Loop electrosurgical excision procedure (LEEP)
The Loop Electrosurgical Excisional Procedure (LEEP) is a medical procedure designed to excise abnormal, potentially precancerous cells from the cervix, often identified through a Pap test. This procedure is primarily used to treat cervical intraepithelial neoplasia (CIN) and can also serve as a diagnostic tool when abnormal cells are suspected higher in the cervical canal. During LEEP, a thin wire loop heated by an electric current is used to cut away affected tissue under the guidance of a colposcope, which allows visualization of the cervix.
Patients typically do not require extensive preparation, but it is important that the procedure is not performed during menstruation. The LEEP process takes about ten to twenty minutes, and patients may experience mild cramping or discomfort afterward. Recovery is usually quick, with most returning to normal activities within one to three days. Post-procedure guidelines include avoiding sexual intercourse, heavy lifting, and the use of tampons for about four weeks to reduce infection risk. Follow-up appointments are necessary to ensure all abnormal cells have been removed and to monitor for potential recurrence. While LEEP is generally considered safe, it is associated with minimal risks, and there have been concerns about its impact on fertility, although findings are inconclusive.
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Loop electrosurgical excisional procedure (LEEP)
ALSO KNOWN AS: Large loop excision of the transformation zone (LLETZ), large loop excision of the cervix (LLEC), loop cone biopsy of the cervix
DEFINITION: Loop electrosurgical excision procedure (LEEP) is a procedure that may be used to excise or cut away abnormal, possibly precancerous cells (cervical intraepithelial neoplasia) on the surface of the cervix as indicated by the results of a Pap test.
Cancers diagnosed or treated: Cervical intraepithelial neoplasia or dysplasia (CIN), abnormal cell changes on the surface of the cervix
Why performed: A LEEP removes abnormal cells that may develop into cervical cancer, as indicated by results of a Pap test and seen on colposcopy (a noninvasive device used to see inside the cervix) on the surface of the cervix. A LEEP may also be used as a diagnostic procedure when abnormal cells are suspected to be high in the cervical canal and are not visible using a colposcope.
Patient preparation: While there is no standard preparation needed for a LEEP, the patient should consult with her doctor or provider. A LEEP is not performed while a patient is menstruating.
Steps of the procedure: The patient, unclothed from the waist down, draped with a cloth or paper, lies on an exam table as for a typical pelvic exam with feet raised in stirrups. A speculum is inserted in the vagina to allow the physician to see inside the vagina and cervix to guide the colposcope to the area with abnormal cells. A tube is attached to the speculum to remove any smoke caused by the procedure. Then, an electrosurgical dispersive pad is placed on the thigh, which allows the electric current to return safely. The physician will attach a single-use disposable loop electrode to the generator handpiece. A vinegar (acetic acid) or iodine solution is used to prepare the cervix, allowing the physician to assess the extent of the abnormal cells. If a cervical block or anesthetic is used to numb the cervix, pain medication is administered beforehand. Once the local anesthetic or block is injected into the cervix, the electro-loop is generated, and the wire loop passes through the surface of the cervix. Finally, an electrosurgical generator sends a painless electrical current that cuts away the affected cervical tissue as the loop wire moves through the cervix, causing the abnormal cells to burst. An iron solution called Monsel's paste is applied to stop the bleeding. The procedure takes about ten to twenty minutes to complete.
After the procedure: The patient may go home following the procedure. While rare, complications may include mild cramping, mild discomfort or pain, bleeding, heavy vaginal discharge, or strong vaginal odor. The patient should report any significant side effects to their doctor. The patient is typically advised not to engage in sexual intercourse for four weeks following the procedure. Ibuprofen (Motrin, Advil) may be taken for cramping. The patient is advised not to lift heavy objects, douche, or use tampons for four weeks following the procedure and is advised to take showers instead of baths to reduce the risk of infection. The patient’s doctor will make a follow-up appointment to perform a colposcopy to check that all abnormal cells have been removed and perform a Pap test to confirm this.
Risks: The LEEP is very safe. The benefits of treating potentially precancerous cells with the procedure outweigh its minimal risks. Those risks may include heavy bleeding, bleeding with clots, severe abdominal cramping, fever, foul-smelling discharge, incomplete removal of abnormal tissue, cervical stenosis (narrowing of the cervix), infection, and possibly cutting or accidental burning of normal tissue if the patient moves during the procedure. Several studies conducted in 2013 also suggest a link between LEEP and subfertility, although previous studies failed to find the procedure to have any effect on fertility.
Results: Typically, the patient returns to normal activity within one to three days after the LEEP. The doctor will disclose the results of the histologic specimen obtained from the LEEP regarding whether invasive cancer may have developed deep in cervical tissue. A follow-up appointment is made to perform a colposcopy to confirm all abnormal cells were removed. A Pap test is repeated to confirm their removal, and the patient is advised to regularly have Pap tests to track the possible recurrence of abnormal cervical cells.
Bibliography
Creasman, William T., et al. Disaia and Creasman Clinical Gynecologic Oncology. 10th ed., Elsevier, 2023.
DerSarkissian, Carol. "What Is LEEP?" WebMD, 10 Sept. 2023, www.webmd.com/women/what-is-leep-procedure. Accessed 20 June 2024.
DiSaia, Philip J., and William T. Creasman. Clinical Gynecologic Oncology. 9th ed. Elsevier, 2018.
"Loop Electrosurgical Excision Procedure (LEEP)." Cleveland Clinic, 18 Mar. 2022, my.clevelandclinic.org/health/treatments/4711-loop-electrosurgical-excision-procedure-leep. Accessed 20 June 2024.
Macksey, Lynn Fitzgerald. Surgical Procedures and Anesthetic Implications: A Handbook for Nurse Anesthesia Practice. 2nd ed. Jones, 2018.
Spracklen, Cassandra N., et al. "Cervical Surgery for Cervical Intraepithelial Neoplasia and Prolonged Time to Conception of a Live Birth: A Case Control Study." BJOG: An International Journal of Obstetrics and Gynecology, vol. 120, no. 8, 2013, pp. 960–65. doi:10.1111/1471-0528.12456.
Yang, Eun Jung, et al. “Loop Electrosurgical Excision Procedure Combined with Cold Coagulation for Cervical Intraepithelial Neoplasia and Adenocarcinoma In-situ: A Feasible Treatment with a Low Risk of Residual/Recurrent Disease.” Infectious Agents and Cancer, vol. 15, no. 58, Oct. 2020, doi:10.1186/s13027-020-00326-3.