Classic Autopsy Techniques

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    CLASSIC AUTOPSY TECHNIQUES  The review by Rössle (1) remains the most comprehensive text on classic autopsy techniques and their variations and combinations.

     The techniques of Albrecht, Fischer, Ghon, eller, !etulle, "auwerc#, Ro#itans#y, $irchow, and %en#er, amon& others, are described. The review is written in German and is not readily available. For a comprehensive 'n&lish text with abundant

    references on autopsy techniques and related matters, readers should consult the manual Autopsy—Performance and Practice, compiled by the (olle&e of American )atholo&ists (2). Four principal autopsy techniques can be distin&uished* TECHNIQUE OF R. VIRCHOW +r&ans are removed one by one. This method has been used most widely, often with some modications. +ri&inally, the rst step was to expose the cranial cavity and, from the bac#, the spinal cord, followed by the thoracic, cervical, and abdominal or&ans, in that order. TECHNIQUE OF C. ROKITANSKY

     This technique is characteri-ed by in situ dissection, in part combined with the removal of or&an bloc#s. +nly secondhand descriptions are available. The term /Ro#itans#y0s technique1 is used erroneously by many patholo&ists to desi&nate the removal techniques by Ghon and !etulle, as described in the next para&raphs. TECHNIQUE OF A. GHON

     Thoracic and cervical or&ans, abdominal or&ans, and the uro&enital system are removed as or&ans bloc#s 2/en bloc1 removal3. 4odications of this technique are now widely used. TECHNIQUE OF M. LETULLE

     Thoracic, cervical, abdominal, and pelvic or&ans are removed as one or&an bloc# 2/en masse1 removal3 and subsequently dissected into or&an bloc#s (3). This technique requires more experience than the other methods but has the &reat advanta&e that the body can be made available to the underta#er in less that 56 min without havin& to rush the dissection. 7nfortunately, the or&an mass is aw#ward to handle.

    From* Handbook of Autopsy Practice, 5rd 'd. 'dited by* 8. !udwi& 9 umana )ress :nc., Totowa, "8

    )ost 4ortem Technique andboo# ;econd 'dition

    4ichael T. ;heaepartment of 4orbid Anatomy and istopatholo&y, Royal !ondon ospital,?hitechapel, !ondon, [email protected] 

    >eborah 8. opster, =;c, 4=(h=, 4R()ath >epartment of istopatholo&y,?hittin&ton ospital, !ondon, [email protected] 

    ?ith BC :llustrations ?ith Forewords by 8ohn . ;inard and )rofessor ;ir (olin =erry

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    Advanta&es and >isadvanta&es of the >i

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    example bein& oesopha&eal varices related to cirrhosis and portal hypertension3 these could be destroyed and thereby ne&lected by transectin& the lower oesopha&eal re&ion. +ne can of course modify this method in such cases to preserve oesopha&eal varices by mixin& the methods available. :n some circumstances it may be worthwhile to eviscerate most of the or&ans by means of one method but also includin& limited aspects of another method for one particular site.

    n itu Dissection  The fourth method that of Ro#itans#y, is in our experience rarely performed but is included here brieEy for the sa#e of completeness. This method involves dissectin& the or&ans in situ with little actual evisceration bein& performed prior to dissection. :t may, however, rarely be useful especially if speed is of the essence and the information &leaned from the examination is anticipated and accepted to be limited. This may be the method of choice when performin& post mortems on patients with hi&hly transmissible diseases so that tissue is not removed from the body. :t therefore poses the most limited ris# or threat to anyone except the prosector. :n the past this method has also been described as particularly useful in post mortem examinations performed in the home A schema for di

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    O :n situ 2Ro#itans#y3

    En Masse Dissectin  The most rapid technique, and probably the most convenient for the technician assistin& at the post mortem, is the en masse procedure. As the intestines obscure the abdominal part of  the dissection and are infrequently the source of si&nicant or fatal disease, they are usually

    removed separately before the remainin& or&ans. +f course the bowel is not ne&lected but once separated is examined and opened later. To do this the si&moid colon is identied and the lateral border is lifted as scalpel stro#es are made posteriorly throu&h the mesentery to free this part of the lar&e intestine. 4obilisation can be aided by manually &raspin& the outer wall of the bowel and pullin& this structure anteriorly. ;imilar dissection proceeds proximally, detachin& the descendin& colon, hepatic Eexure 2bein& careful of the nearby spleen3, and transverse and ascendin& colon, eventually elevatin& and freein& the caecum and appendix.

     The duodenoMHeHunal Hunction, now identied as the fourth part of the duodenum, runs anteroinferiorly Hust beneath the lower border of the stomach.Two li&atures or clamps are applied around the small bowel in this re&ion approximately 5 cm apart. The bowel is divided between these ties.

     The cut end of the distal side is elevated with one hand while the other hand dissects away the mesentery close to the bowel wall, either with scissors or by ma#in& a series of

    controlled sweepin& movements with a )4K6.This is continued distally to the terminal ileum, liftin& the subsequent part of the bowel as the precedin& section is dissected. Finally the ileal and caecal dissections should meet and the maHority of the bowel is free except for the most distal se&ment. The rectum is now identied and the luminal contents massa&ed bac# up into the si&moid colon before one slices across the rectum about 5 cm from the anorectal

     Hunction and divides any nal soft tissue attachments posteriorly. The intestinal tract can now be lifted free and removed to the sin#. :f this is not appropriate, as in the case of matted loops of bowel resultin& from adhesions, peritonitis, or widespread intraabdominal tumour, the intestines should be removed still attached to the entire internal contents and all dissected as described in (hapter L. +nce the bowel has been removed, it is possible to be&in evisceratin& the remainder of the or&ans either from the pelvis, proceedin& superiorly, or by dissectin& inferiorly from the

    mouth and pharynx. !etulle0s method follows the former route and be&ins with blunt dissection of the pelvic or&ans and peritoneum from the surroundin& bones. ;tartin& with the lowest part of the exposed abdominal contents, the prosector0s hands should pass retroperitoneally and inferiorly, forcin& the pelvic structures forward. ;tron& n&ers are needed to detach the or&ans forcibly from the lateral wall, extendin& this blunt dissection as far as possible around the rectum, bladder, and prostate &land in male subHects and in females, the internal &enitalia. +nce freed, this &roup of or&ans is &rasped by the nondominant hand and forceful traction is exerted in an upward direction while the most inferior structures are cut across usin& a lar&e )4K6 #nife as close to the pelvic bones as possible. 'xtreme care must be ta#en at this point with controlled #nife cuts because some of this dissection inevitably will be performed under limited direct visualisation. :n male patients the dissection will proceed Hust distal to the prostate &land, which provides a reasonable &rippin& site to apply the necessary traction.

    :n females this cut should be made throu&h the soft tissue of the upper va&inal wall, and the cervix provides the necessary traction site here. 7sin& the same #nife, the incision is extended laterally to sever the external iliac vessels and accompanyin& soft tissue structures.The internal aspects of the cut ends of these vessels should be inspected as they are transacted, loo#in& particularly for atheroma and thrombi. :t is important to cut laterally toward bone with the blade an&led away from the supportin& hand at all times. The dissection continues laterally on both sides around the entire interior aspect of the pelvis, freein& all soft tissue attachments 2except for the spermatic cord in males3, with each side eventually meetin& in front of the sacrum. :n male cadavers the spermatic cord on each side can be traced at this point from the in&uinal canal to the scrotum by rm blunt

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    dissection of the prepubic subcutaneous tissue and the testis retracted throu&h the defect produced and dissected free and removed with the rest of the pelvic or&ans. A%ternati'e%y, t!e spermatic cord can be transected and t!e testis remo'ed separate%y %ater . ?hen completed, this &roup of or&ans is pulled free from the pelvis and the abdominal or&ans are then approached.

     The diaphra&m is dissected away from the internal surface of the body wall alon& its

    complete len&th. This will require insertin& a hand between diaphra&m and liver and spleen,bein& careful not to inHure the latter, as the capsule is easily dama&ed. A&ain it is essential to direct the #nife toward the bone at all times, cuttin& away fro