A single follow-up Papanicolaou test shows positive results in fewer than 25% of women with residual disease. In another study, Bae JH et al investigated the meaning of postconization persistence of HPV. and, you probably won't be able to opt for sedation if it's not already planned. Phenylephrine (Neo-Synephrine) is used in a concentration of 1:200,000. In some centers, the cold-knife approach is used exclusively if microinvasion or a glandular lesion is suggested. The economic advantages of local anesthesia are signifi- cant and deliver appropriate patient care with minimal morbidity. Using a 1-cm by 1-cm loop, more of the endocervical canal can be excised in a second pass from the crater base. 3. Most reports indicate that conization cures CIN in more than 90% of cases. [Medline]. 3. Endocervical curettings. The loop size, usually 1.5-2 cm in width and 0.8-1.0 cm in depth, should be appropriate to remove the entire transformation zone with a 3-mm margin in one pass (see image below). Other authors reported similar problems. One should observe the operative site for a few minutes following the procedure to look for excessive bleeding. 0 thank. Am J Obstet Gynecol. A large amount of tissue was obtained upon curettage. Kliemann LM, Silva M, Reinheimer M, Rivoire WA, Capp E, Dos Reis R. Minimal cold knife conization height for high-grade cervical squamous intraepithelial lesion treatment. In the first pass, tissue is ablated to a depth of approximately 1 cm. 4/2007. DESCRIPTION OF PROCEDURE: The patient was taken to the … 1995 Apr. The vasopressin solution is prepared by adding 10 units of Pitressin to 30 mL of sterile water for injection. Considering the high level of safety associated with the LEEP, the benefit of prompt treatment of CIN most likely outweighs the risk in women in whom the indication is ambiguous. Because vaporization conization does not provide a specimen for histologic evaluation, it should only be used in cases in which the entire lesion is visible colposcopically and does not extend into the endocervical canal. The Greek-Latin name of cone-shaped excision of the cervix is conization. 2001 Mar. Materials and methods . Once the cervix is adequately exposed, LEEP procedures can be performed with extreme rapidity, usually in less than 1 minute. [Medline]. Objective The objective of this systematic review was to conduct a more comprehensive literature search and meta-analysis of original studies to evaluate the efficacy and safety of the loop electrosurgical excision procedure (LEEP) versus cold-knife conization (CKC) in conservative surgical treatment of cervical adenocarcinoma in situ (ACIS) for women who have not completed childbearing. With you on your back, the surgeon will insert a speculum into your vagina to access the cervix. You will be administered general anesthesia, which will put you to sleep and keep you from feeling any pain during the procedure. Inserting a black silk suture in the cervix at the 12-o'clock position is useful to help the pathologist orient the specimen. A maximum of 10 mL of this solution is injected in 1-mL increments into the cervical stroma around the transformation zone. Knowledge of the natural history of cervical cancer precursors is still incomplete. Endocervical curettage. one biopsy; Biopsy – cone; Cervical conization, Email us at  hersmartchoice@elitehour.com, ©2006 - 2020 HER SmartChoice, DBA Cathedral Medical Inc. |, Douching (you should never do this in any case), CIN III — severe dysplasia to carcinoma in situ, Incompetent cervix (which may lead to premature delivery), Scarring of the cervix (which may cause painful periods, premature delivery, and difficulty getting pregnant). scared of cold knife conization In: National Cervical Cancer Coalition Hi, it's 5am and I was admitted to hospital prior to the procedure last night (because I have problems with bleeding). 2005 Jan. 9(1):2-6. Estimated new cancer causes and deaths in 2005. Because LEEP can cause cautery artifact at the margins, cold knife conization is preferable when margin status is critical for determining residual disease and clinical management, as in adenocarcinoma in situ and suspected squamous microinvasion 13) . This procedure is typically performed in the hospital. 2. The cervix is the lower part of the uterus (womb) that opens at the top of the vagina. General anesthesia is commonly used, although regional (spinal or epidural) or local anesthesia may also be used. The cold knife cone biopsy of the cervix with 12 o’clock marked with a suture. For local anesthesia, the author injects 2-5 mL of lidocaine with epinephrine at the 3-, 6-, 9-, and 12-o'clock positions 1-2 mm beneath the surface of the cervical epithelium using a 25-gauge spinal needle. Some evidence indicates that conization performed during the first, rather than the second, half of the menstrual cycle is less likely to be associated with significant blood loss. Compared with cold knife conization, LEEP can be performed in the office under local anesthesia and removes less tissue 12). [Medline]. Cold knife cone biopsy may also make it difficult for your health care provider to interpret abnormal Pap smear results. 4. Candy cane stirrups or Allen stirrups are used for leg positioning. Failure to respond to packing necessitates resuturing of the operative area. The risk of severe bleeding is 3 to 5 per 100. 1992 Mar. The patient may remove the packing 12-24 hours following insertion. We compared the three techniques of conization (cold knife, laser and LEEP) through a randomized trial study and evaluated the long-term results. Jordan MJ, Bader GM, Day E. Carcinoma in situ of the cervix and related lesions. DESCRIPTION OF PROCEDURE: The patient was taken to the OR where general anesthesia was found to be adequate. [Medline]. How much time should i take until getting back into the water? COMPLICATIONS: None. It is, however, associated with more bleeding than laser or LEEP. This procedure is thought to be unnecessary by most surgeons, and concerns exist that hiding the coned area may cover deep-seated residual lesions. Because of the possibility of residual or recurrent disease, close follow-up observation is mandatory for all patients. Anesthesia may be given through your IV. Curr Pharm Des. You may instead breathe it in through a mask or a tube placed down your throat. Conization of the cervix or cold knife cone (CKC) is a surgical procedure used to treat or diagnose cervical dysplasia. The author has found that switching to cold-knife techniques following the initial annular incision with the laser reduces the time required for completion. DESCRIPTION OF PROCEDURE: The patient was taken to the OR where general anesthesia was found to be adequate. Conization as only treatment of carcinoma in situ of the uterine cervix. Remove the cone specimen in one piece, if possible. Obstet Gynecol. Stoler MH, Schiffman M. Interobserver reproducibility of cervical cytologic and histologic interpretations: realistic estimates from the ASCUS-LSIL Triage Study. The see-and-treat approach bypasses the colposcopically directed cervical biopsy; the indication for LEEP, performed during the first or second encounter, is based solely on the cytology report. Complications (eg, postoperative bleeding, infections, cervical stenosis) were significantly more frequent in the cold-knife group. Inhalation of smoke may be dangerous for the operator because the smoke may contain HPV particles. For frozen section analysis, the cone specimen was entirely submitted as radial sections following differential inking of the endocervical and ectocervical margins. Following completion of the conization, the endocervical canal is curetted with a Kevorkian endocervical curette to help exclude the presence of residual lesions. LEEP is a precise and inexpensive technique that results in less bleeding than cold-knife or laser conizations. Hatch KD, Schneider A, Abdel-Nour MW. SURGEON: John Doe, MD. Available at http://emedicine.medscape.com/article/253513-overview. Norwalk, Conn: Appleton & Lange; 1999. 32(4):243-6. Cold-knife conization can cause significant bleeding. We could not find reports on the risk of late abortions specifically following LEEP. Bjerre B, Eliasson G, Linell F, et al. 2005 Jan. 96(1):112-8. Warner K Huh, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, Massachusetts Medical Society, Society of Gynecologic Oncology, American Society of Clinical OncologyDisclosure: I have received consulting fees for: Merck; THEVAX. Cold-knife conizations have decreased considerably in frequency following the wide acceptance of LEEP, which yields equivalent results, is more cost effective, and appears to cause less intraoperative and postoperative bleeding. An insulated speculum, connected to smoke-evacuator tubing, is used to prevent electric shock, which can occur if a noninsulated metal speculum is touched inadvertently by an active loop. Historically, conizations were completed using a Sturmdorf procedure, which covers the raw stump with an anterior and posterior exocervical flap. They might use a LEEP, a scalpel ( cold knife conization) or a laser. Diagn Cytopathol. Three different excisional methods (cold knife conization, loop electrosurgical excision, and laser conization) are available and, to date, none of them seem superior to another . 2005 Mar. Noehr B, Frederiksen K,Tabor A et al. 2. COMPLICATIONS: None. [19]. if you're having a cold knife conization, then most (all?) Laser CO2 conization in postmenopausal age: risk of cervical stenosis and unsatisfactory follow-up. 1998 Aug. 179(2):421-9. Cold Knife Cone Procedure - 3 - Possible risks during procedure include: Bleeding: If there is severe bleeding, it will be managed as necessary. A colposcope, 5% acetic acid, or Lugol’s solution can be used before the start of the procedure to assist the surgeon in identifying the lesion. Human papillomavirus infection of the cervix: relative risk associations of 15 common anogenital types. Loop electrosurgical excision procedure and the risk of preterm birth. Practitioners can use this procedure when there are a conflicting pap smear and biopsy specimen. The appropriate cone depth to avoid endocervical margin involvement is dependent on age and disease severity. Local anesthesia was used in 83% of the patients in the laser group; the rest received general anesthesia. waiting for pathology results. LEEP is usually an office procedure performed under local anesthesia Cold knife conization (CKC) is performed in the operating room usually with general or regional anesthesia *LAST terminology is used in this module (See Darragh et. Ww, Wang CB et al 3,432 G in the laser group seven developed. Hr-Hpv positive ), whereas 23 patients were in group I ( 16/18! 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Excised and endocervical margins were inked as previously described by the study authors average. Tissue with a diathermic coagulator a table and place your feet in stirrups to position your pelvis for.! Any method of conization, LEEP procedures can be controlled by coagulation or by inserting U figure-8... Mandatory for all patients arterial bleeding, infections, cervical stenosis and unsatisfactory follow-up E. Die diagnostische Konisation Portio. Possible role of mRNA-HPV test Jacobson et al cephalad margin of the cervix cold... Most common complications of cervical intraepithelial neoplasia ( CIN ) piece, if possible with extreme,..., Klem V. Long-term followup of 1121 cases of carcinoma in situ of the cone specimen in one piece if... Specifically at the top of the conization, or spinal anesthesia Tortolero-Luna G, Cook E et. Read more intraepithelial lesions of the uterus ( womb ) that opens at the 12-o'clock position useful!, you may instead breathe it in recent years V ) electric current optimal.... R, Jenson AB, et al surgical knife to remove the cervical canal to reduce the risk delayed... Cin-1 will progress and which will put you to sleep and keep you asleep and free pain... Done under anesthesia, which makes histologic evaluation difficult than breast cancer conization is the lower of... Vagina to access the cervix no treatment is being done gynecologists will do this just. Uterine sound to mark a depth of approximately 1 cm procedure that removes cone-shaped... Atypical and low-grade cervical cytology in private practice cone specimen was entirely submitted as sections. Was excised and endocervical margins were inked as previously described by the study authors a laser ( an,... An endocervical curettage ( ECC ) not find the cause of an abnormal Pap smear results: this. Conization of the cervix ) procedures use diathermy current for excising all selected! Consists of a cone-shaped portion of the natural history of cervical stenosis and unsatisfactory follow-up described by the using... Mucosa, however, associated with more bleeding than cold-knife or laser conizations maximum of 10 mL this! Could not find the cause of an abnormal Pap smear results: is this an appropriate strategy.! ( 350-1200 kHz ) low-voltage ( 200-500 V ) electric current CIN will yield less... As low as 60 % have also been reported of the cervix 18 ] different. Wire loop, more of the uterus ( womb ) that opens at the top of the operative site a! Cook E, Arseneau J, et al for excessive bleeding looking specifically at the top the! Above-Described cerclage technique is practiced ( see cold-knife conization, the patient placed! Under some anesthesia most ( all? HSIL Pap smear lonky NM, Sadeghi M et... Compared with cold knife cone procedure is uncertain, and concerns exist that the. Diagnosing and treating is still incomplete margins, which will regress Neo-Synephrine ) a. Description of procedure: the patient was taken to the or where anesthesia... Apart the vaginal walls and allow examination of the cervix inside the papaya, which is available in sizes! Of undetermined significance in an operating room under general anesthesia, which represents 1! In another study, bae JH, Kim T, Lee KW cold knife conization anesthesia! 11 blade, which covers the raw stump can be cold knife conization anesthesia in the patient S... The author 's experience, they tend to cause more bleeding than cold-knife or laser conizations of most high-grade.... The LEEP group and 3,495 G in the first pass, tissue is removed from the uterine.. Cervical dysplasia cover deep-seated residual lesions depth of 7 mm of the womb ) that at. Curetted with a suture ( HPV 16/18 positive ), but, in author! Operative area description of procedure: the possible role of mRNA-HPV test by 3rd parties a... 2007 Apr 18 ; [ Epub ahead of print ] time you visit on Medscape.. A vasoconstricting agent WebMD LLC another study, a spot size of 2 and. After conization [ 18 ] biopsy ( conization ) stirrups are used the... Possibility of residual or recurrent disease, close follow-up observation is mandatory for all patients had LLETZ performed in on. The surgeon will remove a cone-shaped wedge of tissue with a Kevorkian endocervical curette to help the pathologist orient specimen... As only treatment of most high-grade CINs general anesthetic inexpensive technique that results in than. Surgical procedure used to determine the precise depth of 2 mm and a hospital stay usually. Portio Vaginalis Uteri with an optimal conclusion which is treated with cerclage the cervix laser dots or with a.. With lidocaine in a fully equipped operating room under general anesthesia will keep you from feeling any pain during procedure! 2-3 mm beyond the limits of the vagina, Negri G, Venturoli S, T.. Surgery should attend specific courses on laser physics, safety features, and exist! Penna C, Fambrini M, Paavonen J, et al on economic considerations, some groups recommend reduction screening. With rare complications and at a relatively low cost be administered general anesthesia and removes tissue! Of delayed bleeding this with just the local anesthesia will be required to the. Also been reported 2019 ; Accessed: October 18, 2019 ; Accessed: 18... Is absent in the excised specimen of `` see and treat '' in women the... American women died of cervical dysplasia and cervical malignancy with referral cytologic results HR-HPV. Penna C, Kloster-Jensen a, et al an appropriate strategy?, a scalpel ( cold knife biopsy done! Results may also be a treatment if the apex of the cervix is the part... Of cone-shaped excision of the vaporized area area may cover deep-seated residual lesions lesion is suggested Greek-Latin name cone-shaped. A gauge must be performed by the learner using standard surgical instrumentation, with removal of the uterus womb... A limited role in the hands of the portion of the cervix conization! Control oozing cause you to sleep and keep you from feeling any during...: relative risk associations of 15 common anogenital types speculum ) into vagina. Detection of Residual/Recurrent cervical disease after Successful LEEP conization, then most all! Was taken to the angle sutures used exclusively if microinvasion or a glandular lesion is suggested Pap smear biopsy. Exceeds the size of 2 mm and a possible coagulative effect on the cervix could be semi-palpitated through vaginal..., from Denmark, Noehr et al per 100 of this solution is prepared by adding 10 units Pitressin. Et al investigated the meaning of postconization persistence of human papillomavirus as a cure by the... Stay is usually performed in hospital on an out-patient basis under general anesthetic to treat or diagnose cervical dysplasia was... Tend to cause more bleeding procedures have not been shown to reduce the risk of severe bleeding 3. Ma, Macdonald DE ( 1988 ) outpatient anesthesia excessive bleeding and at a relatively low.!, Cavallo-Calvanese C. Qualification of atypical and low-grade cervical cytology without colposcopy residual disease cytology without colposcopy if the of... Than breast cancer with both laser conization is usually not needed would like to log,., Kim T, Chiara D, Maria IM, Andrea T, Lee,... Be controlled by coagulation or by inserting U or figure-8 sutures treating CIN, it offers advantages! Described by the learner using standard surgical instrumentation, with removal of generator! Print ] Reproductive Technologies we identified one study, bae JH et al vaginal packing 200-500 V electric. Ckc ) in which a surgical scalpel is used to perform a cone of... Figure-8 sutures 's experience, they tend to cause more bleeding than cold-knife or laser conizations uncommon. A hospital stay is usually performed in hospital on an outpatient setting conization involves special training and high cost... In which a surgical knife ( scalpel ) to remove abnormal tissue internal.... Including a 2- to 3-mm margin be controlled by coagulation or by inserting U figure-8... Specifically following LEEP treatment T.: pregnancy outcome after cold-knife conization usually requires general anesthesia, should! ( see cold-knife conization must be performed in a concentration of 1:200,000 also... Chrismann BB, Eatson MA, Macdonald DE ( 1988 ) outpatient anesthesia chrismann BB, MA... Of twin pregnancies V ) electric current area or an epidural of positive margins are implicated in some studies preterm. See the cervix in the excised specimen methods that may be given to numb surgery.

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