LEEP (Loop Electrosurgical Excision Procedure)

Overview

• Tissue specimen available for pathologic review (unlike cryotherapy or ablation)
• Performed in an outpatient/office setting under local anesthesia
• Lower cost than cold-knife conization or laser surgery
• Single-visit "see-and-treat" option possible
• Low complication rate

Indications

• Biopsy-confirmed CIN 2 or CIN 3
• Certain cases of CIN 1 persisting >2 years
• Unsatisfactory colposcopy with suspected high-grade lesion
• Positive endocervical curettage (ECC)
• Discordance between Pap smear, colposcopy, and biopsy findings

Contraindications

Equipment

• Electrosurgical generator with a smoke evacuator (e.g., Utah Medical, CooperSurgical, Ellman Surgitron)
• Loop electrodes: 2.0 × 0.8 cm (standard exocervical), 1 × 1 cm or square (endocervical)
• Ball electrode for hemostasis
• Non-conductive, vented vaginal speculum (required — prevents arcing)
• Dispersive grounding pad
• Local anesthetic (typically 1–2% lidocaine with epinephrine 1:100,000 injected into the cervical stroma)
• Lugol's solution and/or acetic acid (5%) for lesion delineation
• Monsel's paste (ferric subsulfate) for hemostasis

Procedure

Patient Preparation

1. Place patient in dorsal lithotomy position.
2. Insert the non-conductive speculum — standard metal specula are not used because they may conduct current.
3. Apply 5% acetic acid and/or Lugol's iodine to delineate the lesion and TZ.
4. Infiltrate the cervical stroma at 3, 6, 9, and 12 o'clock with local anesthetic containing epinephrine (vasoconstrictive effect reduces bleeding).
5. Attach the grounding pad to the patient's thigh.

Routine LEEP (Exocervical Lesions)

1. Using a 2.0 × 0.8 cm loop electrode, enter the cervix 3–5 mm outside the lateral margin of the TZ.
2. Activate current and pass the loop smoothly through the cervix with steady, even pressure — move too slowly and thermal artifact increases; too fast and incomplete excision results.
3. The loop is brought out on the contralateral side, removing the entire TZ and CIN lesion in a single pass.
4. Submit the specimen in formalin.
5. Apply Monsel's paste or use the ball electrode for hemostasis.

Figure: For lesions too large for a single pass — central portion removed first (A–B), followed by peripheral passes (C–E). All specimens placed in the same formalin container (F).

LEEP Conization (Endocervical Extension — "Cowboy-Hat" Technique)

1. Excise the endocervical portion using a 1 × 1 cm endocervical electrode.
2. Then excise the exocervical portion with the standard 2.0 × 0.8 cm loop.

1. Excise the large ectocervical portion first.
2. Follow with the smaller endocervical electrode.

Caution: Do not excise the endocervical canal deeper than 1.5 cm — increased risk of significant bleeding and cervical stenosis.

Figure: A — Endocervical portion excised first, then ectocervical. B — Ectocervical excised first, then endocervical. C — Longitudinal view showing the "cowboy-hat" configuration of the combined excision.

Pathologic Assessment

• Specimens should ideally be opened along one side and placed in a holder to fix in proper orientation.
• Thermal artifact at the margins is a known limitation — may make margin assessment difficult.
• An endocervical curettage (ECC) performed after LEEP helps assess residual disease above the excised specimen.
• Report should address: CIN grade, endo- and ecto-cervical margin status.

Complications

Obstetric Implications

Follow-Up

• Post-LEEP follow-up typically includes co-testing (HPV + cytology) at 6 months and 12 months.
• Positive margins warrant closer surveillance but not automatic re-treatment.
• Recurrence rate following LEEP for CIN 2/3 is approximately 5–15% depending on margin status and HPV persistence.