The ablative techniques for treating CIN lesions are appropriate only when the extent of the disease is known; colposcopy with biopsy is consistent with preinvasive cervical disease; and invasive carcinoma is not detected. If these criteria are not met, an excisional procedure should be performed.

The excisional techniques are LEEP either as a cone, cold knife conisation (CKC) or carbon dioxide (CO₂) laser conisation.

Excisional methods of treatment of CIN include

The large loop excision of the transformation zone (LLETZ) and the loop electrosurgical excision procedure (LEEP) are both used to describe an excision of the transformation zone with electrocautery. The thin wire loops that excises the tissue and provides a histopathologic specimen has become the therapy of choice. It treats the transformation zone similar to ablative techniques, and it also provides a tissue specimen for histopathological diagnosis as in surgical conisation. The LEEP can be performed as an outpatient procedure (Table 15.2).

Local infiltration at 12, 3, 6 and 9 o’clock positions of the cervix is done. Alternatively paracervical block can begin. The procedure should be performed under colposcopic guidance so that the visualisation of the area to be removed is facilitated. The transformation zone is excised to a depth of 6–7 mm, extending 4–5 mm beyond the diseased area. A 60–80 W setting in the cut mode on the electrocautery machine allows a smooth excision of the lesion (Figs. 15.3 and 15.4).

If the lesion is large, the anterior and posterior portions of the lesion can be excised in separate passes to avoid using excessively large loops. After the removal of the specimen, the bleeding areas can be cauterised using the ball electrode or hemostatic paste; Monsel’s solution (ferrous subsulfate) can be applied to the cervix (Figs 15.4 and 15.5).

Indications of LEEP include

The LEEP procedure has become popular for the treatment of high-grade CIN lesions as it is easily available. The advantage of the LEEP over ablative procedures is that there is a specimen available for histopathology.

Two problems have evolved with the use of LEEP procedures; first, the removal of excessive tissue, and second, the danger of overtreatment. The advantages of performing colposcopy and treatment at one visit avoid patients lost to follow-up in noncompliant populations and decreased expense from repeated visits. The incidence of negative specimens in see-and-treat series varies from 14 to 32.5 % [16, 17]. The negative specimens were related to smaller lesions and younger women. Factors which are contributing to a higher rate of negative see-and-treat specimens include the liberal use of colposcopy to evaluate low-grade lesions on Pap smear. This is relevant for young women who desire fertility preservation. The see-and-treat approach is appropriate for noncompliant patients with a high-grade lesion on LBC/Pap smear that is unequivocal on colposcopy.

Cold knife cone biopsy has the advantage of obtaining an intact specimen. This is important in cases of microinvasive cancer or glandular dysplasia as the specimen obtained by cold knife gives a better idea regarding the depth of the invasion and margin status. The difficulty of using LEEP for excising a cone is that, at times, broken specimens are obtained which are difficult for pathological evaluation.

Conisation of the cervix has a prominent role in the treatment of CIN. Before the advent of colposcopy, conisation was the only method of evaluating an abnormal Pap test. Conisation, being both a diagnostic and a therapeutic method, has the distinct advantage over ablative procedures of providing tissue for biopsy to rule out invasive cancer [18–21].

Conisation is indicated for the evaluation of women with HSIL or AGC-adenocarcinoma in situ and may be considered under the following circumstances: [5]

Lesions which have positive margins are likely to recur after conisation [18–20]. About 23.6 % of patients with endocervical gland involvement recurred compared to the 11.3 % without gland involvement [22]. When compared with conisation, LEEP is the simpler technique, and short-term results are similar to those obtained with conisation or laser excision [23, 24].

In a prospective study examining the long-term effects of LEEP, conisation and laser excision, no difference in the recurrence of dysplasia or in pregnancy outcomes was found [25].

Conisation means the removal of ectocervical lesions and a portion of the endocervix in a cone-shaped manner (Fig. 15.6).

It is performed under general anaesthesia in a lithotomy position after the bladder is emptied. The cervix is exposed, and the vaginal side walls are retracted with preferably insulated Cusco’s speculum with a smoke extractor. After demarcating the limits of the lesion on the ectocervix by colposcopy, the limits of the base of the cone on the cervix can be determined.

The descending cervical branches of the uterus are ligated with a figure-of-eight suture at the 3 and 9 o’clock positions (Fig 15.7). A uterine dilator or sound is placed in the endocervical canal to orient the surgeon to assess the depth and direction of the canal.