Cervical Excision Procedures: Loop Electrosurgical Excision Procedure and Cold Knife Cone

The experience of performing a loop electrosurgical excision procedure (LEEP) can be simulated excising areas of chicken breast or beef tongue. The simulation can be made more lifelike by performing the LEEP through a white foam coffee cup with the bottom removed to simulate the vagina.

• Electrosurgical generator with smoke evacuator, dispersive pad, LEEP electrodes, and electrosurgical pencil
• Boneless chicken breast or beef tongue
• Foam or paper coffee cup with bottom cut out
• Examining gloves
• White correction fluid to simulate lesions on the chicken breast or beef tongue

This simulation is best performed by pairs of students. One to perform the LEEP; one to hold the dinner plate and foam or paper cup. 

1. Place the chicken breast or beef tongue on the dispersive pad (return electrode) on a dinner plate. Make sure that as much of the pad as possible is in contact with the chicken breast or beef tongue.
2. Connect to the electrosurgical generator. An assistant should hold the smoke evacuator tubing above the area of the chicken breast or beef tongue to be excised. If desired, dots made of white correction fluid can serve to mark the location of "lesions."
3. Please note, step 2 should be performed at least three times. Each time an appropriate sized loop is used to excise tissue from the chicken breast or beef tongue.
4. Hold the dinner plate with the dispersive pad and chicken breast or beef tongue at an angle to simulate the angle of the cervix.
5. Prop the cup against the chicken breast or beef tongue and perform the excision. The smoke evacuation tubing may be held within the cup or taped to the top of the cup. This procedure simulates operating within the confined space of the vagina.
6. The pencil with loop should be held at a 90 degree angle to the tissue and the excision performed with a smooth motion, completely excising the tissue to a depth of 5-7 mm.
7. A top hat also may be performed.
8. The edges and peripheral base of the LEEP bed should be cauterized using the ball electrode.
9. Simulate the LEEP through the foam or paper cup while looking through the colposcope. This comes closest to an in vivo LEEP.

High-fidelity simulation: None

Resident conducts a "time out." Resident performs bimanual examination, properly inserts a speculum and visualizes cervix, cleans cervix, places tenaculum, and sounds uterus. Resident properly inserts the copper intrauterine device (IUD) and levonorgestrel IUD. Resident trims strings to 3-4 cm, removes tenaculum, applies hemostatic treatment, if needed, and removes the speculum.

• Kielbasa sausage
• Kabob skewers
• White correction fluid or nail polish
• Grounding pads
• Radiofrequency generator with cord and hand piece
• Weighted speculum and retractors
• Needle and syringe for "local" anesthesia
• Suction for smoke and "blood"
• Vaginal mount
• Long knife handle (angled optional) and blade

Optional Equipment:

• Suture for stay sutures and cloth tape for reinforcement
• Acetic acid or Lugol solution
• Full-size mannequin or pelvic model
• Gauze square

1. Wash kielbasa with soap and water to improve grounding.
2. Place skewers lengthwise through kielbasa for "os" (also creates a tract for "bleeding" via tubing or catheter. See Fig. 1).
3. Wrap kielbasa lengthwise with grounding pad (rubber bands or zip ties may be required for good contact).
4. Create "dysplasia" with white correction fluid.
5. Wrap distal end with cloth tape to hold stay sutures.

 

6. Insert the kielbasa into vaginal mount and place mount in mannequin.
7. Prepare side table with required equipment.
8. Observe the learner or demonstrate, if applicable, how to
   • Administer local anesthesia
   • Cut adequate cone biopsy (see Fig. 3)
   • Achieve hemostasis (see Fig. 4)
   • Place stay sutures (see Fig. 5; optional)

Resident conducts a "time out." Resident performs a bimanual examination, properly inserts speculum and visualizes cervix, cleans cervix, places tenaculum, and sounds uterus. Resident properly inserts the copper intrauterine device (IUD) and levonorgestrel IUD. Resident trims strings to 3-4 cm, removes tenaculum, and applies hemostatic treatment, if needed, and removes the speculum.