A surgeon and scrub nurse to assist are adequate to perform the procedure. An anesthesiologist would manage the anesthesia.

The anesthesiologist will sedate and intubate the patient. The patient is placed in the dorsal lithotomy position with candy cane stirrups or Allen stirrups to position her legs. Colposcopy with 5% acetic acid or Lugol’s solution can be performed in the operating room depending on the surgeon’s preference and ability to see the cervical lesion. The vagina is prepped and draped in usual sterile fashion with drainage of the bladder. Surgical scrub solutions of Hibiclens antimicrobial scrub or Betadine are adequate for vaginal prep. There are no indicated antibiotics necessary for this procedure. A vasoconstrictor solution is mixed. It is typically vasopressin 20IU diluted with 50cc saline before the start of the procedure. Lidocaine without epinephrine can be added to the solution to provide local anesthesia simultaneously.

A weighted speculum is placed in the vagina; a right angle retractor is used to visualize the cervix; the anterior lip of the cervix is then grasped with a tenaculum. If stay sutures are used, they are placed at the three o'clock and nine o’clock position at the cervicovaginal junction. Current literature does not show a decrease in bleeding or hemorrhage, so it is a surgeon’s preference. Typically, 10 cc to 15 cc of dilute vasopressin is injected into the cervix at 2 o'clock, 4 o'clock, 8 o'clock, and 10 o’clock. Blanching will be seen. An angled blade is used to cut the cervix starting at two o’clock outside the transformation zone. A jigsaw cutting technique is performed circumferentially to include the lesion and the transformation zone.  Toothed forceps or an Allis clamp can be used to provide counter traction and elevate the cone bed, take caution not to damage the epithelium. The angled blade creates the cone specimen, and after circumferential excision, the base of the cone is excised with Mayo scissors. The residual endocervical canal is curettage with a Kevorkian curette and specimen captured on a Telfa pad. Then, hemostasis is obtained with Bovie cautery at 40 W ball electrode,[4] or some surgeons will utilize interrupted suture at the cone bed margins. If stay sutures were placed a narrow piece of oxidized cellulose (surgicel) can be placed in the cone bed and tied in with the stay sutures. The patient should be warned that she will pass this packing within the next few weeks. After the cone is removed, a suture is placed at twelve o’clock position to mark for the pathologist.

The most significant complication after cold knife cone is a hemorrhage. This can be intraoperative bleeding or delayed by up to two weeks. Intraoperative bleeding can be managed with multiple techniques utilizing suturing, and even hysterectomy is severe. Post-operative bleeding is between 5% to 15%, but conservative measures in the office using Monsel’s paste, silver nitrate, or packing typically treat the majority of these patients.[5] Occasionally the surgeon must return to the operating room and recauterize or suture the cone bed to obtain hemostasis. Infections following cold knife cone are rare and can be treated with antibiotics. Cervical stenosis and cervical insufficiency are late complications associated with this procedure. Stenosis can be treated with dilation and should be evaluated post-operative if aggressive Bovie cauterization of the endocervical canal was performed or a deep cone bed specimen was obtained. There is mixed data about the risk of preterm delivery and perinatal mortality associated with excisional procedures. There are no randomized controlled trials. Most of the studies show cold knife cone is associated with increased risk of preterm delivery and perinatal mortality, but LEEP is not. Greater depth of excision appears to be an increased risk for PPROM and preterm birth. [6]Increased number of procedures is linked to risk of preterm birth.[7][8]

Recurrence risk of CIN 2,3 after treatment varies by age, the severity of disease at initial treatment, margin status, and treatment modality. Cold knife cone has the lowest recurrence rate based on treatment modality.[9] Cold knife cone requires the operating room but provides a histological specimen with the best specimen margins.[10]

Conization of the cervix is usually performed by the gynecologist, but it is vital to have a cytopathologist as part of the team to interpret the biopsy. The primary care provider and nurse practitioner should educate the patient on the prevention of cervical cancer by emphasizing the importance of safe sex and use of the condom during sexual intercourse. Both males and females should be made aware of the HPV vaccine, which may help prevent or reduce the risk of cervical cancer.