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Dr.ROMAN

Thyroid Removal of the:

The thyroid is a U-shaped or horseshoe-shaped
gland with a superior concavity.

It is formed by two sides, or lobes, on the right and left, and

connected by a median isthmus that overlays the cricoid
cartilage of the larynx,extending downward to the two first
tracheal rings.

It is covered with an inner fibrous layer and outer perithyroid

sheath, part of the superficial fascia of the neck.

This fascia is particularly dense and must be removed with a

scalpel.

Continue the dissection superiorly until reaching the

perithyroid sheath that is attached directly to the gland, along
with the thyroid and cricoid laryngeal cartilage and the first
tracheal rings.

Continue the dissection cutting the median ligament and the

right and left suspensory ligaments, which connect the glands
to the thyroid and cricoid laryngeal cartilage and to the first
tracheal rings.

¥ Average weight of thyroid gland 40 g (range 30–70 g)

¥ Average size of each lobe 6 ¥ 3.5 ¥ 2cm

Dr.ROMAN
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Dr.ROMAN

The Parathyroid Glands:

If an infiltrative tumour has been identified
during evisceration that is causing attachment
of the parathyroid gland(s) to adjacent
structures the glands should be examined in
continuity with the neck organs.

 Otherwise, the now separate glands should be stripped of

any attached fat and weighed together, using scales that
are specially designed for very low weights.

 While removing the thyroid gland from the

thyroid cartilage, identify and save any tissue
resembling the parathyroid glands.

 Normally, these small glands are tan or light

brown and have a more acutely angled edge than
the small lobules of fat, lymph nodes, and
extraneous bits of thyroid tissue that masquerade
as parathyroid glands.
 The superior parathyroid glands, frequently found
at the level of the middle of the posterior border
of each lobe of the thyroid gland, rest in a shallow
groove.
 Unfortunately, the inferior parathyroid glands lie
in various positions, including but not limited to
the fascial sheath of the thyroid gland near its
inferior pole, behind and outside the thyroid gland
immediately superior to the inferior thyroid artery,
or within the substance of the lobe of the thyroid
gland near its inferior posterior border.
 If there is a question of parathyroid disease, weigh
the parathyroid glands because weight is the best
criterion for hyperplasia or hypertrophy.
 After placing the parathyroid glands in a tissue
cassette for safe keeping, continue the
examination.
Average combined weight of 0.12–0.18 g (0.03–0.045
g.each)parathyroid glands.

Average size of each gland 0.3–0.6cm in maximum diameter.


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Dr.ROMAN

Scrutal sac:

 To open the scrotal sac we can give two lateral

incision or we can done by one single midline incision.

 After getting into scrotal sac examine carefully for any

injury,haemorrhage or other pathology.

Testes:

 Incise the inguinal canal from the peritoneal aspect and

 pull out a loop of vas with finger.

 Free the vas to the internal inguinal ring.

 Pull the testes up out of the scrotum with the right

hand,and pull the vas with the left hand.

 Spermatic cords are identified at the inguinal ring.

 Push and lift the testes and spermatic cords up and out of the
inguinal canal, cutting the cords to free the testes.

 The testes are removed from the scrotum by separating

them from the inside of scrotal sac by gentle blunt
dissection.

 The testes and epididymis are held with the left hand and
are cut longitudinally with knife.

 Normal seminal tubules can be lifted like thin long

filaments by toothless pointed forceps.

 Then examined for evidence of any disease or injury

specially echymosis and any clotted blood inside the
scrotum and around the testes.
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Dr.ROMAN

Penis and Male Urethra :

Congenital urethral valves,strictures, and tumors are the

mainindications for examination.

The penis, usually without surrounding skin, should be

leftattached to the urinary bladder.

This can be achieved by either sawing out a portion of the

pubic bone or by pulling the penis through the pubic arch.

These maneuvers require preparatory dissection of soft tissue

and appropriate incisions of the skin of the penis.

The urethra should be opened lengthwise in the anterior

midline.

Histologic sections through urethra and corpora cavernosa are

usually taken in a frontal plane, that is, perpendicular to the
axis of the urethra.

Urethra valves can best be located by injecting radiopaque

material into the urinary bladder.

The urethra should then be opened along the anterior midline

against the direction Of flow of urine.

This will help prevent laceration of the delicate valves.

Fixation of the corpora cavernosa can be achieved by injecting

formalin solution or gelatin-formalin through the vena dorsalis
penis.
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Dr.ROMAN

®Adrenal glands:

∆ They are identified by their relationship to the upper pole

of each kidney.

∆ If the right kidney is taken in the left hand and pulled

forward,the adrenal will be projected forward in the tissues
between the upper pole and the undersurface liver,which tends
to fall backwards when the kidney is pulled forward.

∆ The left adrenal lies much more medially in relation to the

kidney,and can be found kidney by pushing the medial border
of the left kidney forwards,and cutting into the tissues between
the and spleen.

∆ The periadrenal fat is gripped with a forceps and cut ,and

adrenal removed.

∆ Cut the gland gently with a scalpel without applying undue

pressure.

∆ For identification purposes, it is helpful to know that the right

adrenal gland is pyramidal in shape and the left is generally larger
with a semilunar shape.
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Dr.ROMAN

Dr.ROMAN

® Kidney with ureters:↔ The kidneys are symmetric in

appearance and retro peritonalin position.↔ They are located
at roughly the height of the eleventh and twelfth vertebra.†↔
To remove the kidney,first locate it by palpation.↔ Once it
is identified, wrap your hand around it and pull it medially and
upward

Ω The ureters running along each side of the midline are identified through the translucent fat and

fascia these with a small pair of scissors from the renal pelvis to their entranceinto the bladder.

Abdoiminal aorta oppened along the anterior midline.

The renal renal artery ostia are examined for thrombi,emboli or atherosclerosis.

Renal veins are also examined for thrombus.

Measure their average luminal circumference and examine their contents, if any, and the appearance
of their mucosa.

The capsule is stripped with toothed forceps.

Remove the kidneys by blunt dissection in the plane between the renal capsule and the perinephric fat.

Wash the extracted kidneys of any adherent fat, weigh them, and determine the average thickness of
the cortex and medulla.

In most cases, we separate the kidneys from the bladder, leaving a greater length of left than right
ureter attached for identification purposes.

Hold the kidney in left hand between the thumb and fingers,the ureter passing between ring and
middle finger.

Next, slice the kidneys completely in half through their longitudinal (coronal) dissection through the
convex border in the plane so that split in half and open the pelvis .

Beginning from the medial aspect helps center the cut through the pelvis.

Examine the cortex, medullary pyramids, and pelvis, opening individual major and minor calices as
needed. Next, slice the kidneys completely in half through their longitudinal (coronal) axis.

Look after for haemorrhage which can be found in meningococcal septicaemia,bleeding

disease,hypertensi the fundus and incision extended into the urethra.
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Dr.ROMAN

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Dr.ROMAN

Subendocardial or Sheehan’s Hemorrhages:

These are flame-shaped, confluent hemorrhages and tend to occur in one continuous
sheet rather than in patches, seen in the left ventricle, on the left side of the
interventricular septum and on the opposing papillary muscles and adjacent columnae
carnea.

Cause:

 Severe loss of blood or shock,Intracranial damage, such as head injury,

cerebral edema, surgical craniotomy or tumors.

 Death due to ectopic pregnancy, ruptured uterus, abortion, antepartum or

postpartum hemorrhage

 Poisoning, e.g. arsenic or oleander

A volume of 100–250 mL of air is estimated to be required to cause death from

venous air embolus

Pericardium:

The pericardium is first incised by lifting it up free from the anterior cardiac wall and
making a transverse cut near the base.

This cut is then followed by a median inferior-to-superior cut forming an inverted T-

shaped incision.

Fluid in the pericardial sac can be sampled for microbiology or extracted and its
volume measured in the case of effusions or haemopericardium.

Inspection of the Pleural Cavities

Do this with the right hand to outline the convexity of the lung, then lower the hand
downward to reach the costal–vertebral corner.

Incision of the Pericardial Sac: Ю The pericardial sac is incised by making an

upsidedown Y-shaped incision with rounded nose scissors.

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Dr.ROMAN

DISSECTION OF FRESH LUNGS:

Dissection from Hilus

The pulmonary arteries and bronchi are opened from

the hilus toward the periphery

of the mediastinal surface of the lung.

Subsequently,the lungs are cut into several sagittal

slices, that is, parallel with the

mediastinal surface.

This method permits study of many cross-sections of

bronchovascular units and

gives a good overall view of the parenchyma.

Dissection from Incisions Along Lateral Surface of Lung

After separation from the mediastinum, a

bronchopulmonary cuff should remain

on the lungs.

The hilus of the lungs with this cuff is held in the

hand of the prosector.
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Dr.ROMAN

An incision is made from the apex to the base of the

pulmonary lobes along their

longest lateral axis.

For the right middle lobe, this axis lies almost in the
horizontal plane.

The incisions into the upper and lower lobes reach

toward but not into the hilus

and are connected by a third incision that lies at a

right angle to the first and

second.

This third incision divides part of the wall of a main

pulmonary artery, which

usually shines through the pleura in the interlobar

fissure close to the hilus.

One blade of a pair of scissors is introduced into this

opening and the pulmonary

arteries are opened radially in all directions.

The cuts made by the scissors should include the

periphery of the pulmonary

parenchyma and the parietal pleura so that the

lungs can be laid out well.

Subsequently the bronchial tree is dissected in the

same fashion.

This method leaves the dissected lung in continuity

and permits easy

reconstruction of the original position of pulmonary

lesions.

In order to preserve the continuity of most arteries

and bronchi, this method can

be combined with dissection from the hilus.

Histologic Sampling

For routine histologic sampling, a container can be

used with three
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Dr.ROMAN

compartments for the right pulmonary lobes and

two compartments for the left

lobes.

Whatever method is used, the origin of every lung

section should be identified.

WET FIXATION OF LUNGS

Formalin fixation of lungs with a perfusion

apparatus provides excellent

specimens,both by reconstituting the size of the

lung at full inspiration and by

providing good fixation for histologic study.

A prudent approach is to perfuse one lung and

dissect the other in the fresh

state to obtain material for microbiologic study

and for smears, for instance

when Pneumocystis carinii infection is suspected.

Also, pulmonary edema and embolism are best assessed in the

fresh lung.

If no perfusion apparatus is available, lungs can be reinflated with

10% formalin solution

through the main bronchus.

About 2 L of formalin solution is needed for an adult lung.

The inflation can be done with a large syringe or, better still, from
a bottle 30–50 cm above the

specimen.

Subsequently, the main bronchus is clamped and the lung is

floated in a formalin bath.

It should be noted that the organ shrinks again during this period.

Removal and Preparation of Lungs Prior to Wet Fixation

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For most special studies of isolated lungs, it is essential not

to lacerate the organ during

removal.

We usually first produce a pneumothorax through a small

parasternal incision.

In many instances, the chest plate can then be removed

safely.

If one wants to protect the lungs even better, the anterior

attachments of the diaphragm

to the rib cage should be incised so that the hand of an

assistant can be introduced to

hold back the lung during removal of the chest plate.

The remaining rib ends should be covered with a thick

towel or plastic sheet because

the severed bone may lacerate the pleura.

Before the lungs are removed, adhesions must be carefully

dissected as close to the

parietal pleura as possible.

This is particularly difficult at the posterior base of the lower

lobes, where adhesions are

frequently encountered.

If adhesions are extensive, one may attempt to remove the

lungs with the parietal pleura

that must be dissected from the bony and muscular parts of

the chest wall.

Small rents in the pleura should be tied off or sealed with

wound spray (“artificial skin”).

Connection of the lung with the perfusion apparatus is

greatly facilitated if an

extrapulmonary bronchoarterial cuff is left attached to the

lung.

It is also possible to leave the lungs attached to the trachea

and thus perfuse them

simultaneously.
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Dr.ROMAN

Before perfusion, mucus and purulent material should be

suctioned from the bronchi.

Fixation Time

Complete perfusion fixation requires about 3 d.

Consolidated and fibrosed lungs may need longer.

Plugging of bronchi may completely prevent proper

expansion and fixation.

In such an event, the affected portions of the lung will

not inflate.

SLICING OF FIXED LUNGS

Need a special knife and slicing board.

The cork slicing board is mounted in a metal tray

where the draining formalin

solution collects.

The knife has a 78-cm long blade that in many

instances permits the whole lung

to be cut with one uninterrupted pulling motion.

This ensures a smooth and even cut surface without

knife marks.

This knife also works well to prepare even slices of

livers or large spleens.

The lung usually is cut in the frontal or sagittal plane

in slices about 1.5 cm thick.

For frontal sectioning, the lung is placed so that the

hilus is uppermost.
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Dr.ROMAN

We usually make the first cut immediately adjacent

to the hilus.

For the preparation of large and very thin slices,

gelatin infiltration is required.

PAPER-MOUNTED SECTIONS

This method was pioneered by Gough and has undergone

several modifications.

The technique yields very instructive,detailed, esthetically

appealing, and extremely

durable views of pulmonary abnormalities.

After perfusion fixation with formalin and sodium acetate,

2-cm thick slices of the lungs

are washed and embedded in a gelatin mixture that

contains a disinfectant.

After the gelatin mixture has penetrated the tissue, the

block is frozen and large, 400-

μm sections are cut, refixed, and transferred to another

gelatin mixture, and eventually

mounted on paper.

Routine stains can be applied without difficulty.

The technique also can be applied to other organs such

as liver.

Detection of Air Emboli:

In cases of sudden death after pneumothorax,

pneumoperitoneum,

intravenous infusions, childbirth, operations, or sharp instrument

injuries to the neck and thorax,

it is important to check for air embolism to the heart.

A postmortem chest radiograph, or postmortem compute

tomography scan, if possible, should be
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taken and inspected for larger quantities of air in the heart and
great vessels.

Baker described a simple technique for detection of air emboli

during a modified postmortem

dissection.

In suspected cases, the initial superior portion of the body

incision should be limited to just

below the sternal notch to reduce the possibility of air reaching

the heart from a severed

superficial neck vein.

One should reflect the skin and muscles but cut only the rib
cartilages from the

second rib inferiorly.

The sternum and anterior ribs are removed, exposing the

pericardium.

Then the aorta is ligated securely, and a small incision is made in

the anterior

pericardial sac.

The cut edges of the pericardium are grasped with clamps and
the pericardial contents are

inspected, noting in particular any bulging of the right ventricle,

indicating possible distention

by entrapped air.

The pericardial cavity is filled with water, submerging the heart

entirely.

The left circumflex and anterior descendingarteries are

transected in turn, and their contents are

milked toward the incisions.

The prosector must look carefully for intravascular air bubbles

that escape.

The same test is performed with the right coronary artery.

Keeping the heart submerged, one incises in turn the right

atrium, the right ventricle, and

the pulmonary artery,pressing slightly to release any pockets of

trapped air.
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Dr.ROMAN

The same maneuver is performed on the left atrium, the left

ventricle, the superior vena

cava, the inferior vena cava,and the pulmonary veins.

Another method involves using a large (30 mL), airtight

syringe fitted with a needle and

filled halfway with water.

After introduction of the needle into the right ventricle, the

appearance of bubbles

within the syringe indicates entrapped air.

Alternatively, the needle can be hooked in series through

tubing to a stopper-topped

bottle and separatory funnel.

The system is filled with oil, allowing collection of any air.

Detection of Pneumothorax

Detection of a pneumothorax is easily done after the typical Y-

shaped skin incision by holding

the dissected skin and subcutaneous tissues of the chest to form a

pocket adjacent to the ribcage.

The pocket is filled with water, and a scalpel is used to incise the
thoracic cavity.

The presence of air bubbles indicates a pneumothorax.

For neonates and small infants, the thorax may be submerged in

a basin of water.

ESOPHAGUS:

For the demonstration of tracheoesophageal fistulas

or infiltrating tumors, the

esophagus should be left attached to the

mediastinal organs.
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Tracheoesophageal fistulas are demonstrated by

opening the esophagus along

its posterior wall and opening the trachea

anteriorly.

Infiltrating tumors are best demonstrated by cutting

properly oriented sections

Through the previously fixed mediastinal organs.

Intraluminal tumors or strictures are well-displayed

on fixed specimens.

STOMACH:

The stomach routinely is opened along the greater

curvature.

Two ligatures are applied at the cardiac end of the

esophagus and two ligatures below

the pyloric end of the stomach.

The stomach is removed by cutting between the double

ligatures at both ends, and is

opened along the greater curvature.

The mucous membrane is examined for the presence of

any stain, congestion,

hemorrhage, desquamation, ulceration, sloughing or

perforation.

The content of the stomach is noted in respect to quantity,

nature of material/food, state of

digestion, color and smell.

Penetrating ulcers or infiltrating tumors are best

displayed by fixing and sectioning

the stomach together with the pancreas, a portion of

the liver, or whatever the

infiltrated tissue might be.

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Dr.ROMAN

Tumors with predominantly intraluminal growth and

the associated obstruction

can be displayed after formalin fixation of the

unopened specimen and

subsequent dissection.

The stomach is inflated with formalin while it is

suspended in a formalin bath.

Direct Access to the Mouth Floor:

The muscular aponeurotic structures that

form the floor of the mouth

are incised using a narrow blade, making a

horseshoe-shaped incision,

from one corner of the mandible to the other.

Begin the incision just behind the internal

surface of the

mandibular arch and remove the posterior

portion of the digastric muscle

lying just behind the jaw, and the stylohyoid

muscle lying in front

and just above the digastric muscle.

Carry the incision centrally, transecting the

mandibular insertions

of the suprahyoid muscles of the neck,

including the anterior portion

of the digastric, milohyoid, geniohyoid, and

genioglossus muscles.

The mucosa of the oral cavity is then incised,

allowing visualization

the base of the floor.

Using a rubber pronged, toothed forceps to

apply traction, expose
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the superior face of the tongue and the more

posterior located structures,

including the lingual tonsil, the three

epiglottis folds delimiting the

two epiglottic valleculae,epiglottis, and the

two epiglottic folds.

The Floor of the Mouth:

Using a toothed forceps, first place traction on

the anterior portion

of the digastric muscle, then use the scalpel

to cut tangentially and

behind the internal border of the mandible,

then sever the insertion

of this muscle.

Detach the muscle from the front to the back

until the dissection

reaches the tendinous portion of the muscle

that attaches to the hyoid

bone by a fibrous loop.

Proceed in the same manner with the hyoid

muscle, dissecting it free from

the mandibular arch, close to its insertion; the

muscle is then reflected

downward onto the hyoid bone.

Then make a horseshoeshaped incision

behind the mandibular arch,

Thereby creating communication with the

mouth, through which

the tongue may be grasped and pulled

downward,taking care to expose

the superior face of the tongue, its terminal

track, and the structures

located at the back, such as the lingual

tonsil, the three glossoepiglottis
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folds delimiting the two epiglottis

valleculae, and the epiglottis.

Dissection of Intestine:

Small Intestine Removal:

After the spleen has been removed, proceed

to the small intestine,

but first examine it in situ.

Overturn the omentum with the transverse

colon and its mesocolon

in order to visualize the mesentery.

Single loops of the small intestine become

visible as they are drawn

through the examiner’s hand.

The small intestine can then be removed in

toto by resecting

the mesentery that fixes it to the posterior

abdomen wall.

Complete Removal of the Small Intestine:

Even though the small bowel can be removed

as a block

in toto,it is preferable to identify the first

jejunal loop,

where it passes between the duodenum and

jejunum

(the so-called duodenal–jejunal flexure),

first.

It is important to identify this first loop before

attempting to

remove the remainder of the intestine.

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The duodenal–jejunal flexure lies close to left

side of the second lumbar

vertebra, where the suspensory muscle of the

duodenum (Treitz muscle)

fixes the passage point between mesenteric

and nonmesenteric intestine,

anchoring it to the left middle pillar of the

diaphragm.

Make another keyhole incision in the

mesentery and introduce

the prongs of two parallel intestinal clamps.

They should be applied at a distance of 3

centimeters from each other.

With the scalpel held perpendicularly to the

intestinal loop,

divide the wall and then proceed to the

ileocecal junction

at the extreme lower insertion of the

mesentery, in the right iliopsoas

recess.

Make another small keyhole incision in the

mesentery and introduce

the prongs of two parallel intestinal clamps

applied approximately

3 centimeters from each other, and divide the

intestine with a perpendicular

cut.

Isolation and Removal of the Cecum:

To isolate the large intestine, begin at

the cecum.

This first part of the large intestine is

easily immobilized.
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Dr.ROMAN

Simply seize it with the left hand,

pulling it forward and

upward with some force.

Isolation and Removal of the Ascending Colon:

The ascending colon, unlike the cecum,

is a retroperitoneal structure.

Free it with an incision made parallel to

the posterior wall of the

abdomen.

Proceed from the bottom to the top and

from left to right, so as to

detach the colon all the way up the

posterior wall, until reaching the

right or hepatic flexure,situated in the

right hypochondrium.

Isolation and Removal of the Transverse Colon

The transverse colon is interposed between

the two flexures,

right and left, and provided with a broad

transverse mesocolon.

The superior margin of the greater

omentum

(a large fold of the peritoneum shaped

like an apron) is

divided in two roots: anterior and

posterior.

The anterior root fits into the first portion

of the duodenum and

the greater curvature of the stomach.

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Using these two landmarks, colic and

gastric colic, it is easy

to locate the opposite side of the

transverse colon.

In fact, its posterior root fits into the

transverse colon.

Using the left hand, pull the colon

anteriorly.

Make a broad incision from right to left.

This will cut the anterior root of the

omentum into its two components

: the duodenum colic ligament and the

gastrocolic ligament.

Then, as the incision is carried more

posteriorly,

the posterior root is divided.

Isolation and Removal of the Colon Right Flexure:

The colon right flexure, in addition to

being intraperitoneal,is “fixed“

to the overlying liver by a strong

ligament known as the hepatic–colic

ligament.

This ligament must be incised.

Hold the blade parallel to the superior

edge of the flexure.

This will allow resection of the colon

and, at the same time, allow for

its detachment from the abdomen’s

posterior wall.
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Isolation and Removal of the Colon Left Flexure:

Once the transverse colon has been

isolated, proceed to the colon left

flexure or, as it is sometimes called, the

lineal flexure.

This is the point at which the colon

becomes,again, a peritoneal organ,

lying in the left hypocondrium,

immediately below where the spleen

was previously located, anchored to the

left costal tracts of the

diaphragm by a short horizontal ligament,

called the frenocolic

ligament.

All of these connections are severed using

sharp dissection.

Isolation and Removal of the Left,Descending, and Iliac Colon:

The removal of the left colon essentially

follows the same method as

removal on the right.

Isolation and Removal of the Colon Right Flexure:

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The colon right flexure, in addition

to being intra peritoneal, is

“fixed“ to the overlying liver by a

strong ligament known as the

hepatic–colic ligament.

This ligament must be incised.

Hold the blade parallel to the

superior edge of the flexure.

This will allow resection of the

colon and, at the same time,

allow for its detachment from the

abdomen’s posterior wall.

Isolation and Removal of the Sigmoid Colon:

The sigmoid portion of the colon runs a

tortuous course from the medial

border of the psoas muscle to the superior

margin of the third sacral

vertebra area, where it continues into the

rectum.

This part of the intestine is covered with

peritoneum, actually a fold of

peritoneum connecting the upper portion

of the rectum, along with the

sacrum.

To remove the sigmoid, the peritoneum

must be divided first, then the

sigmoid can be pulled forward.

This technique allows for visualization of

the pelvic organs and their

anatomic relationships.
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The root of the transverse mesocolon

inserts into the colon, close to the

posterosuperior taenia coli, and for this

reason it is called mesocolic.

The superior surface of the mesocolon

delimits the omental bag.

At its root, it is shaped like an upside-

down V, with the right sagittal and

median branch lying on the bodies of the

lumbar and the first three sacral

vertebrae; the left branch of the medial

margin of the psoas muscle

ascend to converge with it on the right.

Isolation and Removal of the Rectum:

The inferior half the pelvic rectum is

retroperitoneal and is loosely covered

with the so-called rectal band.

Pull the rectum forward in such a way that

the two pararectal recesses can

be visualized.

Then incise the peritoneum and the

underlying rectosacral ligaments

sagittally, from top to the bottom, taking

care to isolate and detach the

rectum from the sacral wall.

If the cadaver is male, locate the

rectovesical cavity and pull the bladder

forward.

Cut the peritoneum of the rectovesical

cavity, as well as the underlying

connective tissue of the rectosacral

ligaments, thereby isolatingthe rectum
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from the bladder.

If the rectum is incised in the region of the

perineum, it is possible to

remove all of the large intestine merely by

resecting the walls of the

rectum above the external sphincter.

If the cadaver is female, first locate the

rectouterine space (pouch of

Douglas).

With the left hand, gently pull the uterus

and underlying vagina forward.

Make an incision parallel to the rectum,

then incise the rectouterine cavity

and the underlying connective tissue,

including the uterosacral ligaments.

Isolate the rectum from the uterus and

vagina, then remove the rectum and

all of the large intestine by excising the

rectum in the perineal plane area.

LIVER AND HEPATODUODENAL LIGAMENT:

Before removal of the liver,the hepatoduodenal ligament

should be dissected.

First, the common bile duct is incised and opened

toward the hilus and ampulla of

Vater.
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The lowermost portion of the common bile duct runs

retroduodenally.

Remove adherent diaphragm and lesser omentum, and weigh

the liver.

Pathologists have cut the liver variously in parasagittal,

coronal, and horizontal planes.

Only the coronal and horizontal planes include the right and
left lobes of the liver in the same

section.

The middle coronal sections provide the best demonstration of

the hilar structures, but a

horizontal section (preferred) includes the most parenchyma

and therefore demonstrates the

organ’s size to best advantage.

SLICING :

It is almost impossible to slice livers with normalsized

knives without leaving knife

marks on the cut surface.

Smooth cut sections of cirrhotic livers are even more

difficult to prepare.

We use a knife with a 78-cm blade,which in most

instances permits slicing of the

whole organ with an uninterrupted pulling motion.

Usually, the liver is sliced in the frontal plane, each slice

being about 2 cm thick.

The hilar structures may remain attached to one of the

central slices.

However, it is sometimes necessary to expose, on one

cut section, a large

parenchymatous surface or leave the hilar structures

intact.

In these instances,horizontal sections through the liver is

the methods of choice.
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Dr.ROMAN

We routinely slice livers in this manner if they had been

prefixed in our cascade

perfusion system.

FIXATION:

The failure rate with autopsy livers is greater than the

rate with surgically obtained

livers, undoubtedly because of postmortem clotting.

Nevertheless, if the recently described methods are

applied properly, many autopsy

livers can be fixed successfully with this machine.

For the preparation of large histologic sections,

perfusion fixation of the whole liver

yields the best results.

If large slices of fresh livers are placed in a formalin

bath, the fixative often does not

penetrate deep enough.

If the slices are only 3–4 mm thick, they fix readily but
usually with considerable

distortion.

GALLBLADDER:

To avoid spilling of bile and the discoloration of

organs, the gallbladder

usually is removed from its bed intact and

opened in a fine-meshed strainer

over a collecting vessel.

If liver and gallbladder are to be fixed in a

block, it is advisable to first
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Dr.ROMAN

remove the bile from the unopened gallbladder

with a syringe.

Before the tissue block is submerged in the

formalin bath,the gallbladder

and the extrahepatic bile ducts are partially

opened and stuffed with .

formalin-soaked cotton in order to preserve the

normal shape of the

structures.

The cystic duct is very difficult to dissect

because of its numerous folds.

Gallstones sometimes can be cut fresh but

often need a 24-h fixation period

in concentrated formalin to harden them

sufficiently.

If the stones are too hard to cut, a fine scroll

saw may be needed to prepare

an instructive cut surface.

Pancreas:

Dissect the pancreas free of any peripancreatic fat and weigh it.

To examine the pancreatic parenchyma, cut by making serial

transverse slices along its short axis

(parasagittal sections).

This allows adequate examination of the duct system.

Make several serial transverse sections through the head of the

pancreas,allowing examination of

the pancreatic parenchyma and the main duct (Wirsung) and, if

present, the accessory duct

(Santorini).
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Dr.ROMAN

At the point distal to an accessory duct,a probe is inserted into the

main duct.

Then we make a lengthwise coronal section along the probe that

usually reveals a considerable

length of the duct.

The free section of the neck,body, and tail of the pancreas

provides material for microscopy.

Aorta, Diaphragm, and Mesentery:

Dissect the abdominal portion of the aorta from the remaining

organ block.

If the diaphragm was not removed during dissection of the liver,

remove and examine it.

Finally isolate the mesentery.

Palpate its tissues for enlarged lymph nodes and abnormal masses.

The vessels coursing through the mesenteric fat can be examined

by making a series of arcing cuts.

SPLEEN:

Frontal or horizontal sections are prepared, by the same

principles used for

sectioning the liver.

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Dr.ROMAN

Formalin perfusion of the intact organ through the

splenic vessels has proved

unsatisfactory unless the blood has been previously

removed.

Some areas tend to remain unfixed.

If formalin fixation is intended, care must be taken that

the slices are very thin.

Fixative does not penetrate well into the splenic pulp.

The splenic reticulum is best studied by washing the

blood out of the pulp.

This also facilitates fixation of the whole organ.

The spleen is first perfused through the splenic artery or

vein with 0.9% saline.

If the injection pressure is about 100 mm Hg, the splenic

pulp will turn white after

about 1 h.

The perfusion is now continued with 10% formalin

solution.

In some instances it may be useful to fix the organ at

more than its normal volume by

tying the efferent vessels.

Injection into the celiac artery or directly into the splenic

artery is used for splenic

arteriography.
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Dr.ROMAN

EXAMINATION OF THE PARANASAL SINUSES AND SKULL BASE

 Examinations of the frontal, ethmoidal, and sphenoidal sinuses may be approached

rather easily intracranially after the brain has been removed.

 Frequently the entire sinus with surrounding bone does not need to taken, and those
three sinuses can be unroofed with either a chisel or oscillating saw.

 The sphenoidal sinuses can be accessed with a central sphenoid bone excision in
which an oscillating saw is used to isolate a cube of bone containing the sella
turcica,cavernous sinus, sphenoidal sinuses, and intraosseous portions of the internal
carotid arteries.

 The maxillary sinus can be accessed directly without disfigurement using a Caldwell-
Luc approach, in which a small bony foramen is created through the upper gum
posterior to the canine teeth, using a narrow blade of the oscillating saw.

 The ethmoid sinuses can be approached by breaking the cribriform plate with
a chisel and mallet.

 Continued chiseling leads into the maxillary sinuses.

 The frontal sinuses are entered by chiseling away their posterior walls close
to the midline.

 The sphenoidal sinuses can be inspected after the anterior wall and the floor
of the pituitary fossa have been exposed.

 If the block of bone containing the pituitary fossa is removed with an

oscillating saw, the sphenoidal sinuses are exposed even better.
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Dr.ROMAN

Skull and Brain

REMOVAL OF BRAIN IN ADULTS (INCISION OF SCALP)

 The head is elevated slightly with a wooden block or a metal headrest attached to the
autopsy table.

 A sharp scalpel blade can then be used to cut through the whole thickness of the
scalp from the outside.

 The incision should start on the right side of the head just behind the earlobe,as low
as possible without extending below the earlobe,and extend to the comparable level
on the other side.

 This will make reflection of the scalp considerably easier.

 The anterior and posterior halves of the scalp are then reflected forward and
backward, respectively, after short undercutting of the scalp with a sharp knife, which
permits grasping of the edges with the hands.

 The use of a dry towel draped over the scalp edges facilitates further reflection,
usually without the aid of cutting instruments.

 If the reflection is difficult, a scalpel blade can be used to cut the loose connective
tissue that lags behind the reflecting edge as the other hand continues to peel the
scalp.

 The knife edge should be directed toward the skull and not toward the scalp.

 The anterior flap is reflected to a level 1 or 2 cm above the supraorbital ridge.

 The posterior flap is reflected down to a level just above the occipital protuberance.

Procedure:
A wooden block is placed under the shoulders so that the neck is extended and the head fixed
by a headrest.

A coronal incision is made in the scalp, which starts from one mastoid to the opposite mastoid
process just behind the ear and is continued over the vertex of the scalp.

The incision should penetrate upto the periosteum.

The scalp is reflected forwards to the superciliary ridges, and backwards to a point just below
the occipital protuberance.

Presence of hematoma, petechial hemorrhage, edema or fracture is noted.

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Dr.ROMAN

The temporal and masseter muscles are incised on either side for sawing the skull.

The saw-line is made in a slightly V-shaped direction (angle of 120°) so that the skull cap can
fit back into the correct position on reconstruction of the body.

Saw and remove the skull cap, the line of separation is just above the superciliary ridges in
front, to the base of the mastoid process on either side,and just above the occipital
protuberance behind.)

SAWING OF CRANIUM
 The cranium is best opened with an oscillating saw.

 Alternatively, a handsaw can be used.

 The temporalis muscle should be cut with a sharp knife and cleared from the
intended path of the saw blade.

 Ideally, sawing should be stopped just short of cutting through the inner table of the
cranium, which will easily give way with the use of a chisel and a light blow with a
mallet.

 Leaving the dura and underlying leptomeninges intact allows to view the brain with
the overlying cerebrospinal fluid (CSF)still in the subarachnoid space.

 To obtain this view, after removal of the skull cap, the dura must be cut with a pair of
scissors along the line of sawing and reflected.

 To protect the brain, the extended index finger of the hand that holds the neck of the
oscillating saw should gauge the distance of the blade penetration.

 The oscillating blade should be moved from side to side during cutting to avoid deep
penetration in a given area.

 The frontal point of sawing should start approx two fingerbreadths above the
supraorbital ridge.

 While the lateral aspects of the skull are being cut, turning the head to the opposite
side permits the brain to sink away from the cranial vault and thereby diminishes the
chance of injury to the brain.

 A blunt hook may be used to pull the skull cap away from the underlying dura.

 A hand inserted between the skull and the dura (periosteum)helps the blunt
separation of these while the other hand is pulling the skull cap.
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Dr.ROMAN

 If the dura adheres too firmly to the skull, it can be incised along the line of sawing
and the anterior attachment of the falx to the skull can be cut between the frontal
lobes.

 The posterior portion of the falx can be cut from inside after the skull cap is fully
reflected.

 The dura is then peeled off the skull cap.

 The superior sagittal sinus may be opened with a pair of scissors at this time.

 Routinely,the dorsal dural flaps on both sides can be removed easily from the brain
by severing the bridging veins.

 In the presence of epi- or subdural hemorrhage and neoplasia,it is best to leave the
dural flaps attached to the dorsal brain and section them together.

Delivery of the Brain

 Insert four fingers of the left hand between the frontal lobes and the skull.

 Draw them backward and then with the right hand, cut the nerves and vessels as they emerge
from the skull.

 Cut the tentorium along the superior border of the petrous bone.

 Cut the cervical cord, first cervical nerves and vertebral arteries,as far below as possible.

 Support the brain throughout with the left hand.

 Remove the brain along with the cerebellum and brainstem which is supported by the right
hand.

 Examine the venous sinuses and the cranial cavity for antemortem thrombi.

 Remove the pituitary by chiseling the posterior clinoid processes and incising the diaphragm
of the sella turcica around its periphery.

 Pull out the dura and examine the base of the skulland the rest of the cranial cavity for any
fracture.

 Inspect the skull cap for fracture by holding it against the light.

 Remove a wedge shaped portion of the petrous temporal bone and examine the mastoid for
any collection of pus, hemorrhage or fluid in the middle ear.)
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Dr.ROMAN

Examination of Dura :

1. The dura matter is grasped anteriorly with a forcep,and with a scissors or scalpal,the
dura is divided from before backwards at the level of the skull division on both sides.

2. If the dura adheres too firmly to the skull, it can be incised along the line of sawing
and the anterior attachment of the falx to the skull can be cut between the frontal
lobes.

3. The posterior portion of the falx can be cut from inside after the skull cap is fully
reflected.

4. The dura is then peeled off the skull cap.

5. The superior sagittal sinus may be opened with a pair of scissors at this time.

6. Routinely,the dorsal dural flaps on both sides can be removed easily from the brain
by severing the bridging veins.

7. In the presence of epi- or subdural hemorrhage and neoplasia,it is best to leave the
dural flaps attached to the dorsal brain and section them together.

The dura is examined from outside for extradural hemorrhage (weight and volume
is noted, if present)and superior sagittal sinus for antemortem thrombus.

***** („. Subdural hemorrhage can be washed under running water whereas
subarachnoid hemorrhage cannot be washed.)
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Dr.ROMAN

Berry aneurysms
 (size varies from few mm to few cm) are usually present at the
junction of vessels especially at the junction of the posterior
cerebral arteries,the posterior communicating vessels, and the
middle cerebral arteries and the anterior communicating arteries.

 Cerebral infarction may occur due to a thrombus or atheroma.

Fig: Common sites of Berry aneurysms in circle of Willis.

Examination of ventricles:
¥ Before removing the brain an in situ assessment of the lateral
ventricles should be performed.

¥ Gently divide the cerebral hemispheres by placing the fingers on

the cingulate gyrus.
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Dr.ROMAN

¥ Then with the scalpel blade at about 45 degree to the cingulated

gyrus,make a semicircular incision in the inferior concavity,with the
blade inserted to a depth of about 0.8 cm.

¥ The incision will expose the lateral ventricles.

The Vertebral Arteries:

 The vertebral arteries can be examined and dissected in one of two principal ways.

 The first involves removal of the complete cervical spine followed by decalcification of this
block before dissection.

 For decalcification the excised block is first fixed for 3 to 5 days in formalin,followed by 2
to 5 weeks of immersion in a 10% formic acid/ formalin mixture, changing the fluid
regularly.

 When fully decalcified the block of tissue can be serially sliced transversely at 5-mm
intervals and the vertebral arteries inspected macroscopically.

AUTOPSY TECHNIQUES(peripheral nervous system:)

 First the body is turned over and an incision is made in

the back of the thigh to free the sciatic nerve.

 The incision may be extended caudally to allow the

removal of the peroneal and tibial nerves in the leg.

 More conservatively, a 15-cm longitudinal incision in

the popliteal region exposes these nerves at their
bifurcation.

 We removed the sciatic nerve by incising the anterior

surface of the thigh and leg.

 One of the most accessible peripheral nerve is the

sural nerve,removal at autopsy through a small incision
behind the lateral malleolus.

 For best preservation of these nerves, autopsies

should done within 6 h after death.
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Dr.ROMAN

REMOVAL OF BRAIN IN FETUSES AND INFANTS

When the sutures are not closed and the cranial bones are still soft, Beneke’s
technique is used to open the cranium.

The scalp is reflected as in adults.

Starting at the lateral edge of the frontal fontanelle, the cranium and dura on
both sides are cut with a pair of blunt scissors.

This cut leaves a midline strip approx 1 cm wide, containing the superior
sagittal sinus and the falx, and an intact area in the temporal squama on
either side, which serves as a hinge when the bone flap is reflected.

The older the infant, the narrower the sagittal strip will be because
ossification advances toward the midline.

An alternate method of cutting, which follows the cranial suture lines.

With this method,fracture lines will be created along these bone flaps on their
reflection; an optional cut along the posterior base of the frontal bone on
either side will facilitate the procedure.

The falx is then sectioned in a manner similar for adults.

To minimize brain distortion during removal, several methods have been

proposed.

In an early stage of the autopsy,fixatives such as 10% formalin in 70%

alcohol can be infused through the neck arteries; this increases the
consistency of the brain and facilitates its removal.
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Dr.ROMAN

The fixative also can be injected percutaneously into the lateral

ventricles,through the lateral margin of the anterior fontanelle.

In a modification of Beneke’s method the skull is incised lightly along the

cranial sutures and at the fontanelles.

By reversing the scalpel and passing it under the bones, the bones are
separated from the underlying dura.

The bone flaps are reflected after a small nick is made at the base in each of
the bones.

The dura is then cut as close to the base of the skull as possible.

Damage to the brain can be minimized further if the scalp and calvarium are
opened and the falx sectioned with the body in a sitting position and the
infant’s head being supported by an assistant.

The tentorium and vein of Galen are transected in this position by gently
separating the parieto-occipital lobes.

After the tentorium is sectioned, the body is suspended upside down by the
assistant, the brain being supported during the movement by the hand of the
prosector.

The brain is cut away from the base of the skull in this upside-down
position,which minimizes movement of the brain and damage to the brain
substance and its surfaces.

The bone flaps can be repositioned in their normal position on one

side;supporting the head with the hand on this side, the brain can be freed on
the other side.

This is repeated on the opposite side.

The brain is not touched directly during these procedures and,Scalp incision.
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Dr.ROMAN

Dissection of spinal cord

1.Anterior approach

2. Posterior approach

3.Combined approach

Anterior Approach:
 -first cut is made across uppermost part of T1 or T2.

 -head is dropped back, wooden block under mid back.

 -either side of thoracic spine up to length of 15cms.

 -angle of blade changed and adjusted according to the type

of vertebra.

 -muscles removed and vertebra(L1-L4) cut in similar pattern

like thoracic vertebra.

 -Sacrum and L5 is removed together.

 -Carotids are pushed sideways and cervical vertebrae

removed till c2 similarly.

Advantages:
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Dr.ROMAN

-prevents leakage after embalming.

-less mutilation visible.

-course of peripheral nerves for any length in contiguity from spinal

cord can be accessed.

Disadvantages:

-difficult approach to proximal cervical vertebrae.

-conditions like myelomeningocele, and occipital encephalocele

cannot be demonstrated.

-Flexion extension injuries to back of the neck or other injuries along

the posterior vertebral column cannot be demonstrated.

Posterior approach:
 A long midline incision is made and the skin, muscle and
soft tissues are flapped out sidewise or laterally,

 1 inch on either side from the vertebral column.

 The posterior arch is cut with the vibrating saw.This

dissection can extend superiorly along the cervical vertebrae
to the foramen magnum.

 The spinal processes and posterior portions of the laminae

are removed.

 The dura is opened longitudinally to the uppermost part of

the incision, where it is cut circumferentially.

 The nerves are cut and the spinal cord is delivered by steady
traction.

Advantages:

Pathological conditions like myelomeningocele, occipital

encephalocele can be demonstrated.

dissection can be limited up to the desired level and stopped.

both anterior and posterior aspect of vertebra can be accessed.

Disadvantages:
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Dr.ROMAN

-course of peripheral nerves cannot be pursued along its contiguity.

-Embalming leakage

-Cosmetic disadvantage.

Combined approach:
 For complete removal of meningocele,myelomeningocele or
other midline fusion defect.

 Body is turned back and incision is made around the desired

area then continued anteriorly.

REMOVAL OF SPINAL CORD IN INFANTS

ANTERIOR APPROACH (The basic principle is the same as in adults).

Anterior Approach:

 -first cut is made across uppermost part of T1 or T2.

 -head is dropped back, wooden block under mid back.

 -either side of thoracic spine up to length of 15cms.

 -angle of blade changed and adjusted according to the type

of vertebra.

 -muscles removed and vertebra(L1-L4) cut in similar pattern

like thoracic vertebra.

 -Sacrum and L5 is removed together.

 Carotids are pushed sideways and cervical vertebrae

removed till c2 similarly.
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Dr.ROMAN

 The incomplete calcification of the spinal column permits the

use of a scalpel blade instead of an oscillating saw blade.

REMOVAL OF THE EYE AND ORBITAL CONTENTS.

ANTERIOR APPROACH
In the vast majority of instances, the eye is removed by the anterior
approach.

The eyelids are held apart with the aid of retractors.

Using curved scissors, the conjunctival attachments to the limbus are

severed, care being taken not to cut the eyelids.

Tenon’s capsule is left intact to avoid leakage into the empty socket.

The four rectus muscles are cut so that approx 5.0 mm of muscle are left
attached to the globe; this allows orientation of the globe at a later time.

The inferior oblique muscle is then severed.

Rotation of the eye temporally by traction on the stump of the inferior oblique
muscle allows access to the optic nerve and ensures that a long piece of the
intraorbital portion of the optic nerve is obtained.

It is not deemed necessary to ligate the optic stalk as only a portion of the
leakage after enucleation arises from the severed end of the optic nerve.

The socket is dried with a towel and a silastic mold is placed in position.

The disadvantage of this anterior approach is that it excludes adequate

examination of the orbital contents and the lacrimal gland.

TECHNICAL ASPECTS

 The eye is removed by the anterior approach under

aseptic conditions as soon as possible after death but
within 24 h.
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Dr.ROMAN

 The eye is placed with the cornea directed upwards in

a glass receptor that contains sterile saline.

 The specimen is kept at 2–6ºC in a refrigerator.

Anterior or External Removal:

Specialized instruments that aid in removing the eye by the anterior approach
are available (Bausch & Lomb Surgical, St. Louis, Mo).
To prevent inadvertent injury to the eyelids and to make eye removal easier,
separate the eyelids with a Knapp or other appropriate eye speculum.
Using Aebli straight corneal scissors, one should free the conjunctiva from the
sclera around the entire eye.
The conjunctival flap is clamped with a small (Hartmann) mosquito
hemostatic forceps, and the insertion of the medial rectus muscle is exposed.
One then passes an eye muscle hook behind the medial rectus muscle and
pulls the eye laterally.
The muscle is transected 1 to 1.5 cm behind the insertion.
With the muscle hook, one then rotates the eye inferiorly,superiorly, and
medially, transecting in turn the superior, inferior,and lateral rectus muscles.
The medial rectus muscle tag is clamped with the hemostat, and the eye is
pulled forward.
Using the Storz curved enucleation scissors, one should transect the optic
nerve as posteriorly as possible.
Next, the superior and inferior oblique muscles are cut along with any
remaining soft tissue attachments to free the eye.
One then packs the orbit with some cotton or gauze and covers the area with a
plastic shield.

INTRACRANIAL APPROACH (EXENTERATION PROCEDURE)

This method is advisable when there is pathology of
the orbit and the eye.
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Dr.ROMAN

Such conditions include inflammation, neoplasia,

vascular disease,and disease of the orbital portion of
the optic nerve.

The method consists of first cutting the conjunctival

attachments at the limbus by the anterior approach as
outlined earlier, and using the intracranial approach to
expose the orbital contents.

After removal of the brain, two saw cuts are made, one
vertically downward opposite the cribriform plate of the
ethmoid and the second downward and medially,
immediately anterior to the lateral end of the lesser
wing of the sphenoid.

The orbital plate is broken with a chisel and hammer

and the bone is removed piecemeal with the aid of
bone forceps.

Care must be taken not to damage the optic nerve and

other contents of the optic foramen as this area is
exposed.

Curved scissors are used to free the globe and its

attached muscles.

The superior oblique muscle is cut from the body of the

sphenoid bone and the inferior oblique muscle is cut
from the floor of the medial orbit.

Freeing of the conjunctival attachments must proceed

with caution in order to avoid damage to the eyelids
and anterior chamber of the eye.

Posterior or Internal Removal:

The entire orbital contents (eye, optic nerve, extraocular muscles,lacrimal

gland, and orbital fat) may be removed by an internal approach after removal
of the brain and dura.
In fact, this is the method of choice in the evaluation of most inflammatory or
neoplastic disorders and is particularly recommended for evaluation of
suspected trauma in the pediatric age group.
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Dr.ROMAN

With a vibrating saw fitted with a narrow fan-shaped blade, one cuts through
the orbital roof. In infants, the orbital roof can be removed with scissors or
cartilage cutters.
The bone overlying the optic nerve canal is included so that the entire nerve
can be removed intact to the point where it was transected during brain
removal.
The bone flap is lifted with a forceps to expose the orbital contents.
Bluntly dissect the lateral medial and inferior orbital tissues that attach to the
periosteum.
With a scalpel, cut to attachments at the inferior orbital fissure, the extraocular
muscles,vessels and nerves entering the orbit, and the ring of connective tissue
surrounding the optic nerve.
Before removing the specimen, separate the conjunctiva from the sclera as
shown in and bluntly dissect the Tenon fascia that underlies the conjuctiva.
The remaining periosteal attachments are then incised and gentle digital
pressure on the anterior surface of the eye delivers it into the cranial cavity,
although a few inferior attachments may require cutting.
Pack the orbit as like anterior approch.

Fixation and Dissection of the Eye:

 The globe or orbital specimen is fixed in 10% buffered formalin

for 24 to 48 hours.
 After an overnight wash in running water, the eye is stored in 70%
alcohol until cutting.
 If the eye collapses, as it tends to do, inject some alcohol into the
vitreous to restore the shape of the globe before dissection.
 Although eye specimens are generally labeled right or left,this
should be confirmed by observation.
 To orient the eye,identify the tendinous insertion of the superior
oblique muscle and the muscular insertion of the inferior oblique
muscle,both of which pass medially in the orbit.
 The eye is,giving the anterior-posterior, horizontal, and vertical
diameters.
 The vertical and horizontal diameters of the cornea are measured,
nothing in turn the translucency of the cornea,color of the iris, and
shape of the pupil.
 Then transilluminate the globe and outline any opacities with a
marking pencil.
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Dr.ROMAN

 If the eye shows signs of trauma, obtain a radiograph to exclude a

metallic foreign body. Obtain a sample of the optic nerve with a
cross section just behind the globe.
 The eye is cut parallel to the long ciliary arteries, starting adjacent
to the optic nerve and ending just inside the corneal limbus.
 Note the character of the vitreous, filtration angle, position of the
iris,presence or absence of the lens, and position of the retina.
A second cut is made parallel to the first, yielding a central section
approximately 8 mm thick for light microscopic embedding.
This section includes the cornea, lens, optic nerve,and macula.

REMOVAL OF THE LACRIMAL GLAND

 The lobulated, bean-shaped lacrimal gland lies in the
lateral part of the upper orbit in the hollow of the medial
side of the zygomatic process of the frontal bone and is
adjacent to the roof.

 The gland may be obtained either before or after

removal of the globe.

 The lacrimal nerve and artery, which lie in the fat at the
junction of the roof and lateral wall of the orbit,may be
traced to the lacrimal gland.

 The concave medial surface of the gland lies on the

superior levator and lateral rectus muscles; these may
also be traced to the gland.

 Curved scissors are used to free the gland from the

adjacent muscles and the short fibrous bands that bind
it to the orbital margin.

 If only a limited autopsy is permitted, a specimen of

lacrimal gland may be obtained by inserting a biopsy
needle beneath the upper eyelid and aiming upward
and laterally toward this gland.

VITREOUS :
 This is the most frequently used specimen for postmortem chemical analysis.
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Dr.ROMAN

 A 15-gauge needle is inserted at an oblique angle through the sclera at a

point 5 mm lateral to the limbus (corneo-scleral junction).

 The needle will traverse the pars plana and enter the vitreous body.

 Damage to the retinal cells will result in a falsely high potassium value and
thus gentle aspiration of 2–3 mL of vitreous is required.

 The material, which is drawn into a 10 mL sterile syringe may be stored at

4ºC for up to 48 h.

 Forceful aspiration must be avoided because it may detach retinal cells.

 Vitreous is an excellent specimen for alcohol and drug analysis.

 Typically, a panel of six tests is run, comprising sodium, potassium,

chloride,urea nitrogen,creatinine, and glucose.

 Chloride Serum and vitreous Serum chloride values decrease after

death;vitreous sodium is stable.

 Hypoxanthine Vitreous Values increase steadily after death; has been used
to determine postmortem interval.

 Lactic acid Serum and vitreous Values increase after death.

 Potassium Vitreous Values increase steadily after death; has been used to
determine postmortem interval.

 Sodium Serum and vitreous Serum sodium values decrease after

death;vitreous sodium is stable.

 Urea nitrogen Serum and vitreous Values stable after death.

 Dehydration Vitreous High sodium (>155 meq/L) and chloride (>135

meq/L)values with moderate increase (above 40 mg/dL) of urea nitrogen
concentration.

 Diabetes mellitus Vitreous High glucose (>200 mg/dL or >11.1 mmol/L) and
ketone concentrations in diabetic ketoacidosis.

 Uremia Vitreous Marked increase of urea nitrogen and creatinine

concentrations with sodium and chloride values near the normal range.

 Vitreous humor is preserved using sodium fluoride(10 mg/ml).

 A fine hypodermic needle (20 gauge) attached to a syringe is inserted through
the outer canthus into the posterior chamber of the eye, after pulling the eyelid
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Dr.ROMAN

aside, followed by aspiration of 1–2 ml of crystal clear colorless fluid from

each eye.
 Water/saline is re-introduced through the needle to restore the tension in the
globe for cosmetic reasons.

Myocardial infarction (MI)

Age-Related Features of Myocardial Infarction.

age Gross featur Light microscopy

<4 h No change. No change.

4–12 h Slight mottling, with areas of dark discoloration. Intense sacroplasmic eosinophilia and

nuclear pyknosis; contraction bands.

12–24 h Mottled and mildly edematous,with bulging cut As above, with early interstitial edema and surface.

neutrophilic infiltrates.

2–4 d Soft yellow-tan core with mottled border. Maximum neutrophilic infiltrate;

nuclear loss and sarcoplasmic coagulation.

5–7 d Yellow-tan core and irregular infiltration;

dilated hyperemic Basophilic interstitial debris capillaries at border;
early macrophage red-brown border.

8–10 d Yellow-gray core and red-brown border;Numerous

macrophages,with active phagocytosis; pigmented depressed cut surface.

Macrophage.
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Dr.ROMAN

filled with lipofuscin.

11–14 d Yellow-gray core and red-gray border; ongoing phagocytosis

Granulation tissue along borde. depressed cut surface.

2–4 wk Core becoming smaller; border becoming larger, Ongoing scar

formation, dense at outer border; chronic grayer, firmer, and less gelatinous;
less inflammation; dilated peripheral small vessels; central depressed cut
surface. core of necrotic tissue.

>1 mo Firm gray-white or red-gray scar, with scar retraction Mature

scar (dense collagen, focal elastin, and variable wall thinning. hypercellularity;
focal lymphocyte.

Dissecting Heart:
1. Inflow-outflow method.
2. short axis or ventricular slicing method.
3. intramural or ‘sandwich’ technique.
4. Four-Chamber Method.
5. Base of Heart Method.
6. Window Method.
7. Unrolling Method.
8. Partition Method.
9. Injection-Corrosion Method.

Inflow-outflow method ( Following the direction of blood flow):

 First, the right atrium is opened, followed by the tricuspid valve, and then the
pulmonic valve.
 Next, the left atrium is opened, followed by the mitral valve and the aortic
valve.
 During opening,the valves should be examined before being cut and valve
orifice measured.
 Special sections can be taken at this point to evaluate the conduction
(electrical)system of the heart.

Incision 1— Through right atrium.

Incision 2— On the Ant. wall of ryt.ventricle parallel to interventricular septum.
Incision 3— Through tricuspid valve.
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Dr.ROMAN

Incision 4— Through left atrium (after reversing the heart).

Incision 5— Through mitral valve, parallel to the septum (on anterior wall).
Incision 6— Through aortic valve.

Fig: Opening of the heart at autopsy

short axis or ventricular slicing method :

 With the heart in the anatomical position, the first slice is made through the
heart at a point about 3 cm from the apex separating it from the remainder of
the heart.
 Further complete slices are then made in parallel to this slice, 1 cm apart, until
reaching below the atrioventricular valves.
 The remainder is then examined by opening along the path of blood flow.
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Dr.ROMAN

 It is useful if ischemic myocardial disease is suspected as it clearly

demonstrates the distribution of infarction.

Fig: Examination of myocardium

The intramural or ‘sandwich’ technique :

 Used to cut through the thickness of the left ventricle.

 The heart is placed open on the cutting board, with the endocardium
downwards.
 A knife is passed into the cut edge of the left ventricle and sliced right through
the muscle, keeping equidistant between endocardium and epicardium.
 The myocardium can then be opened out like a book, showing the interior
with any infarcts or fibrotic plaques.

Four-Chamber Method :
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 Using a long knife and beginning at the cardiac apex, a cut is extended through
the acute margin of the right ventricle, the obtuse margin of the left
ventricle,and the ventricular septum.
 Cutting is then extended through the mitral and tricuspid valves and through the
atria.
 This will divide the heart into two pieces, both of which show all four chambers.
 The upper half can then be opened along both ventricular outflow tracts,
according to the inflow-outflow method.

Base of Heart Method :

 This method displays all four valves intact at the cardiac base and thus is ideal
for demonstrating anatomic relationships between the valves themselves and
between the valves and the adjacent coronary arteries and the atrioventricular
conduction system.
 The technique is best applied to hearts with prominent valvular disease,
including prosthetic valves.
 The ventricles are sliced in the short-axis plane before the cardiac base is
dissected, and slices can extend above the level of the tips of the mitral papillary
muscles.
 With the cut surface of the ventricles placed on a paper towel, the atria are
removed.
 Begin at the inferior vena cava with scissors and cut into the right atrium,staying
about 0.5–1.0 cm above the tricuspid valve annulus.
 Cut only through the atrial free wall, taking care not to injury the adjacent right
coronary artery.
 End the cut at the upper aspect of the atrial septum, adjacent to the ascending
aorta.
 For the left atrium, first locate the ostium of the coronary sinus, near the
inferior vena cava, and cut in a retrograde fashion along the outer wall of the
coronary sinus in the left atrioventricular groove.
 Then, use scissors or a scalpel to cut through both the inner wall of the
coronary sinus and the adjacent left atrial free wall.
 This cut should extend from the lower aspect of the atrial septum to the level of
the left atrial appendage.
 Continue the cut between the mitral valve annulus below and the appendage
above, dissecting the left atrial wall away from the ascending aorta.
 At the upper border of the atrial septum, the left atrial cut should meet that
from the right atrium.
 Cut through the atria septum, from its upper to lower aspects, and remove the
two atria from the cardiac base.
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Dr.ROMAN

 Transsect the two great arteries along their sinotubular junctions,at the level of
the valve commissures.
 After removing the ascending aorta and pulmonary artery, the arterial sinuses
can be trimmed away with scissors to better demonstrate the two semilunar
valves.
 The aortic valve is located centrally and abuts against the other three valves.
 After photographs have been taken, the right and circumflex coronary arteries
can be evaluated for obstructions.

Window Method:

 This method is useful for the preparation of dry cardiac museum specimens,
using paraffin and other materials or plastination, which is the currently favored
method.
 Hearts should be perfusion-fixed.
 Windows of various sizes can be removed from the chambers or great vessels
with a scalpel.
 The blocks of tissue that are removed in this manner can be used for histologic
study.
 Windows should initially be made small.
 Then, by looking inside the heart, one can determine how much to enlarge the
opening to best demonstrate the lesion of interest.

Unrolling Method :

 This technique can be used to demonstrate opacified epicardial arteries in a

single plane.
 Following postmortem coronary angiography, the ventricular septum and free
walls are unrolled by one of three techniques.
 The method of Rodriguez and Rainer is the simplest and is best accomplished
on fresh hearts.
 All unrolling techniques cause considerable mutilation of the heart and should
be reserved for research studies.

Partition Method:

 Partitioning techniques are used to weigh each ventricle separately for detailed
assessment of ventricular hypertrophy.
 Because these techniques also mutilate the specimen, it is recommended to first
evaluate the heart diagnostically by the short-axis method.
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Dr.ROMAN

 Partitioning begins with the stripping of epicardial fat and coronary vasculature
from the specimen.
 Next the atria and great arteries are removed.
 Excision of the valves is optional.
 Finally, the ventricular free walls are separated from the ventricular septum.

Injection-Corrosion Method :
 Plastic or latex is injected into the coronary vasculature or into the cardiac
chambers and great vessels.
 Casts made from silicon rubber are resilient and nonadhesive and can therefore
be extracted from the coronary arteries or cardiac chambers without resorting
to corrosion of the specimen .

Examination of the Coronary Arteries:

anaTomy
The origin of the left main coronary artery can usually be
identified externally between the aorta and the left
auricle.

It soon divides into the left circumflex artery and the left
anterior descending artery.

The left circumflex artery runs in the atrioventricular

groove between the left atrium and the left ventricle, and
tends to become difficult to identify posteriorly.

The left anterior descending artery runs in the septal

groove between the left and right ventricles, and usually
becomes unidentifiable near the apex.

The right coronary artery is often the largest, but

paradoxically may be the most difficult to find, as it is
often buried within a large amount of epicardial fat.

It emerges between the right auricle and pulmonary

trunk, runs posteriorly in the atrioventricular groove
between the right atrium and ventricle, and then
commonly turns inferiorly to run in the posterior septal
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Dr.ROMAN

groove, where it travels to the apex of the heart and

supplies the posterior septal wall.

Dissection of the Coronary Arteries:

 **Coronary artery disease is seen more commonly than valvular heart disease.
 **The myocardium is examined for fibrosis or recent infarct.
 **The myocardial infarct is easily identifiable when it is of more than 12
hours (h) of age.
 ** If an infarct is identified, sections from its central and peripheral zones are
useful in dating the onset of ischemic damage and determining any recent
extension.
 The extramural coronary arteries are examined by making serial cross-
sectional incisions about 3–5 mm apart, in order to evaluate for atherosclerotic
narrowing, the common site being 1 cm away from the origin of the left
coronary artery.
 The narrowest segments and any areas containing thrombi should be selected
for microscopic examination.
 The anterior descending branch of the left coronary artery is cut downwards
along the front of the septum, then the circumflex branch on the opposite side
of the mitral valve.
 The right coronary artery is followed from the aorta to the cut near the
pulmonary valve and then above the tricuspid valve.
 The presence of acute coronary lesions, viz. plaque rupture, plaque
hemorrhage or thrombus is noted.
 The extent of coronary artery atherosclerosis is categorized based on the
approximate percentage stenosis, caused by the plaque.
 Anything < 50% is considered mild, while 50–75% is considered
moderate and > 75% is severe.

Other Methods for dissecting Coronary arteries:

Method 1: Transverse Sectioning Technique

 A sharp scalpel blade is used to slice completely through
the arteries at intervals of not more than 0.3cm.
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Dr.ROMAN

 Proximally, where atheroma and thrombus are more

likely, the transections should be even closer together if
possible.

 When heavily calcified vessels are encountered, it will be

necessary to transect the vessel with a sharp pair of artery
scissors.

 A firm grip on the heart must be maintained while

cutting through the vessels, usually by grasping the aorta,
pulmonary arteries, and as much of the atria as possible
with one hand, while holding the scalpel with the other.

Method 2: Longitudinal Opening Technique

A sharp pair of artery scissors is used to open the arteries from the
ostia, extending as far down their course as possible.

Examination of valve:

 The circumference of the valve is measured.

 The circumference of mitral valve is 8–10.5 cm (mean 10 cm)and admits two
fingers; tricuspid valve is 10–12.5 cm (12 cm)and admits three fingers; aortic
valve is 6–8 cm (7.5 cm) and pulmonary valve is 7–9 cm (8.5 cm).
 The decrease in circumference is suggestive of stenosis whereas increased
circumference could be due to regurgitation or incompetent valves.

Ventricular hypertrophy:

 An estimate is made by measuring the thickness of the ventricular walls at a

point about 1 cm below the atrioventricular valve.
 The upper limits of normal are: left ventricle: 1.5 cm, right ventricle: 0.5 cm
and atrial muscle: 0.2 cm.

Bone:

 About 200 g is collected. It is convenient to remove about 10–15 cm of the shaft of the femur.

Maggots:
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Dr.ROMAN

These are dropped alive into boiling absolute alcohol or 10% hot formalin which kills
them in an extended condition (to disclose the internal structure of the larvae).
If time of death is an issue, some larvae/maggots should be preserved alive for
examination by an entomologist.
Maggots may reveal the presence of drugs/poisons in decomposed bodies.
The viscera should be refrigerated at about 4°C,if not sent to the laboratory.

Blood:

Central luminal blood is preferred to cavity (pleural,pericardial, or peritoneal)

blood.

Central(“heart blood”)specimens are aspirated from any chamber of the

heart,or from the intrapericardial thoracic aorta, pulmonary artery, or vena
cava.

However, for a growing number of analytes,most notably tricyclic

antidepressants,peripheral blood is preferred over central blood.

Peripheral blood is aspirated by percutaneous puncture before autopsy,from

the femoral vein or the subclavian vein.

The author prefers the femoral approach in order to avoid any question of
artifact in the diagnosis of venous air embolism.

Peripheral blood can be obtained by a technician as soon as the body is

received.

If cocaine intoxication is likely. it is highly desirable to obtain this specimen in a

tube with NaF as soon as possible, in order to inhibit postmortem hydrolysis of
cocaine.

The term, “cavity blood” is used for blood ladled or aspirated from a
hemothorax,hemopericardium, hemoperitoneum, or from the pooled blood
left in the common cavity after removal of the heart and lungs.

Cavity blood analyses should be supplemented by peripheral blood, vitreous, or

solid tissue analyses, because of the real possibility of contamination from
gastric contents.
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Dr.ROMAN

Collecting Blood Samples:

 It is well known that blood drug concentrations measured in the heart (right or
left side) are inaccurate.
 Most of the time the results of measurements made of heart blood will suggest
that more drugs were present at the time of death than was actually the case,
and the measured concentrations will be much higher than if they had been
measured in the periphery.
 On the other hand,heart blood provides an excellent medium for drug
screening, simply for the purpose of detection, even if attempts at quantification
provide little useful information.
 Venous blood should be collected with a needleless syringe.
 An incision through the inferior vena cava, inside the pericardial sac, allows for
the passage of a syringe for blood aspiration.
 The blood samples must be collected in a test tube containing a preservative
(usually 1% sodium fluoride), labeled with the autopsy number and the full
name of the decedent,and then kept in a refrigerated environment at –2°C to
4°C until processing.
 If, for some reason, arterial blood is desired, samples can be taken from the
descending thoracic aorta as it crosses the mediastinum.
 This can be an especially useful approach when there is evidence of extreme
postmortem coagulation.
 The cellular barrier of mucous and serous membranes breaks down after
death, due to which substances (e.g. alcohol and barbiturates) in the stomach
and intestine can migrate to the organs in the thorax and abdomen leading to
erroneous results.
 Before autopsy, 10–20 ml of blood can be drawn from the femoral (best
sample), jugular or subclavian vein by a syringe.
 Blood should never be collected from the pleural or the abdominal cavities, as
it can be contaminated with gastric or intestinal contents, lymph, mucus,
urine, pus or serous fluid.

Cerebrospinal Fluid (CSF) :

 If CSF must be drawn,it is best taken from the cerebral

cisterns after the skull has been opened is such a fashion
that the leptomeninges are relatively intact and the CSF
has not run out.
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Dr.ROMAN

 The situation most often calling for a CSF specimen is

the meningitis autopsy with no urine available for a latex
agglutination test for bacterial antigens.

Uterus:
Removal of the Uterus and Adnexae:
Ŕ- The uterus is midline and partly retroperitoneal.

Ŕ- It is located behind the bladder and in front of the rectum.

Ŕ - The pelvic peritoneum only partially covers the uterus, so that while most of the
uterus is preperitoneal (body and posterior face of the supravaginal part of the
cervix),the remaining part lies deep in the connective tissue of the subperitoneal pelvic
space.†

Ŕ- Remove the uterus and adnexae with toothed forceps while placing tension on
the peritoneum that covers the pelvic organs, pulling the peritoneum toward the
midline, just medial to the hilar veins.

Ŕ- Dissect along the anatomic borders of the organ, then incise the peritoneum
forming the broad ligament (the wide fold of peritoneum that connects the sides of the
uterus to the walls and floor of the pelvis),cutting from back to front.

Ŕ- Finally incise the infundibular ligament and round ligaments.

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Dr.ROMAN

Ŕ- Then make a second, deeper incision, and divide the transverse cervical ligament.

Ŕ - Thereby isolating the uterus from its lateral suspensory structures.

Ŕ - Once the round ligament has been divided, continue on and divide the peritoneum
of the vesical– uterine cavity located in front of the uterus and behind the bladder.

Ŕ - At deeper levels, use sharp dissection to detach the bladder wall from the
contiguous vagina,cutting along the vesical–uterine septum.

Ŕ- After separating the uterus from the nearby structures, both infront of it and on its
side, it is necessary to detach it from behind the rectum.

Ŕ - Pull the peritoneum back using toothed forceps while cutting the peritoneum
close to the uterine–rectal fold and the pouch of Douglas.

Ŕ- Once the pouch of Douglas has been excised, use forceps to grip the rectum and
move the blade forward to excise the back wall of the vagina, and then the vaginal
vault, moving from the back to the front and from top to bottom.

Ŕ- This will allow for the extraction of the uterus together with the vaginal Vault.

Ŕ - The pregnant uterus can be fixed by first puncturing the uterus through the anterior
abdominal wall and replacing the amniotic fluid with formalin solution.

Ŕ - After the prefixed uterus has been opened, the fetus is perfused with formalin
solution through the umbilical cord.

Ŕ - If one intends to preserve uterus and fetus as one specimen, a formalin-gelatin

mixture is injected into the cavity of the uterus.
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Dr.ROMAN

Ovaries and vaginal orifice:

√ The ovaries are bilateral amygdaloid parametrial organs

measuring approximately

3¥ 1.5 ¥ 1 cm before the menopause but becoming atrophic afterwards.

√ Inspect the fallopian tubes and ovaries.

√ Measure the ovaries in three dimensions, and cut them

lengthwise to expose the

parenchyma.

√ Open the fallopian tubes longitudinally following insertion

of a probe, or cut them in serial

cross sections.

√ Together they weigh approximately 10 g. A single sagittal

longitudinal section

through the ovary will display the parenchyma and should identify any small lesion

not visible on the external surface.

√ A single transverse slice of each, 2 to 3 mm in width should

be retained for

histology.
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Dr.ROMAN

√ Open the proximal vagina along its lateral surfaces, noting

any abnormalities of its

epithelial surface.

√ Inspect the uterine cervix, noting any lesions, erosions, and

so forth and the shape and

greatest width of

Arm Dissection:

♫ The arms at autopsy must first be x-rayed.

♫ Once the x-rays have been performed, make a bisacromial

incision along the

volar surfaces of the arm and forearm, stopping at the wrist.

♫ Then continue with a layered dissection, taking pains to

expose all

aponeurotic bands and muscle tendons.

♫ Ideally, the dissection should be extended up to the axilla and

the posterior

axillary line; then continue the incision back to the thoracic–abdominal wall.

♫ This approach allows visibility of the muscular tendons and

the vascular and
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Dr.ROMAN

nerve bundles of the axilla.

♫ Last, isolate and incise the individual muscle heads until

reaching the

acromioclavicular capsule and the humeral diaphysis.

Leg Dissection:↔↔

↔ As with the arms, radiological evaluation of the legs must be

completed

before beginning the dissection.

↔ Make the initial incision in the femoral triangle, at the medial

third of the

inguinal fold, and continue it along the medial border of the thigh–knee and,

if necessary, the leg,until reaching the medial malleolus.

↔ The first structures to be encountered will be the femoral

nerve, artery, and

vein.

↔ Once they have been individually isolated, they should be

followed along

their entire course.

↔ Dissect by anatomic planes, always preserving the underlying

muscular
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Dr.ROMAN

structures.

↔ Make sure to expose all muscles and their insertions, including

that of the

sartorious muscle.

↔ Whatever method is chosen, always pay special attention to

the isolation and

the examination of the vascular structures.

↔ The muscles should be removed one by one to allow for the

visibility of bone

segments and articular structures.

Abdominal Incision :

Once detached, the muscle is reflected.

Preferred approach for abdominal dissection has been described as the

eggshell technique.

Detaching and pulling on one side of the muscle and skin flap exposes the entire
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Dr.ROMAN

peritoneum, resulting in the appearance not unlike the diaphanous inner membrane of an

eggshell.

Once the blade is inserted at the end of the xiphoid process, the incision is then carried

down the linea alba to the pubis and the muscles and skin (including the rectus

abdominus) are divided.

Then the external and the internal obliques, and then the transverse abdominus are

separated from the parietal peritoneum.

At the same time, the preperitoneal connective tissue is dissected,and then the flaps are

retracted.

Occasionally, the neck and abdomen may have to be opened separately.

The Abdominal Wall:

 In the abdominal area, the subcutaneous edge of the incision is retracted using
toothed forceps, held in the left hand (use of a cloth sponge can be helpful), and
the anatomic planes are dissected in succession,always proceeding toward the
midline, using a scalpel oriented tangentially to the planes themselves.

 Dissect the skin from the subcutaneous tissue beginning at the aponeurosis of
the external oblique muscle.

 The external oblique muscle must be detached from the posterior costal plane
above.

 With the blade held obliquely, make a midlateral incision in the aponeurosis
then separate the external oblique and the underlying internal oblique
muscle,everting both laterally.

 Divide the internal oblique muscle,making sure that the blade continues to
remain obliquely oriented toward the midline.

 The aponeurosis of the internal oblique blends in with the transverse muscle
fibers of the abdomen.

 Detach the aponeurosis at the lateral margin of the rectus muscle,and then free
it from the peritoneum, dissecting the preperitoneal connective tissue,
reflecting it downward by traction applied laterally on one side.
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Dr.ROMAN

 At this stage, the rectus muscles of the abdomen are removed, leaving a V-
shaped, upside-down incision at the severed corner of the sternal–costal area.

 Once that has been accomplished, all the sternal–costal insertions of the two
rectus muscles are divided along their lateral margins.

 The muscle is then detached bilaterally, using medial to lateral traction,from

the posterior laminae of the rectus sheath up to the linea alba(this technique is
usually called flap dissection or butterfly flap dissection).

 After creating the flaps, incise the remaining skin, detach it, then position it
tangentially, oriented toward the pubis; the sheaths of the rectus muscles lying
on the midline are separated from the underlying peritoneum and are
simultaneously reflecting downward with their sheaths resting on the pubis.

Thoracic Incision:

Ộ After the intercostals have been transacted, the

following sequence or combined

actions is required.

Ộ With the scalpel oriented tangentially to the plane of the

ribs, dissection is facilitated by

bilateral traction of the costal arches.

Ộ Muscle and skin flaps can then be reflected to reveal the

rib cage.

Ộ The incision should be carried deeper at the level of the

pectoralis minor muscle, always

keping the blade oriented tangentially to the rib cage.

Incision of the Thoracic Wall

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Dr.ROMAN

Before exposing any individual organs, first make a keyhole incision

through the intercostal muscles (external,internal, and posterior
muscles)as well as the parietal pleura.

This is done using the point of a blade in correspondence with the

line at the second intercostal space.

This is done to check for the possible presence of pneumothorax,or

pleural effusion.

Disarticulating Clavicular Joints

The sternoclavicular joints need to be separated before the chest
cavity and its contents can be inspected.

A small knife with a narrow blade is used to incise the ligaments, the
articular capsule, and the insertion of the sternal head into the upper
sternocleidomastoid muscle on the manubrium of the sternum.

Identify the articular heads first by making an incision running

through the articular line by rhythmically moving the corresponding
shoulder with the left hand.

Sink the point of the scalpel into the inferior or superior border of the
articular line,taking care not to damage the arteries and veins of the
neck that lie just below,especially the trunk of the innominate artery.

The result is a half-moon–shaped incision with a lateral concavity.

The Chondrocostal Incision

Once the clavicles have been disconnected on each side, open the
thoracic cavity by removing the sternochondrocostal surface.

Each rib is severed with the rib shears starting from below or, better
still,at the costal arch of the tenth rib (an incision placed here will
involve the diaphragm and its costal insertions).

The process is then carried upward to the first rib at a maximum of 1

to 2 centimeters inside the chondrocostal line.

Rib shears must be held with the right hand, perpendicularly oriented
to the costal arches.

By the time the first intercostal space is reached,position the rib

shears(blade point bent at 30° toward the inside) so that they are
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Dr.ROMAN

aligned with the incision on the sternoclavicular articular surface,

then resect the first rib (because the bone is thicker and stronger in
this area, pressure must be applied to both ends of the rib cutter).

Removal of the Anterior Rib Shield:

Lift the right inferior corner of the sternocostal triangle with the
forceps held in the left hand.

At the same time use the point of a scalpel to dissect the aponeuretic
sternal insertions of the parietal pleura and—from the posterior
surface of the ligaments, particularly the inferior and superior sternal
pericardial ligaments—proceed upward,at all times taking great care
to not cut the underlying pericardial sac.

At the level of manubrium sternum, the ligaments connecting with

the chest plate have more strength.

Be careful not to cut vessels at the base of the neck.

A firmer drawing action,done with the left hand,is required to the

remove the rib shield, thereby opening the pleural cavities and
removing the parietal pleura.

Inspection of the Anterior Chest▲

▲ Inspection of the internal surface of the rib shield is

performed for medicolegal

purposes.

▲ It is important to note possible injuries, which will usually

be manifested as

fractures or hemorrhagic infiltrates.

Incision of the Parietal Peritoneum:

The parietal peritoneum is incised along the midline from the

xiphoid process downward to the pubis.
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Dr.ROMAN

First make a keyhole incision through the area where the

prongs of the forceps are to be introduced.

Hold the forceps vertically and introduce them through the

keyhole,so that the scalpel blade runs between the forceps
opened prongs,from the top to the bottom, tangentially to the
costal arch.

A midlateral oblique incision from the xiphoid process is

carried up to cross the anterior axillary line with the serosal
flaps being turned inferiorly and laterally.

This allows the peritoneal cavity to be opened in such a way

as to permit optimum visibility of the enteroperitoneal
organs.

Organ Removal (Carotid artery,Larynx,Pharynx,Trachea and Tongue)

 After the initial inspection of the organs and body cavities and removal of the gut,prepare for
removal of the remaining viscera.

 Identify and inspect the carotid arteries.

 A long ligature may be placed around each carotid artery where it enters the base of the neck.

 Using scissors or a scalpel,transect the laryngeal pharynx above the epiglottis through the
thyrohyoid membrane or include the hyoid bone by cutting superiorly.

 Transect the esophagus as well, but avoid injury to the carotid arteries.

 Reflect the larynx inferiorly, and cut the carotid arteries below their ligatures.

 It is relatively easy to include the hyoid bone or the tongue and associated tissues as part of
the neck dissection.

 However, the facial artery, a vessel important to the embalmer, is vulnerable to injury during
this dissection.

 Removal of the tongue is facilitated by cutting posterior to the rami of the hyoid bone.

 Through the neck, reach into the oral cavity, grasp the tongue, flip its tip posteriorly into the
neck, and cut the anterior attachments free.
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 removal of The Tongue is faciliTaTed by cuTTing

posTerior To The rami of The hyoid bone.
 Through The neck, reach inTo The oral caviTy,
grasp The Tongue, flip iTs Tip posTeriorly inTo The
neck, and cuT The anTerior aTTachmenTs free.

PITUITARY GLAND :

 The margins of the diaphragma sellae should be incised before the posterior

clinoid is knocked off with a small chisel.

 The tip of the chisel is placed at the crest of the dorsum sellae.

 The chisel can be directed either posteriorly(downward) over and nearly

parallel to the midline anterior fossa or nearly perpendicular to it.

 If the chisel is placed perpendicularly,the pituitary remains visible during the

procedure but a tap is needed over the broad side of the chisel near the tip,

instead of a tap on the end of it.

 The diaphragma must be freed first or the tension on it may result in

squeezing of the tissue in the pituitary fossa.

 A pair of forceps is applied to the edge of the diaphragma and the pituitary

is dissected out, with a sharp blade,away from the base of the fossa.

 The pituitary gland may be removed with its bony encasement, for example,
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Dr.ROMAN

in a case of pituitary adenoma.

 Average weight of pituitary gland 0.6 g (up to 1 g in pregnant women)

 Average size of pituitary gland 2.1 ¥ 1.4 ¥ 0.5cm.

 The gland should be bisected through the stalk in a sagittal plane,and the cut
surfaces of the anterior and posterior lobes examined to identify any small
focal lesions.

 Any focal lesion should be sampled in its entirety for histology.

REMOVAL OF NECK VESSELS

↔ After the primary incision, the skin flap is reflected over the face while subcutaneous tissue is severed by
blunt dissection with scissors.

↔ Keeping the neck straight or slightly overextended facilitates the approach to the
arteries.

↔ The common carotid arteries are followed upward by blunt dissection, with
occasional snips of scissors, up to the bifurcation.

↔ Then, the external and internal carotid arteries are isolated and the dissection is
continued along the latter up to as close to the base of the skull as possible.

↔ The cavernous and petrous portions of the arteries are freed from the bony
enclosure intracranially by chiseling or rongeuring the bone away.

↔ The carotid canal may be enlarged and the artery freed from the soft tissue in this
region.

↔ This can be accomplished by removing a vertical strip of bone mesial to the canal
and just above the entrance of the vertebral artery.

↔ Use of an oscillating saw will facilitate the procedure Then,neck arteries pulled
down from below.

↔ Dissection of the vertebral arteries is a little more time-consuming.

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Dr.ROMAN

↔ First, portions of the occipital and temporal bones above the lateral and posterior
parts of the atlas are removed intracranially by chiseling.

↔ The posterior process of the superior articular surface of the atlas,which hides
the artery, is chiseled away.

↔ The artery is then dissected free from the dura to the transverse
process of the atlas.

↔ Second, in the neck the transverse foramina of the cervical spine up

to the C-3 level are opened with a chisel;the transverse processes are
broken,exposing the vertebral artery.

↔ The chisel should now be directed upward and laterally to follow the
course of the artery in C-2.

The removed arteries are examined either before or after adequate

fixation.

↔Longitudinal sections of these vessels reveal the nature and

extent ofan atheromatous process.

Post-autopsy reconstruction plays a key role in the presentation

of the autopsied body to the relatives. The reconstruction of body
should be of a high standard so that it will not leak, and can be
viewed after autopsy without distressing the next of kin. The
following procedure may be undertaken to ensure a leak proof
and contaminant-free reconstruction technique:
Removal of accumulated fluids: After evisceration of organs from
the thoracic, abdominal and pelvic cavities, residual fluids,
tissues and bowel contents (blood, ascitic or pleural fluid,
Medico-legal Autopsy 111
serosanguineous fluids or fecal matter) should be aspirated,
removed and dried to prevent leakage. This is to prevent any
splashing or welling up of any serosanguineous fluids when
placing the viscera back into the thoraco-abdominal cavities.
Wadding: Once the cavities are dry, they are lined with adequate
wadding or cotton wool to soak up any remaining body fluids or
fluids that might continue to leak following the reconstruction.
Viscera containment: All organs and viscera must be returned to
the body after samples for histopathology and toxicology have
been obtained. These are placed in biohazard bags or clear
plastic bags and then placed into the cavities on top of the
wadding. This will prevent the leakage from the body. However,
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Dr.ROMAN

any foreign objects, for e.g. gloves, aprons, universal containers,

blood tube sets, syringes or needles should be disposed off in
appropriate separate waste bin.
Head: When the skull is opened, the chances of slippage of skull
cap after replacement can be minimized by placing a triangular
or square notch in the midline of the frontal bone incision. A
second notch is placed on either side of the squamous temporal
bones. This will ensure appropriate relocation and minimal
movement of the skull cap. Sufficient wadding is placed inside
the cavity to soak up any fluid. The stripped dura and the brain
are placed into the plastic bag and returned to the cranial cavity.
Suturing: The suturing may start from above (chin) or below (mons
pubis) depending on the individual’s preference. This suturing
process is always initiated with a downward stroke for safety’s sake.
Suturing techniques: The various types of suturing techniques
are: continuous suture, under-stitching, baseball suture, mattress
suture, individual sutures and interlocking suture. Continuous
suture is commonly used to close long incisions. In understitching,
a knot is placed at the end of the suture to secure the
start and then suturing is done in such a way that the skin is
sewn from below which have good cosmetic results.
Sutures: Sutures must be durable enough to hold tissue securely
but flexible enough to be knotted. Nylon should be used to close
the body cavities and suture it. However, cotton is commonly used
in most of the places for suturing because of its cost-effectiveness.
Washing: After reconstruction, the entire body must be cleaned of
any residual bodily fluid or stains. Hot water should be avoided
as it may cause skin damage (abrasion or contusion)—may cause
confusion in case of second autopsy. Detergents containing
disinfectant may be used along with water to assist washing process.