Abstract:

The invention of new endoscopical techniques for surgery and interventional radiology demand
improved training at postgraduate level. The Endogent Centre for Anatomy and Invasive Techniques
support these requirements by establishing hands-on practical training courses by using new
procedures for cadaver embalming. Cadavers fixed by conventional procedures using formalin for
conservation, are of limited use for practical surgical courses due to the profound changes of colour,
strength and fragility of organs and tissues. The new Thiel embalming technique is based on the use
of 4-chloro-3-methylenphenol, various salts for fixation, boric acid for disinfecting, and ethylene
glycol for preservation of tissue plasticity, while the concentration of formalin is kept to the strict
minimum (0.8%). This results in well preserved organs and tissues concerning colour, consistency,
flexibility and plasticity. The articular joints remain freely movable and the peritoneal cavity can be
inflated for laparoscopic procedures. Up to now this cadaver model was used in our institute for
laparoscopic bariatric surgery, colon surgery, arthroscopy and thorax surgery. Another feature is that
the lungs can be ventilated during surgical procedures. Preliminary findings seem to indicate that the
corpses also serve as a suitable phantom for assessing thorax radiological equipment. Expert
clinicians work as tutors and give intensive instructions before the participants start with hands-on
surgery. We intend to expose also our undergraduate medical students to demonstrations of surgical
approaches on Thiel embalmed corpses, in order to reveal the need for detailed anatomical
knowledge in the clinic at an early stage in the medical curriculum.


Key words: endoscopy; Thiel embalming technique; gross anatomy; postgraduate teaching

Introduction


Gross anatomy is one of the fundamental topics in medical education. Dissection courses still play an
important role in learning it, as well in undergraduate as in postgraduate education. In addition new
endoscopical techniques for surgery and interventional radiology are invented and demand improved
training at postgraduate level.

The Endogent Centre for Anatomy and Invasive Techniques at the Ghent University support these
requirements by establishing hands-on practical training courses by using new procedures for
cadaver embalming. This new approach is introduced by Endogent, which is a cooperation and a
collaboration between the surgery-anaesthesia department (Commission of Surgery) of the
University Hospital Ghent and the department of anatomy, embryology, histology and medical
physics (University Ghent).

It is used for training techniques in postgraduate education: workshops for international surgeons
and aspirant-surgeons are organized to learn already known and new invasive techniques on human
bodies. In the future also undergraduate medical students will have the opportunity to get practical
experience through Endogent.

The new procedure for cadaver embalming is the Thiel-embalming method, through which the
corpses, tissues and the organs retain their flexibility and plasticity as in a living person and the
articular joints remain freely movable. The colour of the organs is very similar to the in vivo
condition. Only no bleedings occur.

History

Prof. Em. Walther Thiel, Anatomisches Institut Karl-Franzens-Universitt, Graz, Austria, developed
the new embalming technique and published his method in 1992,*1+ he wrote: An especially low-
odour embalming technique was developed over a 30-years-period using a total of 977 complete
cadavers, numerous cadavers after autopsy, and in vitro series of fresh beef. The colour, consistency
and transparency of the tissue were very well preserved. The technique met high standards of
preservation without releasing harmful substances into the environment. Concentrations of
formaldehyde in room air remained under the limit of detection. The efficacy for disinfection of the
method was confirmed by bacteriologic tests. None of the cadavers or samples developed moulds.


This technique was used at the University of Fribourg, Switzerland, where a comparable centre as
should become Endogent was already active: there the centre is called Swissendos, a
multidisciplinary research and training centre in endoscopic surgery.

Morand et al.*2+ (Fribourg, Switzerland) wrote as follows. The technique allows a floppy
preservation of human tissue similar to that found in living counterparts. Our centre organizes
courses for endoscopy, thoracic surgery, bariatric, antireflux, abdominal wall, colon and rectum
surgery. Video monitors with camera system are available with the possibility of computerized image
recording.

They concluded that endoscopic and thoracoscopic training on cadavers outside the operating
theatre is necessary for surgeons to perform operations; difficult endoscopical and surgical
procedures can be taught step by step under real anatomic situations in small groups.

A delegation of the future Endogent centre twice visited the University of Fribourg in 2005 to follow a
demonstration and to learn the Thiel-embalming technique.

In the summer of 2006 the Ghent Centre was officially opened as the second in Europe. Workshops
are organized for people all over the world. Both clinicians and anatomists are closely working
together.

So Endogent is one of the few centres all over the world in which the embalming technique of Thiel is
used: the human cadavers are preserved in a better way as is needed for practising operation
techniques on post mortem human bodies.


Materials and Methods


Conventional procedure for embalming human corpses

Cadavers fixed by conventional procedures by using (a lot of) formalin for conservation are of limited
use for practical surgical courses due to the profound changes of colour, strength and fragility of
organs and tissues.

A. Embalming solution as normally used in the Ghent Anatomy Department
chloralhydrate 2500 gr
sodiumsulfate 1250 gr
magnesiumsulfate 1250 gr
potassiumnitrate 2500 gr
thymol 300 gr
phenol 5 litre
formalin 5 litre
glycerine 2.5 litre
ethanol 96 10 litre
water up to 100 litre

B. Immersion solution (bath) in which the embalmed corpses are preserved for some weeks
formaline 10 litre
phenol 0.8 litre
ethanol 96 80 litre
water up to +/- 700 litre

Thiel method for embalming human corpses
The new embalming technique (adapted from Thiel)[1] is based on the use of a mixture of
4-chloro-3-methylenphenol,
as well as various salts for fixation,
boric acid for disinfecting and
ethylene glycol for preservation of tissue plasticity,
while the concentration of formalin is kept to the strict minimum (0.8%)

Two stem solutions are prepared (Thiel[1] and Groscurth et al.[3])
A. Stem solution A amounts for Endogent
boric acid 3% 1.9 kg
(mono-)ethylene glycol 30% 19 litre
ammonium nitrate 20% 12.6 kg
potassium nitrate 5% 3.2 kg
water 63.3 litre
Total 100 litre

B. Stem solution B (chlorcresol)
(mono-)ethylene glycol 10% 18.2 litre
4-chloro-3-methylphenol 1% 1.8 kg
Total 20 litre

C. Embalming solution as a mix of stem A, stem B
and additional products
stem solution A 14.3 litre
stem solution B 0.5 litre
formaline 0.3 litre
sodium sulphite 0.7 kg
Total 15.8 litre

Sodium sulphite and formaline are added just before perfusion. The final concentration of
formaldehyde is less than 0.5%. The cadavers are perfused by means of the great saphenous vein (if
this vein is difficult to find or to inject, the femoral or carotid artery are used) with some 12 litres of
this embalming solution.

D. Immersion solution (bath)
(mono-)ethylene glycol 10% 71.9 litre
formaline 2% 14.4 litre
stem solution B 2% 14.4 litre
boric acid 3% 21.6 kg
ammonium nitrate 10% 71.9 kg
potassium nitrate 5% 36 kg
sodium sulphite 7% 50 kg
water 720 litre
Total 1000.2 litre

The bodies are stored for approximately 4-6 weeks in this immersion solution.

Thereafter the bodies are kept at about 4-6 C in vacuum in sealed plastic tubular sheets (otherwise
mummification appears as brown spots on the skin).

The cadavers may be used for months up to approximately one year.

A good preservation of the tissue depends on a special know-how necessitating a tight collaboration
with an anatomy department, as is the case for Swissendos2 and for Endogent.

Advantages we met with are the nearly natural aspect of tissues -it is a simulation of a life model-;
there is a high mobility of joints and organs; bodies can be inflated and ventilated; no rigor occurs;
virtually no coagulation of blood in large vessels is present; there is very low toxicity for the
environment; no development of moulds occur; bacteriological disinfection is very effective.

Minus we met with is the higher cost of the Thiel embalming method products than of the products
of the conventional method; the risk of mummification of hands and feet is higher, therefore a 4C
vacuum conservation is needed; more desquamation and bullae in the skin are seen when the body
is disposed to the air; these bodies are not suitable for dissection during several days or weeks.


Results and Discussion


Set-up for Endogent workshops

Workstations:

About six workstations can be set up in the dissection room. We count for about 110 set-ups each
year, divided into several workshops. Each station consists of a dissection table and a video tower for
laparoscopic, thoracic surgery and interventional techniques. One station is equipped with a camera
for demonstrations through internet, in a conference room or auditorium (college room).

Dossier:

The Thiel cadavers can be used for several times: through a system of dossiers for each cadaver all
interventions are noted and so we know exactly for which sections a cadaver can still be used. As far
as possible first less invasive interventions are done; open surgical interventions, in which more
tissues are damaged, are usually done at last.

Accompaniment:

Expert clinicians work as tutors and give intensive instructions before the participants start with the
hands-on surgery. The groups are kept small to facilitate practical work for each participant and to
give everyone the opportunity to do the intervention him/herself.

Results of the Thiel embalming technique and possibilities for Endogent

In general after Thiel embalming:

The procedure results in well preserved organs and tissues concerning colour, consistency, natural
flexibility, natural plasticity and transparency. Tissues are more recognisable. Low-odour embalming
preservation is a fact. This technique results in high standards of preservation with good disinfecting
efficacy and without releasing harmful substances into the environment. This technique gives us a
compromise between fixation and the in vivo condition/appearance.

But the cadavers can only be used for a short time and must be taken to the refrigerator vacuum
packed after each workshop.

Specific possibilities for applications for Endogent:

The peritoneal cavity can be inflated for laparoscopic procedures.

Concerning thoracic surgery and thoracoscopy, it is possible now to practice/exercise interventions
such as by-pass operations. Also dissection and placement of a by-pass around the arteries of the
lower limb and abdominal arteries are possible.

The lung structure is very well preserved: another feature of the embalming procedure is the fact
that the lungs can be ventilated during surgical procedures. And also endoscopical endobronchial
techniques and bronchoscopy for investigation and treatment through the trachea are anyway
perfectly possible.

Preliminary findings seem to indicate that the corpses also serve as a suitable phantom for assessing
thorax radiological equipment.
Concerning orthopaedics also the articular joints approximate those of a living patient: the structures
feel supple and normal. The joints remain freely movable. Already some orthopaedic workshops have
passed: the embalmed bodies are excellently suitable for training all kinds of arthroscopic
interventions and open surgery.

Up to now this cadaver model was used in our institute for laparoscopic bariatric surgery, colon and
colorectal surgery, open gastro-enterological surgery, arthroscopy (orthopaedic), thorax surgery
(cardiology) and endoscopic gynecological interventions.

We now try out the use of the special techniques from Thiel[4] for fixation of the central nervous
system in order to use Thiel embalmed corpses for neurosurgery.

Extension to undergraduate medical students in the future

We intend to expose also our undergraduate medical students (2nd and 3rd year) to demonstrations
of surgical approaches on Thiel embalmed corpses, in order to reveal the need for detailed
anatomical knowledge in the clinic at an early stage in the medical curriculum.

Some years ago, after the implementation of a new integrated system-based medical curriculum at
our faculty with an important reduction of practical teaching hours, we have reorganized human
gross anatomy practical courses to enhance 3D knowledge; we were imposed by the need for
maximal efficiency of gross anatomy teaching in the dissecting room. Active self-learning practical
courses are introduced on prosected preparations and models, through demonstrations of some
regions and dissection sessions. We also focus on the anatomy of the living person, making use of
medical imaging documents and of surface anatomy.

The recently introduced Thiel embalming method gives us endoscopic approaches of cadavers as a
new tool to teach anatomy, in addition to dissections and prosections. Through endoscopy and the
video tower the students can participate in demonstrations of thoracic, abdominal and arthrologic
topographic anatomy. Also for this reason one station is equipped with a camera for demonstrations
through internet, in a conference room or auditorium (college room).

Conclusion


Thus the cadavers can be used for training of both conventional and new surgical procedures,
including laparoscopy, surgery of thorax, abdomen, and pelvis, as well as arthroscopy. As also
Groscurth et al.*3+ wrote: Hands-on anatomical training courses, as organized by the Swiss
Institutes, using newly established techniques for embalming have been found to be very helpful in
postgraduate training of ongoing specialists. The courses reflect just part of the clinical reality and
therefore have a virtual character, but they prepare the clinicians for the daily work and thus
improve the quality of postgraduate training. In this context cooperation between anatomists and
clinicians is absolutely necessary and plays an important role for the future.

Improvements allow courses to provide students with more realistic simulations of both established
and experimental surgical methods. Through these changes the value of in depth gross anatomy is
enhanced as a topic of fundamental importance for the postgraduate medical and surgical
curriculum.

Postgraduate medical students

Thanks to Endogent one can exercise without any risks and ethically justified in a very realistic
setting: pseudo-life-situations are created. The greatest trump of Endogent is that the study process
removes from the living person to the cadaver, in vivo training without the need of a patient. A step
between first training on an animal model and later on immediately on a patient is offered: training
on human cadavers with almost the same qualities as living patients. The step to take from a human
cadaver to a living patient is much smaller, what results in a considerable shortage of the study time.

Undergraduate medical students

Through the study of anatomy on CT or MR images and the endoscopic approach the students will be
convinced of the need for detailed knowledge of anatomy in a clinical setting. These teaching
methods allow better 3D-impression and facilitation of recognition of structures and topographical
relationships.

Compared to time-consuming dissections of the concerned regions without immediate link to
medical imaging and without endoscopy, as organised in the old curriculum, students will be more
motivated to study the prosected material or to perform dissections.


We found the appropriate proportion for an effective anatomy training program: imaging, living
anatomy and endoscopy in the future reveals the clinical relevance and need to study 3D gross
anatomy in the dissecting room through models and cadaver material.



Acknowledgement


The industrial companies Olympus (Hamburg) and Johnson & Johnson Medical N.V./S.A. sponsor the
facility by providing surgical instruments as well as funding. We thank the Educational Committee of
Medicine of the University of Ghent for financial support.

Special thanks go to our prosectors Aron De Smet and Hubert Stevens for their excellent work in
embalming the human bodies and preparing the workshops.





INTRODUCTION TO EMBALMING
A successful embalming procedure is necessary for a long-lasting preservation of the cadaver for
anatomical study. The procedure consists of arterial embalming with a gravity-tank apparatus fixed
approximately three to four feet above the body. The embalming fluid is prepared from propylene
glycol which keeps the muscles moist; 10% buffered formalin used as a fixative; isopropyl alcohol
used as a preservative; and liquefied phenol, which is used as a mold preventative. Coloring of the
blood vessels is useful in their identification with a small amount of amphyl, which is also used as a
disinfectant.

Dissection of human cadavers to essential in learning the major structures of the body in a three-
dimensional relationship. It is extremely important to fix and preserve cadavers adequately not only
for the sake of anatomical study but also for the financial justification.

Various embalming procedures have been used by embalmers for different purposes. In funeral
homes, the emphasis is on preserving the natural appearance of the deceased person for cosmetic
reasons, which may be at the expense of long lasting preservation. On the contrary, embalmers
employed by the UCI medical school put a great deal of effort into improving the quality of the
embalming so that specimens can withstand varying degrees of handling, drying, and the extended
periods of time the cadavers are exposed during dissection in medical anatomy courses. The
cadavers are kept at room temperature for study and dissection for one to five years.

EMBALMING TECHNIQUE
The modern practice of embalming utilizes the so-called "Arterial embalming" technique (Spriggs,
1971). Arterial embalming consists of the injection of an embalming fluid into the arterial system of
the cadaver and utilizing the whole vascular system. The embalming procedure used at UCI is as
follows:

Arterial Embalming

The cadaver is washed with antiseptic soap and rinsed thoroughly with running water. The external
genital area is covered with a piece of cloth or towel. The body is set in the anatomical position with
hands turned downward. The nasal and buccal cavities may be filled with cotton to avoid any leakage
during or after embalming. This is done to retain all chemicals and fluid for better fixation.

A small incision is made on the superior border of the sternoclavicular notch. The common carotid
artery is exposed by cleaning the fascia of the artery to allow movement and space for the cannula
which is inserted into it. When the carotid artery is raised with aneurism hooks, two (10") pieces of
ligature are placed around the artery with forceps to hold the cannulas in place while embalming.
This is done to help avoid leakage or release of the tube due to pressure exerted by the embalming
apparatus. The common carotid artery is incised about 4 mm long and any blood clots present are
removed with forceps. Two cannulas are used in the same slit made into the artery for better
saturation of the tissues in the head. An L-shaped cannula is then inserted into the carotid via the slit
and tied securely with string.

The L-shaped cannula is connected to polyethylene tubing which is connected to the gravity
embalming tank located above the cadaver. Before the embalming fluid is injected, air is removed
from the connecting tube to avoid any possible airlocks produced by the vessels of the cadaver
during the injection of the fluid. Injection periods vary in each case taking 8 to 24 hours. This
variability is due to the ability of the body to accept the fluid at its own rate.

The gravity-tank is filled with embalming fluid consisting of:

1 gal. isopropyl alcohol
2 gal. propylene glycol
1/4 gal. amphyl
1/2 gal. 10% buffered formalin
50 oz. liquefied phenol
After the fluid is added, the gravity tank is filled with water to reach the tank capacity of ten gallons.
When all prepatory procedures have been completed, the pepcock is turned on to allow the
embalming fluid to flow through the tubing, cannula and into the common carotid artery, thus
dispersing the fluid into the vascular system.

During embalming, a number of small whitish splotches appear on the skin in the region most
effectively embalmed and then they spread peripherally. This splotching effect of embalming can be
used to determine the effectiveness of the embalming condition at any given time. Splotches usually
disappear within several hours without leaving any trace. Any region of the body not exhibiting this
typical splotching is directly injected with embalming fluid with a hypodermic needle under pressure
until the tissue in that region becomes hard enough (Bradbury, 1978).

During embalming, a number of blisters may appear over certain areas of the body surface. When
blisters do appear, it indicates that the pressure of the injecting fluid is too high and later it is
injected with a fluid filled hypodermic needle to ensure preservation of that area.

Any areas not receiving enough embalming fluid arterially is injected by hand or injected using a
porta-boy embalming machine. Commonly the lower extremities, back, and gluteal area require
additional treatment. With a 10 CC syringe and a 14 gauge needle, each finger and toe may be
injected with extra fluid. An additional two gallon solution may be placed into the porta-boy
embalming tank consisting of the following:

52 oz. isopropyl alcohol

34 oz. propylene glycol


13 oz. 10% buffered formalin


10 oz. liquefied phenol


Fill tank to 2 gallon capacity with water

The porta-boy machine pressure is set to 20 lbs. with the rate of flow at 3/4 open. The body is turned
on its side using wood blocks to prop it up so it will not slide on the table. The gluteal area and
perineum are injected with one-half gallon on each side. The needle is placed up along the lower
lumbar region and then injected with approximately one-fourth of a gallon on each side of the spine.
This is done due to the pressure exerted on the back during embalming which may reduce the
saturation of fluid to this area.

The body is then turned on its back. The feet, legs, thigh, hand, forearm, abdomen, thorax, and face
are then injected as needed. When injecting these areas it is best to insert the needle at a higher
point than the injecting area to keep the fluid from leaking out. While doing this protective glasses, a
mask, and impervious gloves are worn. The exposure of harmful chemicals to the embalmer is
greater at this time due to the direct injection and leakage that may occur. To help clear the fumes
from the embalming fluid, water is kept running on the table at all times during the hypodermic
embalming.

Wetting Agent

Without a well-fixed body and preserved cadaver, the study of a dissected cadaver is difficult to
undertake. Additional care is taken to facilitate better preservation of cadavers for future anatomical
studies. A wetting agent is used to saturate the tissues because it helps prevent drying during
dissection. The wetting agent consists of the following:

80 oz. propylene glycol
20 oz. liquefied phenol
10 oz. isopropyl alcohol
Fill tank to 4 gallon capacity with water
This wetting agent is made available to all anatomy laboratory students to allow them to keep their
specimen's tissues soft and flexible for study in the anatomy laboratories.

[a nice picture of embalmed tissue] Get used to it! its GUTSSSSS. .
INJECTION POINTS
The UCI Anatomical Preparation Personnel believe that there are only two efficient primary injection
points, the femoral and common carotid arteries. Each injection site is considered on a case by case
basis.

The femoral artery is a continuation of the external iliac artery. It extends from the inguinal ligament
down through the center of Scarpa's triangle to Hunter's canal, where it becomes the popliteal
artery. The femoral artery is the primary injection point of choice because it is the largest vessel
available. When used, the arms of the cadaver are placed at the sides and the lower part of the body,
including viscera, seem to receive good fluid saturation.
The disadvantages of the femoral artery is that the vessel is deep in obese cases, making it difficult to
locate and difficult to raise. Its many branches and tributaries create possibilities of leakage. When
this procedure is used, there is a danger of short circuiting the arterial chemical before areas of
collateral circulation are filled. This may lead to poor fluid distribution and a poorly embalmed body.

The common carotid arteries are the principle arteries that supply blood to the head and neck. Both
arteries ascend in the neck and divide into two branches. The external carotid supplies blood to the
exterior of the head, face, and most of the neck while the internal carotid supplies blood to most of
the areas within the cranial and orbital cavities. The right common carotid artery begins at the
bifurcation of the innominate artery behind the sternoclavicular articulation and is confined to the
neck. The left common carotid artery is at the highest point of the aortic arch on the left of and
posterior to the innominate artery and consists of both thoracic and cervical portions.
An injection through the right common carotid artery is recommended and care is taken not to push
the canula beyond the bifurcation which could lead to short circuiting and lack of fluid distribution in
the shoulder, hands, and arms. The advantage of this injection point is that it ensures direct fluid
distribution to the face. The fluid can be injected downward where pressure is not as much of a
factor. The upper extremities, thorax, viscera, and lower extremities can be embalmed properly if
there is no blockage within the vascular system.

FORMALDEHYDE
It is known that too much formalin causes unnecessary irritation of the skin, nose, and eyes of the
person dissecting and may create mold. Formalin (37% formaldehyde) hardens tissues quickly and
tends to make the embalmed body stiff and hard if used in excess. Formalin is diluted at UCI with a
10% buffer of water. The embalming fluid provides the embalmed body with moderate degrees of
mobility of the neck, shoulder, pelvic girdles, and limbs and at the same time, yields an adequate
degree of hardness of the muscles for dissection (Bradbury, 1971).

Cautions regarding formaldehyde: Individuals who work with human cadavers after or during
embalming may be exposed to a variety of hazardous materials including various organic vapors and
bodily fluids. Formaldehyde has been recognized for some time as an irritant affecting the mucous
membranes of the respiratory tract and eyes. Some individuals may develop increased sensitivity to
formaldehyde after initial exposure. More recently formaldehyde has been shown to cause nasal
squamous cell carcinoma in exposed rats. Based on toxicological and epidemiological evidence, the
Occupational Safety and Health Administration (OSHA) has found that exposure to formaldehyde
may be associated with cancers of the lung, brain, and bone marrow. Although the data were
deemed to be inconclusive, OSHA determined formaldehyde should be treated as a potential
occupational carcinogen and lowered the 8-hour permissible exposure limit (PEL) to 0.75 ppm and
the short-term exposure limit to 2 ppm. The U.S. Environmental Protection Agency (EPA) classifies
formaldehyde as a probable human carcinogen.

More information on formaldehyde
Information on a formaldehyde air sample test conducted at the UCI embalming laboratory
FACTORS INFLUENCING THE STABILITY OF FLUIDS
Temperature: Extremes in temperature have a detrimental effect on the shelf life of embalming
fluids. Elevated temperatures accelerate polymerization of formaldehyde and cause decomposition
of its disinfectant and preservative components. Depressed temperatures cause precipitation of the
endothermic solutes.

Time: All organic compounds exhibit a tendency to form polymers. Methanol is incorporated into
embalming fluids as an antipolymerization agent for formaldehyde. Nonetheless, the average shelf
life of fluids is betweeen two and five years.

pH: One of the purposes of adding buffers to embalming fluids is to prolong their shelf life. Strongly
alkaline solutions cause decompostion of formaldehyde. Highly acid solutions promote
polymerization.

Light: Light has been cited as a factor influencing the speed of chemical reactions. Light has two
effects on embalming fluids: (1) it causes a color change, thus interfering with the eventual reaction
of the cosmetic dyes; and (2) it increases polymerization of the formaldehyde. As a result, some
manufacturers have adopted tinted containers to prolong the shelf life of their products.

The three essential components of the definition of embalming are disinfection, preservation, and
restoration. Chemical means are employed to achieve these goals, since existing physical methods
are too uneven in their effects. For example, steam-pressure sterilization could achieve excellent
disinfection and preservation, but would be counterrestorative.
Preservative chemicals will generally double as disinfectants. However, supplementary germicides
are included in embalming fluid formulations and modifying agents are added in order to augment
restoration.
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