Ecto-endocervical disease is treated by a combination of shallow and deep excision or destruction.

In the case of a transformation zone of type 2, the squamo-columnar junction is only fully visible if access to the lower segment of the endocervix is obtained. By spreading the cervical os, usually the full extent of the lesion (highlighted in green) can be inspected.

Given the morphological characteristics above, with a lesion extending into the endocervical canal, loop excision either in one or two steps is feasible. The surgeon uses a loop with larger diameter for the outer part and finishes with a loop of smaller diameter for the endocervical part (‘top hat’ procedure). If the ectocervical part of the lesion covers a large area involving the vaginal vault, the combined use of central loop excision and CO₂ laser vaporization or superficial strip excision of the periphery is the best choice.