The art of cold knife conization: a demonstration of technique in live patients and a low-fidelity simulation model

Cervical excision via cold knife conization is recommended for conditions, such as adenocarcinoma in situ or predominantly endocervical high-grade dysplasia. A successful cold knife conization involves visualization, targeting of the pathology, obtaining an unfragmented specimen, and consideration of postexcision endocervical curettage. This article presents a video that demonstrates cold knife conization techniques to facilitate pathologic analysis and a low-fidelity simulation model for learners. The video depicts 2 cold knife conizations in nulliparous patients with (1) high-grade lesion on endocervical curettage and (2) high-grade dysplasia on ectocervical biopsy. In addition, this article demonstrates a low-fidelity simulation model that can be used to familiarize physicians with the conization procedure and essential hemostatic techniques. Although the authors acknowledge the limitations of the model to include lack of bleeding, corresponding patient cases demonstrate essential hemostatic techniques. Using standard surgical instruments, cold knife conization was performed for both patients, allowing for the excision of an appropriately sized intact specimen. Differences in technical approach when excising the ectocervix vs the endocervix were detailed. Endocervical curettage was performed after specimen removal, and the tissue bed was made hemostatic. Both conizations were performed without complication, and negative margins were achieved. In the simulation model, easily obtainable supplies, including small cups, balloons, cling wrap, cotton balls, and hot dogs, were used to create an imitation cervix. This can allow for demonstration and practice with suture placement, excision of an intact specimen, and hemostatic techniques. Using proper technique for adequate cold knife conization specimens facilitates pathologic analysis of dysplasia, cancer, and margin status. Negative margins have a substantial effect on recurrence and the need for future cervical procedures, which may affect future obstetrical outcomes. Low-fidelity simulation models can provide accessible avenues for technical familiarization and training in this procedure.