An Introduction To Autopsy Technique

Step-by-Step Diagrams

Kim A. Collins, MD Grover M. Hutchins, MD

I.

EXTERNAL EXAMINATION

Identify the body. Verify autopsy permit: validity and extent. Weigh, measure, and inspect the body for: - presentation - marks of therapy - identication - perimortem/postmortem changes Measure and compare leg circumferences at 10-cm intervals above the medial malleoli. Make the primary incisions. 1. Y-incision. Stay above the anterior axillary line. 2. Knee incision. 3. Chest-only incision. 4. Abdomen-only incision

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OPENING THE BODY

1. Reect the skin aps. Cut perpendicular to the ribcage. Make relaxing incisions in the peritoneum and musculature about 15 cm above the symphysis. 2. Check for tension pneumothorax. Make a pool of water in the axilla. Push closed clamp through an intercostal muscle beneath the water level. 3. Release the chest plate. Cut ribs medial to costochondral junction and the clavicle lateral to the sternoclavicular joint, with either: a. an oscillating saw; b. a linoleum knife and bone shears; or c. pruning shears (inexpensive alternative). 4. Preserve the muscle attachments to the manubrium and head of the clavicle. 5. Detach the diaphragm from the chest plate. Inspect surfaces and contents of the pleural spaces.

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III.

THORAX

1. Reect chest plate and strap muscles to expose the lower neck. 2. Blunt dissect thymic fat pad from the pericardium. Carry reection upward to lower pole of thyroid. Cut the thymic vein where it enters the innominate vein. 3. Double-clamp, divide, and reect the innominate vein. 4. Open pericardium and clamp edges. Inspect pericardial surfaces and contents. 5. Extend the pericardial incision through the pericardial reection. 6. Isolate and ligate the carotid arteries. 7. Lift the heart cranially and draw blood samples from the left atrium. IN SITU EXAMINATION. Examine the heart. Elevate, palpate, and inspect the lungs. Collect specimens for microbiology, toxicology, etc. Take any cultures after searing the surface.

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IV.

ABDOMEN 1

IN SITU EXAMINATION. Inspect and palpate all organs and surfaces. Collect specimens for microbiology, toxicology, etc. 1. Open the greater omentum between the stomach and colon to inspect the pancreas. 2. Locate the ligament of Treitz. 3. Make a slit through the mesentery close to the bowel wall. 4. Ligate the bowel near the duodenal-jejunal junction. 5. Clamp the proximal jejunum. 6. Cut across the bowel. 7. Detach the mesentery close to the bowel wall, with either: a. scalpel strokes perpendicular to the bowel, or b. scissors. 8. Remove colon. Empty the bowel and cut at the rectosigmoid junction.

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ABDOMEN 2

1. Obtain transverse sections of unopened bowel from: a. proximal jejunum, b. distal ileum, and c. sigmoid colon. 2. Open the small bowel adjacent to or within the line of mesenteric attachment with an enterotome. 3. Open colon and appendix along anterior taenia. 4. Carefully clean and examine the entire intestinal mucosa by pulling the bowel between the index and middle ngers under running water. 5. Take additional sections as needed. Lay the serosal surface on paper towel, invert, and oat in xative.

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VI.

PELVIC ORGANS

1. Free the male pelvic organs from the pelvic wall by blunt nger dissection in the extraperitoneal space. 2. Identify and cut the membranous urethra with scissors, and transect the rectum with a knife. 3. Push the testes from the scrotum into the inguinal canal and detach by cutting the spermatic cord (left long). 4. Expose the shaft of the penis below the symphysis pubis and remove a segment. 5. Free the female pelvic organs by blunt nger dissection in the extraperitoneal space, and transect the urethra, vagina, and rectum with a knife. Elevate the pelvic organs, separate any remaining fascial attachments, and lay them back into the pelvic cavity.

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VII. ORGAN BLOCK REMOVAL

1. Grasp or clamp the trachea and esophagus, and transect them. 2. Retract the thoracic and abdominal organs, and cut the diaphragm attachments. 3. Elevate the lung and cut the pleura with a scalpel along the lateral aspect of the vertebral bodies. 4. Retracting the entire block, continue the pleural cut through the crus of the diaphragm, and extend the cut along the lateral aspects of the lumbar vertebrae above the psoas muscle. 5. With both sides cut, elevate the thoracic viscera and deliver the entire organ block, detaching any remaining connections to the vertebral column.

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VIII. NECK ORGANS AND HEAD

1. Retract the carotid arteries, clamp the end of the trachea, and free the neck organ block with blunt nger dissection. 2. With a long knife, detach the neck organ block by cutting anteriorly and medially on the inner aspect of the mandible. 3. Reect the lower pharynx. 4. Locate and remove the parathyroids. 5. Remove, weigh, and take sections of thyroid. 6. Cut the pharynx in the posterior midline. 7. Cut the larynx and upper trachea in the posterior midline and crack open. 8. Cut the tongue transversely and take sections to demonstrate the lingual tonsil. 9. Separate the hair and incise the scalp across the vertex, beginning behind the right ear. 10. Reect the scalp down to the hairline. 11. Incise and slightly reect the temporalis muscles. Cut the calvarium with an oscillating saw. Detach the dura from the skull cap.

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IX.

REMOVAL OF BRAIN

1. Open superior longitudinal sinus. 2. Cut dura along the line of skull cut and reect toward the midline. Inspect the brain. 3. Retract frontal poles and cut anterior attachments of falx. 4. Elevate olfactory bulbs, retract brain, and cut: a. optic nerves, b. carotid arteries, and c. other nerves 5. Retract brain medially and cut tentorial attachments along the petrous ridges. 6. Retract brain posteriorly and cut remaining cranial nerves as close to bone as possible, vertebral arteries and spinal cord as distally as possible within the spinal canal. 7. Retract cerebellum and brainstem. Support brain and cut remaining dural attachment with scissors.

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X.

BASE OF SKULL

Inspect base of skull. 1. Open dural sinuses. 2. Strip basilar dura by rolling on a large clamp. 3. Pull on skull to check for basilar fractures. 4. Take the pituitary gland; either: a. remove a block which includes the optic nerves, cavernous sinuses, and sella turcica (this exposes spheroid sinus and posterior nasopharynx), or b. remove it from the sella turcica: i) chisel off the posterior clinoid processes, ii) elevate it, iii) blunt dissect the pituitary gland from the sella turcica, and iv) cut the anterior dura. 5. Examine the middle ears; either: a. open the cavity with a chisel, or b. remove a block of petrous ridge. 6. Remove the eyes; either: a. unroof the orbit with a chisel, or b. incise the conjunctiva, hook the eye muscles, and cut muscles and optic nerve with scissors.

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XI.

SPINAL CORD AND NERVES

1. Remove the psoas muscles. 2. With the oscillating saw, expose the spinal cord between L5-S1 and C3-C4 discs. a. In the lumbar region, cut the pedicles and try to avoid injury to the cord. b. In the thoracic area, it is helpful to use the osteotome to expose the heads of the ribs, and aim the saw cut toward the cord through the neck of the rib and the pedicle of the vertebra. c. In the cervical region, cut through the lateral part of the vertebral body downward into the vertebral canal. Beginning at the lower end, lift the vertebral column and detach the anterior ligamentous connections to the cord. 3. Expose all posterior ganglia and nerve roots of interest to be removed in continuity with the cord. Develop the sacral plexus by forcing a nger between it and the pelvic wall. Cut sacral roots but maintain lumbar connections. Remove cord and attached nerves from below upward. Free the upper cervical cord by cutting the dura from within the foramen magnum. 4. Examine the cord by opening the dura in the anterior and/or posterior midline or by sectioning the cord transversely with dura intact, usually after adequate xation. College of American Pathologists 2005 11

XII. BONES AND JOINTS

1. Obtain a complete section of the sternoclavicular joint with the oscillating saw or band saw. 2. Cut vertebral bodies into longitudinal segments with the band saw and take specimens. 3. Section ribs longitudinally through the short axis with the oscillating saw, and take blocks to include the costochondral junction. Squeeze marrow from a portion of rib (or any other bone) for smears or tissue blocks. 4. Take bone biopsies from the iliac crest (or other areas) with a trocar. 5. Open the knee joint, cut and reect the extensor tendon and patella, inspect the joint surfaces, and take synovium or other specimens. 6. Make two parallel cuts 1 cm apart and one-third through the femoral shaft with the oscillating saw. Obtain a specimen of femoral marrow with the chisel.

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XIII. THE ORGAN BLOCK

Keep the organs anatomically arranged. Blunt dissect as much as possible. Inspect, document, and sample. Modify technique as needed. Clean up as you go. 1. From the posterior aspect, identify and open the thoracic duct and cisterna chyli. 2. Open the aorta from the left subclavian to the left external iliac artery in the posterior midline. 3. Rotate and retract the left lung. Open the aortic arch and its branches on their left aspect. 4. Transect the aorta. 5. Reect the aorta and esophagus downward. 6. Separate the heart-lung block by cutting the pericardium from the diaphragm and transecting the inferior vena cava.

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XIV. SEPARATING THE KIDNEY AND LIVER BLOCKS

1. From the posterior aspect, reect the right leaf of the diaphragm. 2. Transect the inferior vena cava. 3. Blunt dissect the right adrenal from its bed and detach, weigh, section, inspect, and sample it. 4. Retract the right kidney posteriorly. 5. Reect the left leaf of the diaphragm. 6. Pull the esophagus through the hiatus. 7. Detach, inspect, and sample the diaphragm. 8. Treat the left adrenal and kidney as the right. 9. Transect the inferior vena cava just below its attachment to the liver. 10. Open the hepatic segment of the inferior vena cava and inspect the hepatic veins. 11. Identify and transect the celiac axis and superior mesenteric artery close to the aorta. 12. Grasp the aorta and inferior vena cava, and pull the kidney block from the liver block, breaking the few remaining connections.

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XV. THE LIVER BLOCK 1

From the Posterior Aspect 1. Open the celiac axis and its branches. 2. Open the superior mesenteric artery and its branches. 3. Open the posterior midline of the portal vein and its hilar branches. 4. Open the splenic vein to the hilum. 5. Rotate the mesentery. 6. Open the superior mesenteric vein and branches. From the Anterior Aspect 7. Rotate the liver up and back to expose its hilum. 8. Open the esophagus, stomach, and duodenum following the greater curvatures, and inspect and sample them. 9. Probe the common bile duct and pancreatic duct from the ampulla of Vater. 10. Blunt dissect the gallbladder from its bed, and open, inspect, and sample it and the extrahepatic biliary tree. 11. Transect the duodenum and remove the stomach and esophagus. 12. Open any remaining branches of extrahepatic arteries and veins. College of American Pathologists 2005

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XVI. THE LIVER BLOCK 2

1. Grasp the pedicle of the liver, and section the liver along its longest axis on either side of the hilum. 2. Breadloaf the detached parts of the liver, and inspect and sample them. 3. Using a towel for protection, grasp the pancreas from behind, breadloaf it, and inspect and sample it. 4. Section the spleen in the same manner as the liver, breadloaf the parts removed, and inspect and sample them. 5. Section, inspect, and sample the hilar, peripancreatic, and mesenteric lymph nodes.

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XVII. THE KIDNEY BLOCK

1. From the anterior aspect and avoiding the ureter, open the inferior vena cava, renal veins, and right iliac veins. 2. Rotate the lower block and open the remaining iliac veins. 3. Open the remaining iliac arterial branches. 4. From the posterior aspect, open the renal arteries. 5. Weigh the kidneys and bisect them so as to remove the posterior halves. 6. Open the collecting systems and the ureters down to the bladder. 7. Strip the capsule from the anterior half of each kidney. 8. Breadloaf, inspect, and sample the posterior halves of the kidneys.

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XVIII. THE PELVIC ORGANS

1. From the posterior aspect, open the rectum in the posterior midline and inspect it. 2. Reect the rectum from the other pelvic organs by blunt and sharp dissection, beginning at the anal end, and clean, inspect, and sample it. 3. From the anterior aspect, open the bladder from the apex toward, but not into, the urethra, and inspect and sample it. Male 4. From the posterior aspect, breadloaf the prostate, leaving the slices attached by the anterior capsule, and inspect and sample them. 5. Breadloaf the seminal vesicles across their long axes, and inspect and sample them. Female 6. From the posterior aspect, cut the lateral aspects of the vagina, cervix, and uterus, and inspect and sample them. 7. Breadloaf the ovaries and fallopian tubes across their long axes, and inspect and sample them.

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XIX. SEPARATING THE HEART AND LUNGS

1. From the anterior aspect, rotate the lungs laterally and under to expose the mediastinum. 2. Open the pulmonary trunk and major branches, transecting the superior vena cava, and inspect for emboli. 3. Transect the pulmonary artery. 4. Elevate the heart and transect the pulmonary veins, in turn, the pericardial reections, and any other attachments to remove the heart. 5. Open the superior vena cava and its branches.

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XX. THE LUNGS

Weigh the lungs. 1. From the posterior aspect, rotate the anterior aspects of the lungs medially and under. 2. Open the trachea, mainstem bronchi, and proximal lobar bronchi. 3. Section the lungs by placing the knife in the notch formed at the bifurcation of the mainstem bronchi, and slice laterally. 4. Open the intrapulmonary bronchi and vessels exposed on the cut surfaces. 5. Breadloaf the detached sections and the anterior parts of the lungs from lateral to medial, and inspect and sample. 6. Section the carinal, peribronchial, and paratracheal lymph nodes in the same plane as the lung slices.

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XXI. THE HEART

1. Identify the venae cavae and open the right atrium. 2. Open into the right atrial appendage. 3. Detach the free wall of the right ventricle close to the septum. 4. Continue the cut along the right ventricular outow tract through the pulmonary valve commissure. 5. Transect the moderator band. 6. Open the left atrium between the superior pulmonary veins. 7. Extend the cut to the other pulmonary veins. 8. Open into the left atrial appendage. 9. Pass a knife through the mitral valve, pierce the apex, and slice upward perpendicular to the interventricular septum. 10. Reect the pulmonary trunk from the aorta. 11. With scissors, cut down the aorta, through the commissure between the two coronary cusps, and into the myocardium. 12. Angle the scissors and cut to transect the left anterior descending coronary artery and myocardium. 13. Position the knife parallel to the interventricular septum and, engaging the ends of the scissorscut and the apical knife-cut, slice the free wall of the left ventricle from the septum. 14. Transect the coronary arteries at close intervals. Inspect everything, weigh the heart, and take College of American Pathologists 2005 samples.

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XXII. THE PERINATAL AUTOPSY

Check for pneumothoraces with needle and syringe at highest ventral area on right and left side of chest before making incision. Measure amount of pneumothorax by withdrawing air with syringe. 1. Make the primary incision so that skin ellipses containing the breasts may be removed and examined. 2. Encircle the umbilicus with the primary incision so that it may be removed in continuity with the umbilical vessels. 3. Extend the incision around the perineum so that the external genitalia and anus remain in continuity with the organ block. 4. Carefully cut the symphysis pubis, manually spread the pelvic bones, and deliver the perineal block. 5. Incise and reect the scalp. 6. Beginning in the anterior fontanelle, incise the dura on each side of, and close to, the superior longitudinal sinus. 7. Reect, without detaching, the parietal bones. 8. Cut the falx and complete the brain removal as in the adult, but deliver the brain directly into a container of xative.8. 22

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