What are the optimal settings for a Loop Electrosurgical Excision Procedure (LEEP) to minimize char edges and bleeding?

Optimal LEEP Settings to Minimize Char and Bleeding

For LEEP procedures, use blended current settings (specifically Endocut Q mode, effect 2-3, cut duration 1, cut interval 4) or pure coagulation current at 30-50 watts to minimize both thermal artifact and bleeding risk, while avoiding pure cutting current which increases immediate bleeding. 1, 2

Electrosurgical Generator Settings

Recommended Current Type

• Blended currents are preferred over pure cutting currents because pure cutting current causes rapid transection with increased likelihood of immediate bleeding requiring intervention 1
• Pure coagulating current is acceptable and commonly used, though it may produce more thermal artifact than blended current 1
• Microprocessor-controlled units (such as Endocut mode) provide superior results by alternating short cutting bursts with prolonged coagulation periods and limiting peak voltage based on impedance feedback 1

Specific Settings for ERBE Units

• Endocut Q mode: Effect 2-3, Cut duration 1, Cut interval 4 is the recommended setting based on electrosurgical excision guidelines 1
• These settings balance adequate tissue cutting with hemostasis while minimizing char formation 1
• Maximum wattage should typically be 30-50 watts for cervical procedures 1, 2

Avoiding Excessive Thermal Damage

• Conventional blended currents produce better margin evaluability (75.7% vs 60.3%) compared to microprocessor-controlled currents, though both are acceptable 1
• Lower effect settings and controlled cut intervals reduce thermal spread and char formation 1
• The goal is adequate hemostasis without excessive coagulation that creates char edges interfering with pathologic interpretation 1, 2

Additional Techniques to Minimize Bleeding

Local Anesthesia with Vasoconstrictor

• Inject local anesthesia containing epinephrine (lidocaine 2% with epinephrine 1:100,000) into the cervix before excision 3
• This significantly reduces both immediate and delayed hemorrhage (delayed bleeding rate reduced from higher baseline to 6.2% with epinephrine use, P=0.001) 3
• The vasoconstrictor effect of epinephrine is effective for preventing delayed hemorrhage up to 30 days post-procedure 3

Hemostatic Agents

• Apply ferric subsulfate (Monsel's solution) to the excision bed after the procedure for continued hemostasis 4
• Ball cautery electrode can be used for additional hemostasis of specific bleeding points after specimen removal 4
• Fibrin glue or hemostatic patches may be used, though evidence for preventing delayed bleeding is limited 3

Common Pitfalls to Avoid

Current Selection Errors

• Never use pure cutting current alone as it causes rapid transection with minimal coagulation, leading to immediate bleeding requiring intervention 1
• Avoid excessively high wattage settings (>50-60 watts for cervical tissue) which increase thermal damage and char formation 1

Technique Issues

• Avoid prolonged or repeated passes with the loop electrode, as this increases thermal artifact and char at margins 1, 2
• Ensure adequate specimen depth without excessive tissue removal - larger specimens correlate with increased bleeding risk 5
• Do not apply excessive pressure or slow movement speed, which increases thermal spread 1, 2

Post-Procedure Considerations

• Cold knife conization produces clearer margins with less thermal artifact than LEEP, but LEEP is acceptable when adequate margins and non-fragmented specimens without excessive electrosurgical artifact can be obtained 1, 2
• If margins are difficult to interpret due to thermal artifact, consider cold knife technique for future procedures 1

Equipment Standardization

• Ensure all electrosurgical generators in your facility have saved, clearly labeled programs with consistent settings to avoid errors and ensure reproducibility 1
• Consult with your equipment representative to identify settings that approximate the recommended tissue effects if using non-ERBE units 1