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CLASSIC AUTOPSY TECHNIQUES The review by Rössle (1) remains the most comprehensive text on classic autopsytechniques 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 Germanand is not readily available. For a comprehensive 'n&lish text with abundant

references on autopsy techniques and related matters, readers should consult themanual 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, oftenwith some modications. +ri&inally, the rst step was to expose the cranial cavityand, from the bac#, the spinal cord, followed by the thoracic, cervical, andabdominal or&ans, in that order.TECHNIQUE OF C. ROKITANSKY

This technique is characteri-ed by in situ dissection, in part combined with theremoval of or&an bloc#s. +nly secondhand descriptions are available. The term/Ro#itans#y0s technique1 is used erroneously by many patholo&ists to desi&nate theremoval 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 areremoved as or&ans bloc#s 2/en bloc1 removal3. 4odications of this technique arenow 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). Thistechnique requires more experience than the other methods but has the &reatadvanta&e that the body can be made available to the underta#er in less that 56min without havin& to rush the dissection. 7nfortunately, the or&an mass isaw#ward to handle.

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

)ost 4ortem Techniqueandboo#;econd 'dition

4ichael T. ;heaepartment of 4orbid Anatomy and istopatholo&y, Royal !ondon ospital,?hitechapel,!ondon, 7@

>eborah 8. opster, =;c, 4=(h=, 4R()ath>epartment of istopatholo&y,?hittin&ton ospital, !ondon, 7@

?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 couldbe destroyed and thereby ne&lected by transectin& the lower oesopha&eal re&ion. +ne canof course modify this method in such cases to preserve oesopha&eal varices by mixin& themethods available. :n some circumstances it may be worthwhile to eviscerate most of theor&ans by means of one method but also includin& limited aspects of another method forone particular site.

n itu Dissection The fourth method that of Ro#itans#y, is in our experience rarely performed but is includedhere brieEy for the sa#e of completeness. This method involves dissectin& the or&ans in situwith little actual evisceration bein& performed prior to dissection. :t may, however, rarely beuseful especially if speed is of the essence and the information &leaned from theexamination is anticipated and accepted to be limited. This may be the method of choicewhen performin& post mortems on patients with hi&hly transmissible diseases so that tissueis not removed from the body. :t therefore poses the most limited ris# or threat to anyoneexcept the prosector. :n the past this method has also been described as particularly usefulin post mortem examinations performed in the homeA schema for di


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O :n situ 2Ro#itans#y3

En Masse Dissectin The most rapid technique, and probably the most convenient for the technician assistin& atthe post mortem, is the en masse procedure. As the intestines obscure the abdominal part of the dissection and are infrequently the source of si&nicant or fatal disease, they are usually

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

The duodenoMHeHunal Hunction, now identied as the fourth part of the duodenum, runsanteroinferiorly Hust beneath the lower border of the stomach.Two li&atures or clamps areapplied around the small bowel in this re&ion approximately 5 cm apart. The bowel is dividedbetween these ties.

The cut end of the distal side is elevated with one hand while the other hand dissects awaythe 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 ilealand caecal dissections should meet and the maHority of the bowel is free except for the mostdistal se&ment. The rectum is now identied and the luminal contents massa&ed bac# upinto 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 cannow belifted free and removed to the sin#. :f this is not appropriate, as in the case of matted loopsof bowel resultin& from adhesions, peritonitis, or widespread intraabdominal tumour, theintestines should be removed still attached to the entire internal contents and all dissectedas described in (hapter L.+nce the bowel has been removed, it is possible to be&in evisceratin& the remainder of theor&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 bluntdissection of the pelvic or&ans and peritoneum from the surroundin& bones. ;tartin& withthe lowest part of the exposed abdominal contents, the prosector0s hands should passretroperitoneally and inferiorly, forcin& the pelvic structures forward.;tron& n&ers are needed to detach the or&ans forcibly from the lateral wall, extendin& thisblunt dissection as far as possible around the rectum, bladder, and prostate &land in malesubHects and in females, the internal &enitalia. +nce freed, this &roup of or&ans is &raspedby the nondominant hand and forceful traction is exerted in an upward direction while themost inferior structures are cut across usin& a lar&e )4K6 #nife as close to the pelvic bonesas possible. 'xtreme care must be ta#en at this point with controlled #nife cuts becausesome 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 providesa 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 thecervix provides the necessary traction site here. 7sin& the same #nife, the incision isextended laterally to sever the external iliac vessels and accompanyin& soft tissuestructures.The internal aspects of the cut ends of these vessels should be inspected as theyare transacted, loo#in& particularly for atheroma and thrombi. :t is important to cut laterallytoward bone with the blade an&led away from the supportin& hand at alltimes. The dissection continues laterally on both sides around the entire interior aspect ofthe pelvis, freein& all soft tissue attachments 2except for the spermatic cord in males3, witheach side eventually meetin& in front of the sacrum. :n male cadavers the spermatic cord oneach 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 defectproduced 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 . ?hencompleted, this &roup of or&ans is pulled free from the pelvis and the abdominal or&ans arethen 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 essentialto direct the #nife toward the bone at all times, cuttin& away from n&ers to avoidunnecessary inHuries. Then, be&innin& on the left side, the abdominal contents are freedfrom their posterior aspect startin& with the bowel 2if not already removed3,left #idney, ureter, and adrenal &land. This is done by rst identifyin& the descendin& colon,which is then &rasped, pulled medially, and the posterior mesenteric attachments dividedwith cuts. The initial #nife cuts free the more taut attachments of this part of the colon,which will then be partly releasedJ blunt dissection is usually adequate for furtherdetachment. :f the bowel has been removed then a similar technique is followed, startin&with the perinephric soft tissue on the ri&ht. The dissection is extended as posteriorly aspossible retroperitoneally, still wor#in& toward the vertebral column at the midline and thens#irtin& the internal body wall, to include all of the retroperitoneal structures and overlyin&tissue. A similar technique is used throu&hout, with the or&ans and soft tissue retractedanteromedially or pushed down and protected with one hand while the other hand uses acombination of forceful blunt dissection and #nife cuts to free all of the attachments. :n thisway the adHacent or&ans are also freed as they presentJ the spleen, left #idney, and leftadrenal &land are brou&ht into this a&&re&ate of or&ans, now lyin& free from the posteriorbody wall.

The dissection is continued all the way to the midline to include the paraaortic tissue andaorta, with only abdominal wall structures remainin& intact.A similar method is used to free the or&ans on the ri&ht side of the abdomen includin& liver,ri&ht #idney, ri&ht adrenal &land, ascendin& colon, appendix, and caecum 2if present3.=e&innin& at the caecum, a lateral cut is made in the adHacent soft tissue and the caecumand ascendin& colon can be pulled medially exactly as in the case of the descendin& colonon the left side. A combination of blunt and sharp dissection behind the ascendin& colon in afashion identical to that on the left and continuin& retroperitoneally toward the midlineshould similarly free all of the anterior structures.

The dissection continues behind the liver, #idney, ri&ht adrenal &land, and the more medialstructures, once a&ain movin& toward the aorta.+nce the midline is reached, the aorta is freed from its posterior nei&hbourin& structures bycuttin& throu&h the retroaortic soft tissue Hust in front of the vertebral column.Themesenteric root is also detached from the parietal peritoneum. The ri&htsided or&ans willnow be detached to Hoin thepreviously freed or&ans on the left. :n this way the abdominal or&ans includin& theduodenum 2and intestines if still attached3, stomach and pancreas, to&ether with the pelvicor&ans, should then all be free from their anchorin& tissues, and the thoracic structures areall that remain to be addressed.A similar principle of detachin& all surroundin& and posterior attachments is followed forremoval of the thoracic or&ans, with peripheral pleural adhesions bein& bro#en or cut and

the lun&s retracted toward the mediastinum in turn and all or&ans freed from the vertebralcolumn by appropriate blunt or sharp dissection. +nce a&ain, be&in on the left side andretract the lun& by dividin& any posterior attachments still present. The same is done on theri&ht.:f required it is important to loo# carefully at the thoracic duct at this pointJ otherwise it willbe diDcult to identify later.The thoracic duct lies to the ri&ht of the vertebral column in themidline, behind the aorta.The ri&ht lun& is lifted forward and pushed to the lefthand side.

The parietal pleura is incised alon& the upper lateral aspects of the thoracic vertebral bodiesand the duct identied. This is usually most easily found about B to 5cm above the


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diaphra&m. The a-y&ous vein can also be identied and the thoracic duct should runbetween it and the hemia-y&os vein, behind the aorta and alon& the anterior border ofvertebral bodies. :t is recommended that a loose li&ature be placed around the thoracic duct,which can aid locali-ation and produce levera&e to allow careful dissection superiorly andinferiorly before removal.

The only structures that are now intact, and restrict removal of the viscera, are the branches

of the maHor vessels arisin& from the proximal aorta and the soft tissue between the thoracicaorta, superior mediastinum, and vertebral column.The vessels can be severed usin& the)4K6 by slicin&the soft tissue structures at the thoracic inlet beneath the medial clavicular area in a lateraland posterior movement to transect these lar&e branches.

The nec# cuts made previously to free the cervical structures are now extended to thethoracic inlet dissection Hust described. )ullin& the upper thoracicPcervical tissues forwardand inferiorly should free all of the posterior soft tissue attachments, and all of the visceralcon&lomerate should now be free. The entire a&&re&ate can now be removed to thedissection area 2often this is extremely heavy so be carefulJ Fi&. 5.3. The method of or&anseparation is described in (hapter K, and or&an dissection is discussed inthe relevant chapters.

Fi&ure 5.. =ul#y sin&le a&&re&ate of or&ans removed en masse and transferred to the dissectin& tablefor further dissection.

The en mass technique is summari-ed as follows*M +pen the body in the routine manner.M />rop1 the ton&ue.M Remove the bowel from the duodenum to the rectum.M >issect the pelvic structures away from pelvic wall by &raspin& the prostate &land orcervix.M Transect the iliac vessels.


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M >etach the diaphra&m from the body wall.M Free the left #idney, adrenal &land, and ureter.M (ontinue the dissection posteriorly to the midline to release the spleen and pancreas.M Free the liver, ri&ht #idney, adrenal &land, and ureter.M (ontinue medially behind the retroperitoneal structures.M Free the thoracic or&ans peripherally on the left and ri&ht.

M :dentify the thoracic duct if required.M Free the thoracic or&ans by posterior thoracic wall dissection.M >issect the few remainin& vascular and soft tissue attachments.M Remove the or&an con&lomerate to the board and follow the dissection outlined in (hapterK.

En !"c Dissectin The second and seemin&ly more popular method of or&an removal amon& physicians andtechnicians, at least in the 7nited @in&dom, is the en bloc technique, which is a modicationof a method ori&inally described by Ghon. This involves extractin& the or&ans in fourseparate bloc#s 2pluc#s3*the thoracic pluc# 2nec# structures, heart, lun&s, and mediastinum3J the coeliac bloc# 2liver,stomach, spleen, pancreas, and duodenum3J the intestinesJ and the uro&enital bloc#, leavin&

the neurolo&ical system to be removed as a fth bloc# as necessary. The hi&hest thoracic bloc# is removed by reEectin& the ton&ue, nec# structures, and thoracicor&ans in much the same way as described in the previous chapter and section, but thistime from above movin& inferiorly, to include the pleura with the lun&s.?ith the ton&ue andnec# structures freed as discussed in the section on preparation, attention moves to thethorax. All pleural adhesions are obliterated manually or usin& a scalpel.:ncisions will be necessary throu&h the subclavian vessels beneath the medial ends of theclavicles on both sides to free all si&nicant anchorin& structures. At this point loo# for thethoracic duct, if relevant, before proceedin&.

The ri&ht lun& is pushed across the chest toward the left and the medial pleural surfaceinspected.The thoracic duct is said to be found most easily by dissectin& between the aortaand a-y&ous vein in the re&ion of the posterior thoracic wall. The parietal pleura is thenincised alon& the upper lateral aspects of thoracic vertebrae and the duct identied about B

to 5cm above the diaphra&m.The thoracic duct then runs between the a-y&ous andhemia-y&os veins, behind the aorta alon& the anterior border of vertebralbodies. :t is useful to place a loose li&ature around the duct to aid careful dissection up anddown before removal.Further blunt dissection may be necessary between the superior mediastinum and vertebralcolumn, but it should now be possible to place a hand or hands around the larynx, pharynx,trachea, and oesopha&us and pull anteriorly to strip the loose soft tissue connections of theposterior mediastinum and vertebral bodies. Further traction in a caudal direction shouldrelease all of the thoracic structures from the posterior thoracic wall as far down as thediaphra&m.:t is important here to refrain from bein& too a&&ressive if there is any su&&estion oflaryn&eal inHury such as after stran&ulation or han&in&.

The tracheal cartila&es and hyoid bone must be carefully palpated for evidence of suchinHury. :f necessary this area should not be handled further until Qray lms of the larynx areta#en, which may be especially relevant in forensic cases as described in the section onnec# dissection in (hapter B.As the or&ans are pulled forward, the lower ends of the oesopha&us and thoracic aorta areexposed and chec#ed, and after the area around the lower oesopha&us is tied with a len&thof strin& or a clamp these can be cut throu&h above the tie 2or clamp3. This of courseassumes that there is no evidence of oesopha&eal varices, tumours, achalasia, andaneurysms within the inferior mediastinum.?hen the latter is the case it is advisable tofollow either the en masse removal method described earlier or the modication detailed in


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later para&raphs for assessin& lower oesopha&eal varices.The tie is important so as to retainthe stomach contents within the &astric lumen.

The cuts are made above the upper surface of the diaphra&m 2occasionally the diaphra&mmay also require some freein&3, and at this point the thoracic pluc# should be separate andeasily removed to the dissectin& area 2Fi&s. 5.B.and 5.53. The inner parietal pleural surfaceof the chest wall should now be inspected for evidence of tumour, plaques, or other disease

process.*ne common%y used a%ternati'e to t!is simp%e met!od of t!oracic e'isceration is used incases of porta% !ypertension secondary to %i'er cirr!osis #it! suspected oesop!a+ea%'arices !e oesop!a+us is tied and se'ered more superior%y t!an usua%, #e%% a#ay from t!eoesop!a+o+astric -unction !is is usua%%y around t!e midd%e portion of t!e oesop!a+us,%ea'in+ t!e superior part #it! t!e t!oracic b%ock and retainin+ t!e inferior se+ment attac!edto t!e stomac! !e %o#er oesop!a+us is t!en remo'ed in continuity #it! t!e stomac!to+et!er #it! t!e rest of t!e coe%iac b%ock (see %ater) n t!is #ay t!einte+rity of t!e %o#er oesop!a+us is maintained, and it is !oped any 'arices present s!ou%dnot co%%apse

Fi&ure 5.B. The thoracic pluc# viewed from the front. 2(ourtesy of 4r. >ean 8ansen,?hittin&tonospital.3


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Fi&ure 5.5. The thoracic pluc# viewed from behind. 2(ourtesy of 4r. >ean 8ansen, ?hittin&ton ospital.3

The latter can be demonstrated by evertin& the oesopha&us 2turnin& it inside out by pushin&the tied end alon& the oesopha&us and into the &astric cardia3. 'vertin& the oesopha&usmay be aided by

introducin& lon&handled forceps throu&h the &astroMoesopha&eal Hunction lumen, claspin&the tied end of the oesopha&us and pullin& this end bac# throu&h the lower oesopha&us intothe &astric cavity. For optimal demonstration, the varices can be inHected and the method forthis is described in (hapter L.At this point it is useful for the novice to identify and inspect the adrenal &lands prior toabdominal dissection 2particularly in cadavers with a lar&e amount of intraabdominaladipose tissue3, as they occasionally can be diDcult to identify at a later sta&e. A briefinspection at this sta&e will probably be all that is required to identify or exclude si&nicantpatholo&y in either &land.

The next step is to identify and transect the distal duodenum close to the duodenoMHeHunal Hunction. To do this the Hunction is identied by followin& the duodenal loop and locatin& apoint where it be&ins to turn inferiorly beside the pancreas. At this site a hole about 5 cm indiameter is made in the mesentery cm from the mesenteric border of the intestinal wall.

Two clamps are applied or two len&ths of strin& are tied as li&atures around the bowel wallseveral centimetres apart and the intestine cut between them2Fi&. 5.K3. Then one can either be&in here or at the rectum and dissect the bowel from themesentery usin& lar&e scissors or a #nife. :f startin& at the rectum, a hand is placed into theposterior pelvis and the rectum &ripped circumferentially. ere the luminal contents aremassa&ed bac# up into the upper rectum and the lower rectum is cut throu&h with a #nife orlar&e scissors about 5 cm above the anorectal Hunction. :t is important not to cut tooinferiorly and ris# penetratin& the anal s#in. The cut end is lifted and themesorectum dissected.


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Fi&ure 5.K. The duodenum is cut between two ties. 2(ourtesy of 4r. >ean 8ansen, ?hittin&ton ospital.3


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Fi&ure 5.N. The mesentery is dissected from the intestine close to its wall as lon& as there is nosi&nicant mesenteric patholo&y. 2(ourtesy of 4r. >ean 8ansen,?hittin&ton ospital.3

:t is preferable to dissect the intestine close to its wall 2Fi&. 5.N3, leavin& the mesenteryremainin& in the abdomen unless si&nicant mesenteric patholo&y, such as vasculopathy, is

expected. 'ither scissors or a )4K6 can be used for this procedureJ with the latter a bow andstrin& action is required, cuttin& close to the bowel wall extendin& from the rectum tovarious parts of the colon to appendix, terminal ileum, and proximally 2or vice versa3.Thesmall and lar&e bowels can now be lifted from the abdomen for later dissection. :n mostcases nothin& will be lost by dissectin& the bowel out in this way, but when there is anysu&&estion of mesenteric vascular patholo&y, the mesentery should be dissected at its rootin to transect the mesenteric arteries and veins close to their ori&ins or draina&e routes.For this the dissection be&ins at the rectum as before, but as the bowel is lifted free themesenteric base is dissected from its attachment, remainin& in continuity with the small andlar&e intestines. :f this is the case it may be better to remove the intestines with the rest ofthe abdominal contents as described in the previous section on the en massetechnique.?hen intestinal contents are required for analysis a se&ment is tied o< and sentas described earlier.


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Fi&ure 5.. The abdominal or&ans are removed by displacin& the spleen medially and dissectin& theposterior soft tissue to the midline. 2(ourtesy of 4r. >ean 8ansen, ?hittin&ton ospital.3

"ext we turn to the coeliac bloc#, which includes the liver, biliary system, stomach,duodenum, spleen and pancreas. This &roup of or&ans is removed by carefully dissectin&

alon& a plane Hust anterior to the aorta and inferior to the diaphra&m, cuttin& throu&h theanterior aortic branches as they appear 2the coeliac and mesenteric arteries3. :t is usual tobe&in on the left side of the abdomen and rst free the spleen from any peripheralattachments, bein& careful not to dama&e the splenic capsule with excessive clumsiness.

Then proceedin& medially behind the spleen toward the vertebral column, the spleen,pancreas, and surroundin& soft tissue are freed from the underlyin& retroperitonealstructures 2Fi&. 5.3. The aorta is left intact but the coeliac artery is cut close to its ori&in Hustbelow the liver 2Fi&. 5.L3.

A%ternati'e%y, a s!ort se+ment or rin+ of aorta can be taken #it! t!e coe%iac b%ock, #!ic!contains t!e coe%iac a.is.A similar method is followed on the ri&ht side by freein& the liver from the diaphra&msuperiorly and anteriorly, which will usually require cuttin& the posterior part of each leaf ofthe diaphra&m and which may be aided by dissectin& the falciform li&ament.The liver is

retracted medially and dissected from the underlyin& tissues, bein& particularly careful notto dama&e the nearby ri&ht adrenal &land 2Fi&. 5.C3. This &roup of or&ans can then be liftedfree after the inferior vena cava is severed. As with the other bloc#s,it is important to inspect the or&ans for &ross lesions such as tumours, ulcers, metastaticdisease, or cirrhosis.


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Fi&ure 5.L. The coeliac bloc# is separated by cuttin& throu&h the vessels ori&inatin& from the anterioraspect of the abdominal aorta. 2(ourtesy of 4r. >ean 8ansen, ?hittin&ton ospital.3

This leaves the adrenal &lands, #idneys, ureters, bladder, and &enital or&ans as the lastbloc# with the attached abdominal aorta and iliac vessels.

The #idneys are inspected rst by dissectin& the fat around the posterolateral aspect of the#idney with a curved incision and extendin& the cuts medially behind the aorta.@eep awatchful eye out for beni&n cortical cysts while doin& this because these are very commonand can unexpectedly shower the prosector with cystic EuidA&ain be&in on the left and free the #idney by retractin& it medially while dissectin&posteriorly 2Fi&. 5.I3. ;uperiorly the dissection continues to include the adrenal &land withthe #idney, and both are eventually freed from the underlyin& soft tissue. A similar methodof dissection is followed on the ri&ht, a&ain dissectin& in a medial direction behind the#idney, aimin& to #eep the adrenal &land with the #idney. :f the dissection continuesposteriorly and carefully the renal vessels will not be inHured durin& this part of theevisceration and the soft tissue behind the ureters can also be dissected free from behind.


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Fi&ure 5.C. The liver is lifted medially and the posterior soft tissues dissected to detach the ri&ht side of the coeliac bloc#. 2(ourtesy of 4r. >ean 8ansen,?hittin&ton ospital.3

The ureters and surroundin& vessels are located and traced to the pelvic brim, freein& thesurroundin& soft tissue connections. (omplete the dissection of this superior &roup of

structures from the vertebral column by retraction of the aorta and extendin& the blunt orscalpel dissection of the soft tissue posterior to the abdominal aorta, Hust anterior to thelumbar spine, down toward the lumbosacral Hunction. At this point the #idneys and upperabdominal aorta are freed and the lower urinary tract is still intact, but requires dissection.

The idea now is to remove the pelvic or&ans to&ether by dissectin& around the inside of thepelvic bones and severin& the lar&e external iliac vessels. 4ost of this dissection can beperformedwith stron& n&ers followin& the line of the inner pelvic surface.


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Fi&ure 5.I. The left #idney is &rasped and its posterior attachments divided. 2(ourtesy of 4r. >ean 8ansen,?hittin&ton ospital.3

The bladder is rst separated from the pubis inferiorly by blunt dissection and this dissectionis continued around the urethra and prostate in males and the va&ina in females and nally

the rectum. )osterior soft tissue attachments are divided around the sacral promontory. =yextendin& the retroaortic dissection behind the common iliac vessels, the pelvic or&ans cannow be &rasped with one hand at their most inferior point and pulled up while cuts are madethrou&h the Eoor of the pelvis. For the routine examination the lowest point is mar#ed by theprostate in males and the cervix and upper va&ina in females. :n common with the otherevisceration methods, a rm &rip around these structures allows an important element oflevera&e so that traction can be applied in a superior direction to permit a #nife to passthrou&h the urethra, va&ina, and rectum, #eepin& the prostate and cervix intact and incontinuity with the rest of the tract. The external iliac vessels are divided and any remainin&soft tissue strands are dissected or pulled apart. The or&ans can now be removed from thebody. Retainin& the entire &enitourinary tract complete in this way allows excellentdemonstration of proximal eilated ureters indicate that there isobstruction to urine Eow in the tract beneath the dilated portion.

This is commonly caused by calculi, cervical neoplasms, or beni&n or mali&nant prostaticdisease obstructin& the lower tract. :n addition, the male uro&enital tract can also bedemonstrated in its entirety 2if time permit3 and the testes and vasa deferentia can also beincluded in this bloc#. The testes are removed by retractin& the spermatic cord in thein&uinal canal after blunt dissection of the subcutaneous tissue of the lower abdominal wallin the pubic re&ion usin& n&ers. To do this, two or three n&ers are forcibly introduced intothe soft tissue overlyin& the pubic symphysis and a channel is produced from the medialpart of the in&uinal canal to the scrotal sac. The spermatic cord is &rasped here andwithdrawn toward the abdomen. !oose soft tissue attachments in the scrotum may need alittle encoura&ement to detach by &entle scalpel cuts. +nce freed the vas deferens within


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the spermatic cord is traced to the posterior surface of the bladder close to the seminalvesicles.These procedures are rather time consumin& and rarely demonstrate si&nicantpatholo&ical lesions relevant to the cause of death, but they may impress an examiner in anotherwise mediocre post mortem examination performance. =loc# dissection is a&aindescribed in (hapter K.

The standard en bloc technique is summarised as follows*!oracic b%ock M )erform routine dissection of the nec# and brin& the ton&ue down.M Free pleural adhesions and identify the thoracic duct.M Apply caudal traction on the nec# structures, which should release posterior attachments.M :dentify the lower oesopha&us, tie, and transect 2if no si&nicant patholo&y hereJ ifpatholo&y tie and transect hi&her3.M >ivide the descendin& aorta.M Remove the /pluc#.1ntestina% b%ock M :dentify the duodenoMHeHunal Hunction.M Tie and cut between ties.M :dentify the upper rectumPlower si&moid colon and free them from surroundin& soft tissue.M (ut across the upper rectum and be&in cuttin& across the mesentery close to the bowelwall 2or be&in at the upper duodenal tie and proceed inferiorly3.M Free the small and lar&e intestines.M Remove to the sin#./oe%iac b%ock M :dentify the spleen and pull medially to enable dissection posteriorly in front of left #idneyto the midline.M Free the liver and dissect the posterior peritoneal soft tissue and retroperitnoneal tissueanterior to the ri&ht #idney to the midline.M !ift the or&an &roup and cut across the anterior aortic branches as they appear.M !ift the bloc# away for dissection 2see (hapter K3.0ro+enita% b%ock M >issect behind the left #idney to release it 2include the adrenal &land3.M >o the same on the ri&ht.M >issect the retroperitoneal soft tissue to expose ureters and trace to the bladder.M =lunt dissect soft tissue around lower bladder.M Grasp the lower bladder and prostate &landPcervix and cut below to release.M Release the pelvic or&ans from peripheral attachments 2include spermatic cords and testesif required3.M >ivide the iliac vessels.M !ift the bloc# away for dissection 2see (hapter K3.

In#i$i#%a" O&'an Re($a" )t*e Vi&c*+ Met*#,:n this technique the or&ans are removed one by one sequentially, isolated, and dissectedimmediately after removal. The maHority of complete and detailed or&an dissection methodsare described in the relevant chapters rather than here to avoid extensive repetition.:ndividual or&an removal is said to be the one of the most widely used techniquesworldwide. As ori&inally described, the rst step was to expose the cranial cavity to assessaccurately the quantity of blood in the cerebral vessels, proceedin& to thespinal cord followed by thoracic, cervical, and abdominal or&ans, in that order. As discussedearlier, this technique is e


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and the cranial cavity is now left until last, the examination proceedin& throu&h theperitoneal, pleural, and then pericardial cavities, which are opened and inspected, with theor&ans removed from those areas in reverse order.

The rst step is to inspect the abdominal wall. Then assess the abdominal cavity and removeany Euid and establish its amount and appearance.

The abdominal or&ans are inspected and palpated before any dissection ta#es place. :t is

su&&ested that the &astrointestinal tract be chec#ed rst, includin& the appendix andmesenteric lymph nodes. "ext assess the spleen, liver, #idneys, and pelvic or&ans. Thepancreas can be inspected by tearin&throu&h the omentum between the stomach and colon, openin& the lesser sac.Attention is now directed to the thorax. f t!e e.amination is restricted to an abdomina%incision on%y, Ma%%ory 1 su++ests t!at t!e ma-ority of t!e t!oracic contents can be remo'edfrom be%o# o do t!is, rst t!e diap!ra+m is detac!ed from a%% of its perip!era% t!oracicca+e attac!ments 4e.t, t!e posterior mediastina% structures are pus!ed a#ay from t!e 'ertebra% co%umn by b%unt dissection #it!t!e !and!e arc! of t!e aorta is t!en %ocated and pu%%ed inferior%y !e %oca% structures area%so pu%%ed do#n and t!e +reat 'esse%s are transected -ust abo'e t!eir ori+ins A rm +raspsand forcefu% cauda% traction #i%% a%%o# a%% of t!ese structures to be re%eased and pu%%ed do#nto#ard t!e abdomen !e tissue is t!en cut across as !i+! as possib%eRoutinely, however, the thoracic contents will be exposed by removin& the sternum. :nexaminin& the thorax it is rst necessary to inspect the pleural cavities thorou&hly andcollect any Euid as described previously."ext, dissect away all pleural adhesions by blunt dissection or with the #nife blade. :f theparietal pleura is rmly attached to the lun&s it will need to be stripped with the lun& asdescribed earlier. To recap brieEy, this is done by pushin& the parietal pleura away from thechest wall toward the lun& by ndin& the plane immediately outside this serosal surface atthe point where the sternum has been removed and wor#in& the hand alon& this plane.?hen wor#in& in the thorax one must be careful of any sharp ed&es at the ends of the cutribs. A towel can be placed over the exposed bone or the chest wall s#in can be wrappedbac# over to cover these rou&h ed&es. Attention is turned to the anterior mediastinal softtissue, and interstitial emphysemashould be chec#ed for. :n an adult the normal thymus will be atrophic but it should beinspected at this point in case unexpected patholo&y is present. "ow the pericardium needsto be inspected before it is opened. :f a haemopericardium is present the outer surface willoften appear blue before it is opened and the clotted and Euid blood can be collectedthrou&h the incision described below and quantied by measurin& its volume in a measurin&

Hu&. "ormal pericardial Euid is straw coloured and has a volumeof N to N6 ml. The simple way to open the pericardium is to lift the middle of the anteriorwall with n&ertips or forceps and snip throu&h with mediumsi-ed scissors to create a smallhole.Then this incision is continued superiorly alon& the ri&ht border to the root of the lar&evessels ori&inatin& from the heart and inferolaterally toward the apex. !iftin& the sac retainsany contents for assessment. =lunt dissection may be required for loose adhesions, but withdense adhesions, such as after cardiac sur&ery, this may not be possible and thepericardium will need to be dissected later with the heart. ?hen the pericardial sac isemptied the external form and epicardial surface of the heart can be assessed.

The heart is then removed by liftin& the apex and cuttin& throu&h the attached vessels in

order of presentation. This will entail transectin& the inferior vena cava rst, then thepulmonary veins on both sides, followed by the superior vena cava, the pulmonary artery,and lastly the aorta. :f there is a suspicion of a pulmonary embolus it is important to openthe pulmonary arteries rst. *b'ious%y it is a%so possib%e to remo'e t!e !eart in t!e mannerdescribed %ater for b%ock dissection of t!e t#o pre'ious%y out%ined e'isceration met!ods nbrief, t!is in'o%'es passin+ t#o n+ers be!ind t!e aorta and main pu%monary artery -ustabo'e t!eir ori+ins from t!e %eft and ri+!t 'entric%es and cuttin+ across t!ese #it! scissors!eir %umina are inspected 4e.t, t!e !eart is %ifted and t!e 'eins returnin+ b%ood to t!e!eart


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from t!e systemic and pu%monary circu%ations are cut t!rou+! as c%ose to t!e outer pericardia% surface as possib%e. The heart is lifted free for further dissection. The exposed posterior pericardial surface cannow be inspected. (learly either a Ghon type of evisceration or preferably the en massetechnique is much more appropriate if extracardiac vascular disease is suspected such asvena caval thrombi or a dissectin& aortic aneurysm. :n this case more information can be

&ained from #eepin& the cardiovascular system as intact as possible so that the extent ofinvolvement of the patholo&ical process can be establishedaccurately. This is discussed further in the relevant sections later in this chapter.After the left lun& is freed from all of its pleural attachments it should be lifted forward out of the pleural cavity and the root held with the noncuttin& hand while the dominant hand isused to cut throu&h this hilar tissue to detach the lun& throu&h the primary bronchus,vessels, and pleura. An identical method is used to remove the ri&ht lun&. :f the lun&s are tobe inEated it is important to cut the primary bronchus toward the carina to leave a lon&enou&h stump for cannulation. :f the thoracic duct requires inspection this should be doneearly in the examinationJ otherwise it becomes too diDcult to identify. This may benecessary in patients with miliary tuberculosis or a chylous hydrothorax. To do this, removethe leftlun& as described earlier. =efore the ri&ht lun& is removed it is lifted forward out of pleuralcavity and pushed to the left. The parietal pleura is then incised alon& the upper lateralaspects of the thoracic vertebrae and the duct identied. :t lies to the ri&ht and posterior tothe aorta and is found by dissectin& between the aorta and the a-y&ous vein, and is mosteasily identied B to 5 cm above the diaphra&m. +nce the a-y&ous vein is identied thethoracic duct will be found lyin& between it and the hemia-y&osvein, where it runs behind the aorta alon& the anterior border of vertebral bodies. :t is oftenhelpful to place a loose li&ature around it and carefully dissect up and down before removal.:f this proves too diDcult it may be necessary to rst identify the cisterna chyli which lies inthe abdomen in the ri&ht retroaortic and paravertebral tissue at the level of !BM5 beforeproceedin& superiorly into the thorax. The ri&ht lun& can subsequently be removed asdescribed previously for the left. 4ovin& to the nec#, the soft tissue attachments around thelateral and posterior aspects of the upper oesopha&us and trachea are dissected to free thestructures of the nec#. The or&ans can then either be removed for separation or dissected insitu. :f removed to&ether this is very similar to the thoracic bloc# evisceration methoddescribed earlier for the en bloc section 2without the heart and lun&s3. :f not then theposterior wall of the pharynx is cut throu&h Hust next to the uvula from behind and thepharynx is inspected. The tonsils are incised and the posterior wall of the oesopha&us is slitin the midline. :f the mucosal surface is normal, cut throu&h the oesopha&us 2dividin& intotwo3 to open the posterior wall of the trachea. The tracheal mucosa is nowinspected. !on&itudinal incisions can then be made in each lateral lobe of the thyroid or thethyroid can be removed prior to dissection as described later.

The parathyroid &lands should now be identied, all four if possible. :f patholo&ical,identication is usually strai&htforward as lon& as one #nows where to loo# and what theparathyroids loo# li#e. They are Eattish oval structures, yellowbrown in color, and their si-eis variable, about mm in len&th by B to 5 mm in the other dimensions. >espite variations innumber, si-e, and site they are usually found on the posterior surface of the medial side ofthe lateral lobes of the thyroid, close to the oesopha&us. :f it proves

diDcult to nd them rst identify the inferior thyroidal artery and trace it to the thyroid&land. The inferior parathyroid &land is usually located Hust below the site at which the arteryenters the thyroid &land, and the superior &land lies several millimetres above this area. :t isthe inferior &land in fact that is particularly variable, sometimes bein& associated with thethymus, lyin& embedded in the thyroid, anterior to the lower thyroid or even on its own inthe soft tissue beneath. The carotid bodies can also be seen at this point immediately at or

Hust above the bifurcation of common carotids on the medial side. They are usually about Nmm in len&th.


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The abdominal or&ans are inspected in situ and all intraabdominal Euid is collected in amanner similar to that used for the other serosal cavities.:f peritonitis is found the source should be identied by palpation and inspection beforedissection. +nce a&ain, if di


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mesentery can be removed by dissectin& it free from the duodenum and the intestinesremoved to the sin#.

A%ternati'e%y, t!e mesentery and sma%% bo#e% can be kept in continuity #it! t!e duodenumand subse5uent%y remo'ed #it! it to+et!er #it! t!e stomac! and pancreas. The latter isbest done by initially separatin& the stomach from the liver by blunt dissection and thencuttin& throu&h the diaphra&m around the oesopha&us to free it.

"ext the hepatic hilar structures will have to be divided, and this is accomplished bystretchin& the hepatoduodenal li&ament to demonstrate the vessels that run here, followedby cuttin& throu&h these structures in the followin& order* hepatic artery, common bile duct,and portal vein. These are inspected as they are cut and can be traced superiorly into theporta hepatis and early hepatic branches, and inferiorly as they present."ow &rasp all of the structures anterior to the aorta and inferior vena cava and cut frombelow alon& the plane immediately in front of the aorta toward the chest.The last structureto be cut is the lower oesopha&us, which may require tyin& rst to retain the &astriccontents. :f oesopha&eal varices are suspected, however, the oesopha&us should be dividedhi&her up and the lower portion retained with the stomach as described earlier. This &roup of or&ans is very much li#e the coeliac pluc# obtained by means of the en bloc technique 2butwithout the liver3, and a similar or&an separation and dissection technique can be applied.:n brief, the stomach and intestines can be opened with scissors, the small bowel alon& themesenteric side. The stomach is usually opened alon& the &reater curve, with care to avoidany mural lesion, which should be #ept as complete as possible for later dissection. Theduodenum is opened with sharp scissors throu&h its anterior wall and the incision iscontinued to the pylorus proximally and the distal duodenum caudally. The lar&e bowel isopened in a similar manner alon& the antimesenteric border 2see (hapter L3.

The liver is usually the last or&an last to be removed, althou&h if it is clearly normal it maybe removed before the rest of the intraabdominal or&ans to provide more space fordissection of the latter. To do this, pass the left hand between the ri&ht lobe of the liver andthe diaphra&m and push the liver forward out of the ri&ht hypochondrium. :t is su&&estedthat a useful tip to help removal of the liver is to slice throu&h the entire or&an in ahori-ontal plane at this point. =lunt dissection is required to separate the &allbladder fromthe undersurface of the liver, possibly with additional &entle scalpel movements, and thehepatic duct cut throu&h. Remove the &allbladder for dissection by cuttin& throu&h one wall,inspectin& themucosa and contents."ow &rasp the liver by placin& the thumb under the lower anterior border and insert theremainin& n&ers into the lon& incision for &rip. !ift the or&an and cut throu&h thehepatoduodenal li&ament under close supervision as described earlier. "ext dissect o< thehepato&astric li&ament, inferior vena cava, falciform li&ament, coronary li&ament, and thesoft tissue between the liver and ri&ht #idney, bein& careful not to dama&e the ri&ht adrenal&land.Finally, elevate the ri&ht lobe and free all the attachments here, as far posteriorly as thevertebral column. The liver can now be lifted away.

The pancreas can be identied by liftin& the anterior wall of the stomach and palpatin& theposterior soft tissue. The soft tissue around the pancreas is dissected away and the or&anscan be removed for assessment.The superior border of the pancreas may be identied byfollowin& the course of the

splenic artery, which lies above it. The &enitourinary tract and lar&e abdominal vessels now remain in the body. The #idneysand adrenal &lands are either removed to&ether or each #idney is shelled out of its capsulefollowed by subsequent removal of the adrenal &lands. +nce a&ain be&in on the left side. :fthe #idney and adrenal &land are to be removed to&ether, the soft tissue medial to andabove the left adrenal &land is cut into and a curved incision is made toward the lateralabdominal body wall. This is Hoined by a further curved incision extendin& alon& the lateralborder of the #idney to meet at the lateral aspect of the superior cut described. The incisionsshould penetrate the peritoneum and perinephric fat. The left hand is introduced into the


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hole produced lateral to the #idney and the latter is &rasped and elevated as the soft tissuedissectionis continued posteromedially.The left #idney and adrenal &land can now be held free from alllateral and posterior attachments but medially the renal vessels and ureter are stillattached. >ependin& on the presence or absence of si&nicant ureteric patholo&y the ureteris divided either hi&h, close to its pelvic Hunction, or more inferiorly and can be opened alon&

its len&th at this point. The renal vessels are transected as close to the aorta and inferiorvena cava as possible so that the renal artery and vein can be opened and inspected. Anidentical procedure is followed on the ri&hthand side. The adrenal &land on each side cannow be dissected o< and the perinephric fat cleared away.!e second met!od in'o%'es a simi%ar %atera% cur'ed incision on eac! side but t!en n+ersare #orked into t!e p%ane around t!e capsu%e, #!ic! is nicked and pee%ed back to e.poset!e subcapsu%ar surface !e kidneys are remo'ed by pee%in+ t!e capsu%es a#ay media%%y tot!e !i%a and by cuttin+ t!rou+! t!erena% 'esse%s and upper ureter !e capsu%es remain #it!in t!e body The adrenals aredissected free from the overlyin& perinephric fat.?hen the lower urinary tract is obstructed, however, with associated upper urinary tractchan&es, the whole tract should be removed to&ether.

This method involves the same perinephric soft tissue dissection as described earlier but therenal hilar structures are not divided. The ureters are traced in the surroundin&retroperitoneal soft tissue and the latter dissected away down to pelvic brim.The pelvicor&ans are dissected free from the lateral pelvic wall and inferior attachments 2as describedin both the en bloc and en masse evisceration techniques and a&ain later3 and the&enitourinary tract removed in continuity for dissection as described for the&enitourinary bloc# of the Ghon technique.:n fact the pelvic or&ans are most neatly and easily removed by the same method that hasbeen described previously.This involves strippin& the peritoneum from the pelvic wall withstron& n&er action even when the structures of the upper urinary tract have already beenisolated and removed.

The blunt dissection be&ins over the anterior bladder surface, at its lower border, and thesoft tissue separation is continued laterally on both sides until the n&ers meet beneathrectum. +nce the posterior aspect is freed from the sacrum and local tissues the onlyattachments inferiorly are the lower rectum and &enital openin&s and posteriorly theperitoneum and vessels.A cut is made throu&h the rectum, Hust below the prostate or urethraand va&ina after the inferior structures 2prostate or cervicova&inal area3 are &rasped withthe noncuttin& hand and traction is exerted in an upward direction while cuttin&.

The posterior attachments are now transacted with care not to inHure the ureters if stillattached. The spermatic cord can now be located in the in&uinal canal and transected toallow removal of the pelvic or&ans. The testes can also be removed to&ether with the pelvicor&ans by dissectin& the soft tissue over the pubic bones, beneath the s#in, and insertin&n&ers around the spermatic cord into the scrotum and pushin& the testes superiorlythrou&h the incision at the same time. A limited amount of careful cuttin& may be requiredto free the testis completely. :f the cord has been severed the testes can be removed ontheir own in this way. +r&an separation and dissection will a&ain follow the same protocol asthat for the &enitourinary bloc# of the en bloc technique.At this sta&e there are few remainin& structures left in the body to be examined. The inferior

vena cava and its branches can be opened in situ, extendin& the dissection to include iliacvessels and more peripheral veins if required. ;imilarly the aorta should be opened in situthrou&hout its len&th, includin& iliac vessels and main branches, althou&h it is obviouslyeasier to remove the thic#er walled aorta intact before openin& than the thinner and moredelicate venous structures. $ertebral bone marrow can beassessed by sawin& the bodies of the lower lumbar vertebrae parallel to the surface about cm deep usin& either a handsaw or an electric saw. For a more detailed description of thisand extensive bone marrow samplin& see (hapter 6.


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The $irchow 2individual or&an3 technique is summarised as follows 2or&an dissection mayoccur at the same time3*M :nspect the abdominal contents.M :nspect the pleural cavities.M +pen the pericardium and remove the heart.M Remove the left and then the ri&ht lun&s.

M Assess the pharynx, oesopha&us, trachea, parathyroid &lands, and thyroid &land.M Remove the spleen.M Assess biliary tract patency.M Remove the intestines.M +pen the stomach.M Remove the liver.M Remove the pancreas.M ;hell out the left and ri&ht #idneys and adrenal &lands.M Trace the ureters.M >issect the pelvic structures.M :nspect and open the lar&e arteries and veins.

In Sit% Met*# )R-itans- Tec*ni/%e,

Followin& this method, the thorax and abdomen are opened in the usual fashion and thecavities and or&ans are inspected in situ before they are dissected. The superior mediastinal structures are examined rst, be&innin& with the thymus, then thearch of the aorta and its main branches, and nally the superior vena cava and its branches.:nspection then turns to the pleural cavities, where all Euid is collected and adhesionsdivided as described earlier. "ow &rasp and lift the ri&ht lun& forward, #eepin& the hilumintact, and ma#e a supercial lon&itudinal cut in pleura with the scalpel or )4K6 alon& thelateral vertebral bodies at the posteromedial aspect of the ri&ht pleural cavity to expose thea-y&ous vein and the thoracic duct. :nspect these carefully.The ri&ht lun& is then lifted out of the chest and laid on the anterior chest wall. An&lin& it sli&htly with the left hand, hold thefront half of the medial surface toward the prosector. After this is done, a lon&itudinal slice ismade throu&h all three lobes from anterior to posterior about B cm below the anteriorborder. The slice is made deeply, almost completely throu&h the substance of the lun&, to

almost divide the lun& into two equal halves. Further cuts are made throu&h any focallesions identied. The lun& is then placed bac# into the ri&ht cavity. The left lun& is liftedfrom the left pleural cavity and an identical procedure is followed on this side, slicin&throu&h both lobes, and the lun& returned to the thoracic cavity.

The heart and pericardial cavity are inspected and opened next. The rst step is to pic# upthe anterior pericardium with toothed forceps and cut superiorly and inferiorly after ma#in&a small hole in the sac. Any Euid or blood is obviously removed at this point forquantication. This allows the anterior border of the heart to be inspected throu&h the holeand the heart can be lifted out of the hole by insertin& a hand around the heart and pushin&the pericardium aside. As the heart is lifted it is swun& sli&htly to the ri&ht so that the ri&htventricle and auricle lie a&ainst the cut ends of the ribs of the ri&ht chest ca&e. Then the rstincision is made with a )4K6, cuttin& into the left border of the heart from the apex andcontinuin& the dissection to the area where the left pulmonary veins drain into the leftatrium. Try to avoid cuttin& throu&h the mitral valve durin& this incision and wait until theventricle has been opened completely, the contents removed, and the valves palpated andassessed completely before continuin&.

Then the point of the #nife is inserted throu&h the valve and the incision continued to theleft pulmonary veins. The endocardial surface of the left atrium and ventricle can now beexamined.The incision should be made in such a way as to leave the anterior and posteriorpapillary muscles intact so that they can be examined without bein& transected. Then lift theheart a&ain and do the same on the ri&ht side.:nsert the point of the #nife throu&h the wall at the ri&ht border of the heart at the apex andcut from the apex to a point midway between the Hunction of the entry points of the vena


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cavae into the ri&ht atrium. old the #nife with the blade pointin& outward and cut frominside to out 2endocardium to epicardium3. The ed&es of the incision are then held apart andthe endocardial surface of the ri&ht atrium and ventricle should then be wiped with a spon&eand examined. "ext &rasp the apex a&ain with the left thumb inside the cavity of the ri&htventricle. )ush the point of the #nife throu&h the pulmonary conus and valve to a point 5 cmabove the valve where an incision is made throu&h the anterior wall of the artery. Then the

incision is continued to cut throu&h the pulmonary artery and anterior left ventricular wall ina line toward the apex, #eepin& as anteriorly as possible. The aorta now needs to be opened.To do this &rasp the apical area a&ain by holdin& thetrian&ular wed&e of myocardium of the anterior wall of the heart between the n&ers andthumb of the left hand. !ift this tissue and rotate the heart sli&htly to the ri&ht while passin&the #nife or the blade of a lar&e pair of scissors throu&h the left ventricle into the aorta. Aswith the pulmonary artery, the point of the #nife should be pushed throu&h the anterioraortic wall above the valve and a cut made throu&h the aorta, which will also divide theposterior part of the pulmonary outEow tract, anterior ri&ht ventricular wall, and part of theventricular septum. A%ternati'e%y, scissors can be used to cut t!rou+! t!e aorta, cuttin+across t!e pu%monary 'a%'e about 1cm abo'e t!e 'a%'e rin+ e.tendin+ into t!e aorta. Thislatter method retains the septum intact and the valves can be inspected more easily.Attention now turns to the abdomen. A&ain, all of the intraabdominal or&ans are examinedbefore dissection be&ins and the peritoneum inspected. +nce a complete &ross examinationhas been made, dissection starts with the liver. The left hand is passed between the ri&htlobe of the liver and the diaphra&m, liftin& the liver out of the ri&ht hypochondrium.+nce the liver is exposed, a deep transverse cut is made across both lobes.

The &allbladder is then inspected and dissected free from its hepatic attachments.(ut the cystic duct close to the common bile duct and remove the &allbladder beforeopenin&. To remove the liver lift it once a&ain with the noncuttin& hand with the thumbunderneath and the n&ers inserted into the previous transverse incision and expose thehepatoduodenal li&ament.?ith &entle slicin& movements, open the structures contained within the li&amentJ thehepatic artery, common bile duct, and portal vein. These are inspected as they are cut andcan be traced superiorly and inferiorly as they present. Then cut throu&h the inferior venacava, the falciform li&ament, thecoronary li&ament, and the soft tissue above the ri&ht adrenal &land. The liver should nowbe separate and can be inspected in isolation and moved out of the way for laterexamination.

The spleen is then lifted out of the left hypochondrium and rested on the rib ca&e on the left.A hori-ontal section is made throu&h the bul# of the parenchyma from the diaphra&maticsurface to the hilum. The cut surface is inspected before the hilar structures are severed andthe spleen removed.

To &ain access to the ri&ht #idney rst lift the caecum and dissect the posterior soft tissueattachments of this and the ascendin& colon. >isplace this section of the lar&e intestinemedially to reveal the underlyin& ri&ht #idney.Grasp the #idney with the noncuttin& hand and dissect the surroundin& soft tissue laterallyby ma#in& a curved incision in the perinephric fat parallel to the convex outer border.(ontinue the dissection posteriorly and superiorly, freein& all of the soft tissue but bein&careful to leave the hilar vessels, ureter, and adrenal &land intact 2Fi&. 5.I3. >issect the hilar

soft tissue to identify the renal vessels and cut across these midway to the #idney. Theureter is untouched at this sta&e. "ow bisect the #idney from its convexity to the hilumthrou&h calyces and pelvis and inspect the cut surface. ;trip the capsule by &rippin& the cuted&e with toothed forceps and peelin& it awayJ examine the subcapsular surface. +pen therenal pelvis with scissors by piercin& the wall and cut alon& the ureter inferiorly down to thepelvicbrim 2Fi&. 5.63. 4a#e a sa&ittal section throu&h the ri&ht adrenal &land and inspect the cutsurface. The procedure is virtually identical for examinin& the left #idney and adrenal &land


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but in this case it is the soft tissue around the descendin& colon that needs to be separatedin order to expose the underlyin& #idney and adrenal &land.

To free the pelvic or&ans, blunt dissection of the peripheral soft tissue is required, usin&stron& n&er movements to separate the or&ans from the pelvic side wall be&innin& in theprevesicular space and extendin& posterolaterally to end behind the rectum. Grasp the mostinferior structures, the prostate &land or cervix and upper va&ina, with the noncuttin& hand

and apply traction in an upward direction while the )4K6 sweeps across the pelvic Eoor withthe blade dividin& all of the soft tissue. The posterior softtissue attachments between the rectum and the coccy&eal bone are dissected o< and thepelvic or&ans are lifted out onto the front of the symphysis pubis.The iliac vessels are leftintact.The rectum is opened throu&h its posterior wall and cleaned, and the mucosal surfaceis inspected.Removal of the uro&enital or&ans will vary to some extent dependin& on the &ender of thecadaver. :n males pointed scissors are used to ma#e a hole in the anterior wall of the bladderand the incision continued into the urethra, cuttin& throu&h the prostate &land. The cutsurface is inspected as the cuts are made. "ow examine the ureteric openin&s on each sidefrom the inner aspect of the bladder and probe if necessary. The testes are withdrawn intothe abdomen by blunt dissection beneath the pubic s#in and)oupart0s li&ament. Firm manipulation with the n&ertips may be necessary to free thespermatic cord and testis. +nce free, both are retracted into the pelvis. 'ach is cut in half todemonstrate the pulp of the testis and a section is made throu&h the epididymis.

Fi&ure 5.6. The ureters are opened with scissors form the renal pelvis to the bladder. 2(ourtesy of 4r.>ean 8ansen,?hittin&ton ospital.3

Returnin& now to the posterior aspect of the pelvic bloc# of or&ans, the rectum is dissectedo< by cuttin& alon& its anterior wall and the underlyin& seminal vesicles incised. :f the penis


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needs to be removed the anterior s#in incision is extended to a point about halfway alon&the dorsal side of the penis. The envelopin& s#in is dissected o< by liftin& each cut ed&e inturn followed by scalpel slices alon& the dermoMsubcutaneous tissue Hunction laterally sothat the dissection on each side meets in the midline at the ventral aspect. The penis isdivided immediately proximal to the coronal sulcus. The corpora cavernosa with inte&ralurethra are now forced bac# into the pelvis under the pubic arch and the lateral attachments

divided.:n females the bladder is opened throu&h the anterior wall via the urethra continuin& theincision upwards in the midline. A&ain the ureteric orices and mucosa should be inspected.

The va&ina and uterus can be opened by either cuttin& throu&h the anterior wall a&ain withscissors throu&h the external cervical os or similarly throu&h the posterior wall afterremovin& the rectum. The former method will obviously cut throu&h the posterior bladderwall and separate the bladder into two halves. +nce the central fundal area is reached in theuterus the incisions are extended laterally on each side to the cornu. The fallopian tubes areopened lon&itudinally with scissors from the mbrial end. The ovaries are sectionedlon&itudinally. Allpelvic or&ans can now be removed from the body if necessary.

The remainin& or&ans still lyin& within the abdominal cavity are the stomach, intestines, andpancreas. ;tart by openin& the stomach by ma#in& a Kcm incision in the anterior wall at thelevel of the pylorus with the pointed end of a pair of scissors. 'xamine and collect anycontents as described previously. (arry this incision superiorly about Bcm below and parallelto the lesser curve up to the cardia and esopha&eal Hunction. To examine the duodenum rstdissect all attachments between the upper &astrointestinaltract and the transverse colon. Return now to the pyloric incision and continue this inferiorlythrou&h the &astroduodenal Hunction alon& the anterior wall of the duodenum as far as thebe&innin& of the HeHunum.?ash o< any adherent material from the &astric and duodenal mucosa and inspect thesurface closely. !ocalise the ampulla of $ater and probe it. +nce probe patency isestablished, insert scissors throu&h the openin& and cut to expose the bile duct mucosalsurface.

To inspect the pancreas cut throu&h the adipose tissue attached to the stomach and lift thelower border of the stomach upwards. The transverse colon can be displaced downwardsand the anterior surface of the pancreas should now be exposed. A transverse cut across thepancreas with a scalpel will demonstrate the parenchyma and it should be possible toidentify the main pancreatic duct. After a small probe is placed into its lumen the duct isopened toward both the head and the tail with small scissors.Althou&h Ro#itans#y0s method describes openin& the intestines while they are still within thebody, this will clearly be a very messy procedure in most cases and removal of the bowel tothe sin# before openin& as described for all the other methods is hi&hly recommended.owever, for the sa#e of completeness the former method will be outlined here. =e&in byincisin& the wall of the most distal part of the terminal ileum and insert the hoo#endedbowel scissors. (ut with the scissors proximally alon& the underside at the border of theattachment of its mesentery. (ontinue the cuttin& all the way to Hoin the anterior duodenalincision. At this point the lar&e intestine is opened by returnin& to the terminal ileum andcuttin&distally throu&h the ileocaecal valve into the caecum and beyond. The dissection proceeds

distally by cuttin& throu&h the anterior lon&itudinal muscle band to the previously cut end of the upper rectum. The appendix is opened lon&itudinally with scissors. :t is only at this sta&ethat the stomach, intestines, and pancreas are removed from the body by cuttin& throu&h allof the mesenteric attachments.

The last remainin& structures to be examined are the internal body surfaces, diaphra&m,vertebral column, and lar&e posterior vessels. There is no need in most cases to remove thediaphra&m and it can be inspected in situ, as can the inner surface of the body wall2includin& the pelvis3. The vertebral


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column is inspected for deformities and if required a piece of lumbar vertebral boneremoved with either a handsaw or electric saw for examination.For the latter the saw cuts are made parallel to the surface about cm into the bul# of thevertebral bodies. Finally, all that remains to be done is to dissect, open, and inspect theinferior vena cava and its branches, the iliac veins, and the abdominal aorta with itsbranches.

The in situ 2Ro#itans#y3 method is summarised as follows*M :nspect the mediastinum and pleural cavities.M !ift the lun&s anteriorly and slice each lobe.M +pen the pericardium and dissect the heart, rst the left side and then the ri&ht.M :nspect the abdominal contents.M ;lice the liver.M >issect the &allbladder.M ;lice the spleen.M ;lice the #idneys and adrenal &lands.M +pen the bladder.M >issect the internal &enitalia.M +pen the stomach.M ;lice the pancreas.M +pen the intestines.M +pen and inspect the lar&e posterior vessels.


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