Current Routine Autopsy Techniques

GENERAL POLICIES Autopsy techniques are learned from a preceptor in the autopsy room. This time-honored method still is integrated in the training of all anatomic pathologists and therefore, printed or audiovisual teaching aids, referenced in the earlier editions of this book, have played no appreciable role. Thus, a detailed description of autopsy techniques is beyond the scope of this book. Nevertheless, some recent guidelines may be helpful (2,4,5). Pathologists generally achieve the best results if they use the methods with which they are most familiar, even if the situation at hand would cause the expert to choose a different approach. Special considerations in medicolegal autopsies are discussed in Chapter 2.

ADULT AUTOPSIES After the external descriptions, the body is weighed and body length is determined; roentgeno-graphic studies may be needed at this time. This is followed by the Y-shaped primary incision and, if indicated, removal of material from the abdomen for microbiologic study. Subsequent steps include collection of abdominal effusions and exudates; search for hernias; incision of anterior abdominal musculature and breasts; search for pneumothorax (see under that heading in Part II); cutting the lower ribs so that chest plate can be lifted and fluid in pleural cavities can be collected; removal of chest plate; removal of thymic fat pad; incision of pericardial sac and collection of pericardial contents; and, if indicated, removal of blood for microbiologic, serologic, biochemical, or toxicologi-cal studies (the descending thoracic aorta often is a good puncture site, particularly in cases of extensive postmortem clotting). In some institutions, ligatures are placed to identify the carotid, subclavian, and femoral arteries for the convenience of the embalmer.

At this point, the techniques may be varied according to personal preference or the type of lesion. En masse removal (Letulle technique) yields the best results if pathologic lesions are expected to involve or pass through the diaphragmatic plane, as in the presence of acute aortic dissection. The preparation is then carried out from the posterior aspect of the organ mass. Organ blocks (Ghon technique) are removed routinely or only when pathologic processes make the preservation of vascular supplies desirable. In all other cases, Virchow's organ-by-organ removal technique can be followed.

Special attention must be paid to the removal of the neck organs and the floor of the mouth. Whether these structures are removed together with the chest organs or as a separate tissue block, lacerations of the skin in the neck area or even of the lips may occur if the prosector is inexperienced or works hastily. Furthermore, the prosector can easily cut or stab the assisting hand during the removal of the soft palate and the floor of the mouth. These procedures should not be attempted without the guidance of an experienced preceptor; work should be slow and deliberate in these areas. (See also below under, "Lesions of Face, Arms, or Hands.") In medicolegal autopsies, particularly in cases of suspected strangulation, extensive skin incisions of the neck area are indicated and permitted (6). In these instances, the brain should be removed first so that blood is drained from the neck and the chance of an artifactual hemorrhage is minimized (6). For further details, see references by V.I. Adams in Chapter 2. The central nervous system, peripheral nerves, muscles, bones, and joints usually are exposed at the end of the autopsy, before or after embalming.

The routine selection of organs and tissues for histologic study depends on the macroscopic findings, clinical diagnoses, teaching obligations, research protocols, personal attitudes, institutional policies, and, linked to all of them, economic considerations. If an institution has a very restrictive policy for the histologic study of autopsy material, it is particularly important that samples of all major organs and tissues are saved in formalin or, preferably, in paraffin blocks. This also should be done if histologic study is done primarily with frozen sections (7).

PEDIATRIC AUTOPSIES Perinatal and pediatric autopsy techniques and related reporting procedures differ in some important aspects from adult autopsies (8-10). It is often preferable if such autopsies are performed by pathologists experienced in perinatal pathology. Excellent texts are available (11-15). A perinatal autopsy protocol, published in 1995 by the Armed Forces Institute of Pathology, and the manual on pediatric autopsies from the same institution, reprinted in 1997, can be ordered from the American Registry of Pathology Sales Office, AFIP, Room 1077, Washington, DC 20306-6000.

The external examination, particularly of fetuses and new-borns, has to concentrate on the search for malformations such as cleft palate, choanal atresia, or stenosis and atresia of the anus and vagina. Face, ears, and hands may show characteristic changes—for instance, in Down's syndrome, renal agenesis, or gargoylism. The placenta, fetal membranes and umbilical cord must be studied in all autopsies of fetuses and newborns (8). For further details, see "Stillbirth" in Part II of this book.

The removal of the brain in fetuses and newborns is described in Chapter 6. Dr.Waters, the coauthor of the pediatric disease procedures in Part II, recommends a horizontal cut over the occiput from behind one ear to the other, combined with a midline cut, running caudally from the first cut. This leaves the face un-marred and allows support for the brain as the attachments are being cut. This procedure appears most suitable for preterm infants and demonstration of the Arnold-Chiari malformation.

In infants, the whole chest cavity can be opened under water in order to demonstrate a pneumothorax. However, only a chest roentgenogram can provide a reliable permanent record (see also under "Pneumothorax" in Part II). For organ removal, any of the described techniques may be suitable but for the demonstration of rare malformations such as anomalous pulmonary venous connections in fetuses and infants, the en masse removal (after Letulle) is recommended.

As a minimum requirement for pediatric autopsies, histo-logic sections should be taken from lungs, liver, kidney, thymus, costochondral junction of a rib, and brain. In fetuses and newborns, placenta, fetal membranes and umbilical cord should be added.

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