CHAPTER 5. Equipment for a colposcopic examination CHAPTER 1 CHAPTER CHAPTER 5 CHAPTER This chapter describes the which allows the colposcope head to interference. Any shorter and it is equipment needed to perform a col- be placed more precisely and with- difficult to use handheld instruments poscopic examination and its more out interfering with the operator’s under direct colposcopic view; any common uses in clinical practice. comfort. There are a large number of longer and it is too far to comfortably A step-by-step description of the colposcopes on the market. Fig. 5.1 colposcopy technique and how to shows a typical colposcope mounted Fig. 5.1. A typical colposcope with a optimize the examination follows in on a floor stand. movable base. Chapter 6. Certain instrument character- istics should be considered before 5.1 Colposcope buying a colposcope. It must be binocular, so that depth of field may The colposcope is a relatively simple be appreciated. This is particularly instrument that allows examination important when performing exci- of the cervix under light illumination sional treatment and when trying to at various low-power magnifications. assess surface contour and perform It consists of a binocular microscope examination of endocervical epitheli- and light source, often incorporating um (Carcopino et al., 2014). The lens a beam splitter to allow attachment should have a focal length of 30 cm, of a still or video camera. It may ei- which is short enough to allow the ther be attached to a central upright examiner to reach the cervix with in- rigid bar, as in the original colpo- struments, swabs, and spatulas and scope introduced in Germany in the yet long enough to allow the colpos- 1920s, or be connected to a weight- copist’s hands to move between the ed stand with an adjustable arm, colposcope and the cervix without Chapter 5. Equipment for a colposcopic examination 37 Fig. 5.2. Two views of the colposcope head, showing the two eyepieces (e), entire cervix in one field, especially the magnification changer (m), the camera access port (c), and the 30 cm during treatment. A good colposcope lens (l). Coarse focus is attained by moving the entire colposcope head. will have a low enough magnification Fine focus is achieved using the fine focus handle (f). setting to allow this (i.e. 4×). Three or four different magnifications between e 4× and 15× are ideal. Rapid change m from one magnification to another is effected with a simple knob (the c magnification changer). For coarse focus, the colposcope head can be l moved manually, and for fine focus, there is a separate knob. f Before starting a colposcopic examination, one should first con- reach the cervix. The colposcope lamps last longer. Most colposcopes firm personal visual acuity settings, head must be universally movable have a green filter, which takes away in other words that the colposcope and should be easily fixed once in the background redness so that the is set up properly for the examiner’s position, so as to allow the colposco- vessels appear black and fine ves- eyes (see Chapter 6). It is prudent to pist freedom of hand movement. A sel changes may be more easily do this while looking at an inanimate camera attachment (and therefore a appreciated. object at the beginning of a clinic beam splitter) is very useful for both Also, most colposcopes have session, before a patient undresses. training and documentation. a magnification changer, although Colposcope manufacturers near- The colposcope head (Fig. 5.2) some are variable and allow a zoom ly all supply a camera, monitor, and comprises an objective lens; two capacity. In practice, it is rarely nec- computerized image storage and da- eyepieces, which may be adjusted to essary to examine at a greater mag- tabase package. Fig. 5.3 illustrates each person’s eye position and may nification than 15×. There is a trade- an integrated colposcopy system. be focused independently; and a off. At greater magnification, the field light source, which in the instrument of view diminishes, the depth of fo- 5.2 Gynaecological couch shown comes from a light cable at- cus decreases, and the light required and operator’s stool tached to a light source. Halogen increases. At higher magnifications, lights are very powerful, are easily it is sometimes easier to appreciate For most women, any gynaecolog- replaced, and are relatively inex- fine vessel changes. However, it is ical examination couch (Fig. 5.4) pensive. Light-emitting diode (LED) important to be able to visualize the that allows the patient to adopt the Fig. 5.3. A colposcope with inte- Fig. 5.4. A colposcopy/hysteroscopy gynaecological examination couch. It grated video camera, monitor, and may be elevated and flattened independently. A waste receptacle is fitted data collection system attached to just below the patient’s perineum. the colposcope’s movable stand. 38 lithotomy or semi-lithotomy position to an electrosurgical unit (ESU) has been performed, and also as an may be used to perform colposco- (Fig. 5.5). The loop electrode is educational tool for attending colpos- py. However, it is important that the housed in a so-called pencil. Suc- copy trainees. base of the couch may be tilted so tion tubing will connect the ESU to that the TZ on the cervix will become the suction speculum, and a ground 5.4 Computerized data almost perpendicular to the colpo- plate will connect the patient to the management system scopic line of vision. The back of the ESU. Some ESUs have a suction couch should also be adjustable, unit incorporated into the unit; others Many companies provide a software and it should be possible to easily do not, in which case it will be nec- package that allows sociodemo- elevate or lower the whole couch. A essary to have a separate suction graphic, clinical, colposcopic, and comfortable couch is hugely impor- machine. The equipment for LLETZ/ laboratory data and image capture tant for the patient, who will need to LEEP, thermal coagulation, and cryo- as well as automatic audit of colpo- be in position for several minutes in surgery is described in Chapter 11. scopic diagnostic performance. In relative undress and who is very like- this way, it is relatively easy to cre- ly to be anxious. It is important to be 5.3 Camera system ate a full audit of performance for an able to elevate or lower and tilt the individual colposcopist and to main- couch to allow optimal positioning Almost all of the major camera com- tain a clinical database for the clinic of the patient. Also, an examiner’s panies will supply a camera and at- service. However, the programs are stool that can be elevated or lowered tachment for a colposcope. Unfortu- expensive. is very helpful. Being able to quickly nately, the colposcopes usually need flatten the couch so as to deal with a C-mount for the camera to attach 5.5 Instrument trolley the rare vasovagal attack is impor- to the colposcope, and C-mounts tant. Finally, the same couch may be are expensive. Many modern colpo- An instrument trolley may seem an used for most outpatient gynaeco- scopes have a camera system incor- unnecessary luxury in colposcopy logical procedures (e.g. hysterosco- porated into the instrument, without clinics where budgets are tight. How- py, intrauterine contraceptive device the need for a C-mount. Nowadays, ever, the reusable and disposable [IUCD] insertion, and transvaginal the cost of a reasonable video cam- equipment and the fluids needed to ultrasonography). era is almost the same as that of a perform a proper colposcopic ex- CHAPTER 5 CHAPTER If a decision is made to perform still image camera, and very high amination have to be housed some- excisional treatment, it should usu- quality video images can be obtained where, and to have them all to hand ally be performed as an outpatient and stored for future reference. This in one compartmentalized trolley procedure using electrosurgery to is immensely valuable as a clinical is both efficient and ergonomically resect the TZ epithelium, i.e. LLETZ/ aid in following up screen-positive sensible. The last thing a colposco- LEEP. A loop electrode is attached patients, whether or not treatment pist or the patient needs is to have to wait for an assistant to find a par- ticular instrument when it is needed. Fig. 5.5. A portable, battery-driven electrosurgical unit incorporating a Finally, if instruments are not housed suction unit. Ports for the electrosurgical pencil and the ground plate are displayed. A simple electrical battery charger access point and the on/off in a compartmentalized trolley they switch complete the display at the front. The suction port site is at the rear are not within arm’s length of the of the unit. colposcopist, and they should be. Figs. 5.6–5.8 illustrate how some reusable instruments and some dis- posable equipment may be conve- niently housed in a trolley. The con- tents of the top, middle, and bottom drawers are shown in Figs. 5.6, 5.7, and 5.8, respectively. In Fig. 5.9, the top surface of the trolley shows some instruments laid out for a colposcop- ic examination. A needle disposal box and a fluid tray are attached on the side (Fig. 5.10). Chapter 5. Equipment for a colposcopic examination 39 Fig. 5.6. Open top drawer of a colposcopy clinic trolley, Fig. 5.7. Open middle drawer of a colposcopy clinic which conveniently stores in adjustable compartments trolley, which stores a variety of disposable examination a variety of disposable equipment: lubricating jelly, gloves, gauze swabs, and cotton balls.