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Bloodless technique of cold knife conization (ring biopsy)
Bloodless technique of cold knife conization (ring biopsy)
I ‘I 11 A s long been recognized that excessivt blood loss is a frequent accompaniment ot adequate cold knife conization (ring biopsy ) of the cervix, done primarily to confirm a preclinical or a preinvasive carcinoma of the cervix as suspected by doubtful or positi\x* cytology. Many techniques have been drveloped in an attempt to contro’l the blood loss. In 1815, Lisfranc,’ during the treatment of a suspected ten-ical carcinoma, removed a wedge-shaped portion of the cer\.is fot diagnosis. He suggested, at that time, that the portion of th(- cervix to by removed cstend from the vagina to the margin of the internal 0s. Emmett,2 in 1874, reported Hughier and Marion Sims had also performed a similar operation for diagnosis of cervical carcinoma. Jn 1916, Sturmdorf ’ described conization followed by inversion of flaps of mucosa over the bare areas \vith the use of sutures for hcmostasis. In 1928. Hyam? introduced electroconization for WI’vicitis. In 1948, Ayre” developed a special knife in order to obtairk a more complctc. ring- or cone-shaped sptximen with Sreatcr (xase. In 1949. Gusberg” produced the endoct:I.vic.al coning biopsy currtte which WC\, probably the first of the specialized instruments for cold conization of the cervix. Since, rhrn there ha1.e been many articles?.!’ p’tb-
lished show+ specialized instruments which were designed to control hemorrhage and facilitate the operation. In 1951, at a seminar on ring biopsy at 7’he Cancer Institute in Miami, it was suggested that the blood loss could be decreased by injection of the cervix with Novocain and Adrenalin prior to the operation. King biopsy is usually considered ;I minor surgical procedure. Howpveri a study by Roydl” of the morbidity and complications of 80 cases of Sturmdorf’s conization reveals a 43.4 per cent complication rate I Table Ti
Table I. Complications Sturmdorf’s
in 80 cases of
conization
Febrile response (over 99.6” F. i Without other complications With other complications Bleeding requiring rrpackinq Bleeding requirine repacking and resuturilg Bleeding requiring hysterectomy” .Accidents durinx opmation Marked infrction of the uterus Interferencr with eregnancy~ *The patient who required hysterectomy talized 38 day? III blood
and
was
given
transfusions
Cold knife conization is a method and is considered accurate diagnosis of early cinoma. Four quadrant 1lrovc.d difficult to intrrpret
Pltserrted in movie form before 7’h, Pan American Cytology Congru~c, Miami. Florida, April. 1957
67
totaling
18 10 7 7 I i 1 ‘> wa hospi5,000 ml.
prime diagnostic necessary in the preclinical carbiopsies have or misleading iI
Bloodless
4,5.5 per cent of 110 cases as reported Harris and Peters0n.l’
Technique
ot
Ring
Biopsy
63
by
Technique An improved simplified bloodless technique* of ring biopsy has been developed in which the average blood loss can be decreased from 200 ml. to less than 5 ml. This method is so simple, easy, and safe that it can be, and has been, used in all trimesters of pregnancy, without a single pregnancy loss. The procedure is ordinarily clone in the hospital under Pentothal-Nitrous oxide anesthesia. Lugol’s solution for a Schiller test is applied to the cervix and the l.agina to delineate properly the margin of nonstaining, abnormal tissue to be removed (Fig. 1). If the entire portio of the cervix stains well, as it does in a few cases of carcinoma, then at least all tissue 1.5 cm. from the squamocolumnar junction should be removed for biopsy. The cervix is brought into view with 2 tenacula, placed at 3 and 9 o’clock. Great care is used not to disturb the cpithelium at the squamocolumnar junction. The key to this technique lies in the production of an intraceruical tourniquet by injection into the cervical stroma of sterile saline to which 3 drops of Adrenalin per ounce has been added (Figs. 2 and 3). The injection is made far away from the squamocolumnar junction, actually around the circumference of the cervix close to the vaginal fornix at 6 or 8 points. Enough solution (50 to 200 InI.) is injected to produce ballooning and blanching of the entire cervix (Fig. 3). If enough solution is not injected to produce rhis blanching and ballooning effect, the cantire technique will be a failure. It is of extreme importance that the injection be made within the cervicaE stroma, not :jubrnucosally (inset, Fig. 2). This requires great l‘orce, necessitating the use of a control syringe with finger rings and a 2 inch, 20 Xauge needle bent to a 45 degree angle (Fig. 2). Following the injection, a cone of tissue *This technique was developed by us in 1951; subsequently, we have discovered that a similar technique withmt cauterization has been used by Gary HietP* of Fort Worth, Texas, and J. M. Singleton’* of Kansas City, MO.
Fig. 1. Cervix injection.
stained
with
Lug01
solution
before
is removed, including a portion well beyond the nonstaining area plus at least two thirds of the cervical canal (Fig. 4). A No. 11 BardParker blade with an angled handle can be used. It is extremely important that the knife point extend to the endocervical canal but not through to the opposite side, in order to prevent undercutting, which can lead to troublesome bleeding. If the injection is properly made, the biopsy site will show no bleeding. The entire raw area is then coagulated with a Bovie unit for subsequent hemostasis. If the coagulation is not done within 15 minutes, the area usually bleeds profusely. The entire blood loss, if the injection technique has been properly followed, is not more than 5 ml., and an entirely dry field should be obtained. Following the conization, if the patient is not pregnant, the cervix is dilated and a routine fractional curettaae is done. Than, a pledqet of Oxycel
64
Scott,
Welch,
and
Blake
Fig. fcxt
Fig. 3. Injection completed. Inset shows cone of cwvix to be removed.
2. Ballooning and blanching: and bites of Injection.
1.1’.
Volume Sumhcr
-
79 1
Bloodless
Technique
of
Ring
Biopsy
65
S
Fig.
4. Line
of incision
and orienting
suture
at 12 o’clock.
cotton is placed against the cervix with press,ure for a moment or two and allowed to remain. No packs or sutures are required. Complications
and
morbidity
All 88 patients in our series returned home within 48 hours following operation unless definitive therapy was contemplated on the same hospital admission. None was rehcwpiralized for complications (Table II).
‘Table II Postoperative hemorrhage* Cystitis .4cute perisalpingitist Pyelonephritis, parametritis, and ovarian abscess
(9.7
per
cent)
9 1 1
Summary 1
*Hemorrhage occurred on the second to the twentyfourth postoperative day; this was controlled either in the office or in the emergency room at the hospital by recaukrization and the placing of Oxycel against the cervix. tion
JrThis was for an early
discovered invasive
at the carcinoma.
These patients are discharged on the first or second postoperative day and instructed to use an ointment composed of allantoin and sulfanilamide (Allantomide Vaginal Cream) nightly to minimize secondary slough. Unless the uterus is removed for definitive therapy later, the cervix is periodically dilated to prevent cervical stenosis. Of these 88 patients, 2 have had 2 pregnancies without prolonged labor or other difficulties attributable to the conization. Two had cesarean hysterectomy for definitive therapy, and one had cesarean section for cephalopelvic disproportion.
time
of follow-up
opera-
A bloodless technique of cold knife conization to confirm preclinical or preinvasive carcinoma of the cervix is presented. An intracervical tourniquet is produced by injection of the cervical stroma with
66
Scott, Welch, and Blake:
REFERENCES
I. Lisfranc, J.: Gaz. m&d., Paris 2: X8.5, 1815. 2. Emmett, Thomas: Am. J. Ohst. 7: 442, 1874. X. Sturmdorf, A.: Surg. Gynrc. R: Ohst. 22: 99, 1916. ,i. Hyams, M. N.: NW York J Med. 28: 6,&h, 1928. 5. Ayrc, J. E.: J. A. M. A. 138: I I, 1948. 6. Gusberg, S. B.: AM. J. ORST. & GYNEC:. 57: 752, 1949. 70: 7. Spencrr, 1:. (:.: :%M. J. ( )EST. & (:YNRC. 447, 1955.
8. r). III.
Seiger, N. W.: Obst. PC Cynec. 12: 294, 1958. Sriger, N. W.: Obst. Lt. Gynec. 9: 361, 1957. Boyd, J. R.: 4&f J. (hRT. & C;YNE(:. 75: 98:1, 1958. ! i. Harris, J. kf., and Peterson, I’.: ;\M. J. 013~~1. & GYNEC. 70: 1092, 19% I .!. Hictt, Gary: Personal rolrltllunication, 19.58. 1I(. Singleton, J. M.: Personal c.omrnunic.ation, 1957.
I ‘I 11 A s long been recognized that excessivt blood loss is a frequent accompaniment ot adequate cold knife conization (ring biopsy ) of the cervix, done primarily to confirm a preclinical or a preinvasive carcinoma of the cervix as suspected by doubtful or positi\x* cytology. Many techniques have been drveloped in an attempt to contro’l the blood loss. In 1815, Lisfranc,’ during the treatment of a suspected ten-ical carcinoma, removed a wedge-shaped portion of the cer\.is fot diagnosis. He suggested, at that time, that the portion of th(- cervix to by removed cstend from the vagina to the margin of the internal 0s. Emmett,2 in 1874, reported Hughier and Marion Sims had also performed a similar operation for diagnosis of cervical carcinoma. Jn 1916, Sturmdorf ’ described conization followed by inversion of flaps of mucosa over the bare areas \vith the use of sutures for hcmostasis. In 1928. Hyam? introduced electroconization for WI’vicitis. In 1948, Ayre” developed a special knife in order to obtairk a more complctc. ring- or cone-shaped sptximen with Sreatcr (xase. In 1949. Gusberg” produced the endoct:I.vic.al coning biopsy currtte which WC\, probably the first of the specialized instruments for cold conization of the cervix. Since, rhrn there ha1.e been many articles?.!’ p’tb-
lished show+ specialized instruments which were designed to control hemorrhage and facilitate the operation. In 1951, at a seminar on ring biopsy at 7’he Cancer Institute in Miami, it was suggested that the blood loss could be decreased by injection of the cervix with Novocain and Adrenalin prior to the operation. King biopsy is usually considered ;I minor surgical procedure. Howpveri a study by Roydl” of the morbidity and complications of 80 cases of Sturmdorf’s conization reveals a 43.4 per cent complication rate I Table Ti
Table I. Complications Sturmdorf’s
in 80 cases of
conization
Febrile response (over 99.6” F. i Without other complications With other complications Bleeding requiring rrpackinq Bleeding requirine repacking and resuturilg Bleeding requiring hysterectomy” .Accidents durinx opmation Marked infrction of the uterus Interferencr with eregnancy~ *The patient who required hysterectomy talized 38 day? III blood
and
was
given
transfusions
Cold knife conization is a method and is considered accurate diagnosis of early cinoma. Four quadrant 1lrovc.d difficult to intrrpret
Pltserrted in movie form before 7’h, Pan American Cytology Congru~c, Miami. Florida, April. 1957
67
totaling
18 10 7 7 I i 1 ‘> wa hospi5,000 ml.
prime diagnostic necessary in the preclinical carbiopsies have or misleading iI
Bloodless
4,5.5 per cent of 110 cases as reported Harris and Peters0n.l’
Technique
ot
Ring
Biopsy
63
by
Technique An improved simplified bloodless technique* of ring biopsy has been developed in which the average blood loss can be decreased from 200 ml. to less than 5 ml. This method is so simple, easy, and safe that it can be, and has been, used in all trimesters of pregnancy, without a single pregnancy loss. The procedure is ordinarily clone in the hospital under Pentothal-Nitrous oxide anesthesia. Lugol’s solution for a Schiller test is applied to the cervix and the l.agina to delineate properly the margin of nonstaining, abnormal tissue to be removed (Fig. 1). If the entire portio of the cervix stains well, as it does in a few cases of carcinoma, then at least all tissue 1.5 cm. from the squamocolumnar junction should be removed for biopsy. The cervix is brought into view with 2 tenacula, placed at 3 and 9 o’clock. Great care is used not to disturb the cpithelium at the squamocolumnar junction. The key to this technique lies in the production of an intraceruical tourniquet by injection into the cervical stroma of sterile saline to which 3 drops of Adrenalin per ounce has been added (Figs. 2 and 3). The injection is made far away from the squamocolumnar junction, actually around the circumference of the cervix close to the vaginal fornix at 6 or 8 points. Enough solution (50 to 200 InI.) is injected to produce ballooning and blanching of the entire cervix (Fig. 3). If enough solution is not injected to produce rhis blanching and ballooning effect, the cantire technique will be a failure. It is of extreme importance that the injection be made within the cervicaE stroma, not :jubrnucosally (inset, Fig. 2). This requires great l‘orce, necessitating the use of a control syringe with finger rings and a 2 inch, 20 Xauge needle bent to a 45 degree angle (Fig. 2). Following the injection, a cone of tissue *This technique was developed by us in 1951; subsequently, we have discovered that a similar technique withmt cauterization has been used by Gary HietP* of Fort Worth, Texas, and J. M. Singleton’* of Kansas City, MO.
Fig. 1. Cervix injection.
stained
with
Lug01
solution
before
is removed, including a portion well beyond the nonstaining area plus at least two thirds of the cervical canal (Fig. 4). A No. 11 BardParker blade with an angled handle can be used. It is extremely important that the knife point extend to the endocervical canal but not through to the opposite side, in order to prevent undercutting, which can lead to troublesome bleeding. If the injection is properly made, the biopsy site will show no bleeding. The entire raw area is then coagulated with a Bovie unit for subsequent hemostasis. If the coagulation is not done within 15 minutes, the area usually bleeds profusely. The entire blood loss, if the injection technique has been properly followed, is not more than 5 ml., and an entirely dry field should be obtained. Following the conization, if the patient is not pregnant, the cervix is dilated and a routine fractional curettaae is done. Than, a pledqet of Oxycel
64
Scott,
Welch,
and
Blake
Fig. fcxt
Fig. 3. Injection completed. Inset shows cone of cwvix to be removed.
2. Ballooning and blanching: and bites of Injection.
1.1’.
Volume Sumhcr
-
79 1
Bloodless
Technique
of
Ring
Biopsy
65
S
Fig.
4. Line
of incision
and orienting
suture
at 12 o’clock.
cotton is placed against the cervix with press,ure for a moment or two and allowed to remain. No packs or sutures are required. Complications
and
morbidity
All 88 patients in our series returned home within 48 hours following operation unless definitive therapy was contemplated on the same hospital admission. None was rehcwpiralized for complications (Table II).
‘Table II Postoperative hemorrhage* Cystitis .4cute perisalpingitist Pyelonephritis, parametritis, and ovarian abscess
(9.7
per
cent)
9 1 1
Summary 1
*Hemorrhage occurred on the second to the twentyfourth postoperative day; this was controlled either in the office or in the emergency room at the hospital by recaukrization and the placing of Oxycel against the cervix. tion
JrThis was for an early
discovered invasive
at the carcinoma.
These patients are discharged on the first or second postoperative day and instructed to use an ointment composed of allantoin and sulfanilamide (Allantomide Vaginal Cream) nightly to minimize secondary slough. Unless the uterus is removed for definitive therapy later, the cervix is periodically dilated to prevent cervical stenosis. Of these 88 patients, 2 have had 2 pregnancies without prolonged labor or other difficulties attributable to the conization. Two had cesarean hysterectomy for definitive therapy, and one had cesarean section for cephalopelvic disproportion.
time
of follow-up
opera-
A bloodless technique of cold knife conization to confirm preclinical or preinvasive carcinoma of the cervix is presented. An intracervical tourniquet is produced by injection of the cervical stroma with
66
Scott, Welch, and Blake:
REFERENCES
I. Lisfranc, J.: Gaz. m&d., Paris 2: X8.5, 1815. 2. Emmett, Thomas: Am. J. Ohst. 7: 442, 1874. X. Sturmdorf, A.: Surg. Gynrc. R: Ohst. 22: 99, 1916. ,i. Hyams, M. N.: NW York J Med. 28: 6,&h, 1928. 5. Ayrc, J. E.: J. A. M. A. 138: I I, 1948. 6. Gusberg, S. B.: AM. J. ORST. & GYNEC:. 57: 752, 1949. 70: 7. Spencrr, 1:. (:.: :%M. J. ( )EST. & (:YNRC. 447, 1955.
8. r). III.
Seiger, N. W.: Obst. PC Cynec. 12: 294, 1958. Sriger, N. W.: Obst. Lt. Gynec. 9: 361, 1957. Boyd, J. R.: 4&f J. (hRT. & C;YNE(:. 75: 98:1, 1958. ! i. Harris, J. kf., and Peterson, I’.: ;\M. J. 013~~1. & GYNEC. 70: 1092, 19% I .!. Hictt, Gary: Personal rolrltllunication, 19.58. 1I(. Singleton, J. M.: Personal c.omrnunic.ation, 1957.