Basic Postmortem Examination

Identification

One of the worst outcomes for an autopsy is to examine the wrong patient, overstep restrictions explicitly written on the autopsy consent form, or lose valuable information or materials from mislabeling. Because of this, many institutions have adopted a simple “time out” method in which all members of the autopsy team, immediately before examining the body, focus on a team statement of the patient name, medical identifiers, and autopsy restrictions for the case they are about to begin. Check the toe tag or other identifier of the body, match it with a copy of the autopsy consent form, and document as needed before continuing. After the autopsy examination, a copy of the consent form, contact information for the autopsy service, and a note that “an autopsy has been performed” may be included with the body. This will facilitate communications with others who may handle the body, including transplant donation networks and those making funeral preparations. Be sure to document and pass along clothes and personal belongings associated with the body.

Inspection and Palpation

Remove any bandages, and document any therapeutic devices. Remove superficial, peripheral venous catheters, but leave in place indwelling central lines, endotracheal tubes, feeding tubes, urinary bladder catheters, and so forth until the internal examination confirms their proper location. Measure the body length, and if possible, weigh it. Note the anteroposterior dimension of the chest, and identify any abdominal distention. Determine whether the appearance of the extremities and joint mobility are symmetrical. Document abnormalities by measuring the circumferences of the chest (at the level of the nipples), abdomen (at the umbilicus), or extremities (bilaterally at a specific distance above or below an anatomic landmark such as the superior margin of the patella or the acromioclavicular joint).

Inspect the skin anteriorly and posteriorly. Note its color and elasticity, and characterize any cutaneous lesions. Document surgical and nonsurgical scars. Record any tattoos or other identifying features. While inspecting the dorsum, also inspect the anus. Examine the character and color of the nails. Estimate the degree of rigor mortis by flexing the joints. Note the color, length, and character of the hair. Inspect and palpate the scalp and skull. Examine the eyes, including the condition of the conjunctivae and sclerae and the color of the irides. Measure the diameters of the pupils. Examine the ears and their location. If necessary, use an otoscope to inspect the external ear canal. Inspect the nose, including the nasal mucosa and the integrity of the nasal septum, and note any nasal discharge. Open the mouth and inspect the buccal mucosa and the tongue. Examine the teeth and their state of repair. In the case of unidentified bodies, prepare a detailed dental chart or consult a forensic odontologist.

The illumination provided by an otoscope or penlight may be helpful in examining nasal and oral cavities. Palpate the neck, noting the position of the trachea and the size and consistency of the thyroid gland. Check for cervical, axillary, or inguinal lymphadenopathy. Examine the breasts and palpate for masses. Examine the infraclavicular region for the presence of a pacemaker or implantable defibrillator. Palpate the abdomen. Inspect the genitalia. In the male, palpate the scrotum, determining whether the testes are descended and noting any abnormalities. In the female, separate the legs and inspect the vulva. In some forensic cases, a vaginal speculum is required to complete a detailed inspection of the vagina and cervix that includes appropriate sampling of secretions. Before beginning the internal examination, consider the need to document any significant findings with photographs. Keep a handheld camera ready during the remainder of the dissection for photographs of in situ findings.

Organ Removal

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 ( Fig. 4-7 ). If they are flaccid and thin walled, they are best left with the body if later embalming is likely. 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, and some pathologists do this routinely because it allows a much better examination of the oropharynx and superior neck. 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. More extensive neck dissections are discussed in Chapter 6 .

Reflect the larynx and esophagus downward, and free the neck organs by cutting the vascular and connective tissue attachments at the lateral aspects of the thoracic inlet. Next, cut the right and left hemidiaphragms along their lateral and posterior body walls. On each side, while the posterior aspect of the upper abdominal cavity is exposed, extend the cut through the psoas muscle to the vertebral column. This makes removal of the organ block easier.

Next, turn your attention to the pelvis. Using your hand and fingers, separate the bladder and prostate from the pelvic wall. Extend the plane of dissection posteriorly, separating the rectum along the coccyx ( Fig. 4-8 ). Some physical exertion is necessary here to separate the pelvic organs completely along their entire circumference. Using long-handled scissors, transect at the level of the proximal urethra (distal to the prostate in the male and through the proximal vagina in the female). Continue the cut through the rectum, generally not less than 2 cm above the anorectal junction ( Fig. 4-9 ). Reflect the pelvic organs upward and outward, exposing in turn the iliac vessels bilaterally. Divide these, along with any connective tissue attachments, along the pelvic brim and curve of the sacrum.

At this point, the organ block is ready for removal. Lift the neck and thoracic organs anteriorly and then inferiorly, carefully separating the aorta and other posterior attachments from the vertebral column. Continue applying inferior and upward traction, cutting as needed any remaining diaphragmatic or posterior abdominal wall attachments ( Fig. 4-10 ). An assistant makes this a relatively easy maneuver. If you are working alone, it may be easier to cut posterior attachments by rotating the organ block to one side and then the other before lifting it out of the body.

Inspection of the Body Cavities and Removal of the Testes

After removal of the thoracic and abdominal viscera, make a final inspection of the body cavities and their walls. Take samples of sciatic nerve, skeletal muscle (psoas or deltoid), and skin for eventual microscopic examination. Remove the testes by entering the scrotal sac through the inguinal canal from above the pubic ramus. Push and lift the testes and spermatic cords up and out of the inguinal canal, cutting the cords to free the testes ( Fig. 4-11 ).

Initial Dissection and Separation of the Organ Blocks

We place the adult organ block, posterior side up, on a polypropylene or polyethylene cutting board measuring approximately 75 × 50 × 3 cm. Placing this at a workstation that accommodates a chair or elevating the dissection to a height comfortable for a standing examiner reduces stress on one's back. Safety can be maximized—especially if there is more than one dissector—by doing most of the block dissection with both hands occupied by toothed forceps and scissors—with pauses for rinsing, examination, probing, blunt dissection, and use of a large knife. A general strategy for hollow viscera and vascular structures is to open, rinse, and examine as the dissection progresses.

Beginning distally, open the inferior vena cava to the level of the diaphragm, carefully sparing the right renal artery. Note the appearance of the para-aortic lymph nodes, sampling them for microscopy as needed. Next, starting at the distal aortic arch, open the descending aorta and iliac and renal arteries posteriorly, and examine their intimal surfaces ( Fig. 4-12 ). Gently probe the proximal portions of the other major arterial branches of the abdominal aorta for patency. If there are dissections, ruptures, or significant aneurysm of the thoracic aorta, leave the involved portions, or even entire aorta, with the aortic arch. Otherwise, transect the aorta at the distal arch and reflect it downward from the posterior mediastinal tissues. We leave the abdominal aorta attached to the retroperitoneal tissues until dissection of the abdominal organs is completed, but some institutions will remove the aorta along with 1 cm portions of midabdominal tributaries if they are not significantly occluded. In fetuses and infants, the aorta is initially opened only below the level of the diaphragm, at the point where it can subsequently be transected during separation of the thoracic and abdominal organs. Thus the descending thoracic aorta is left in continuity with the aortic arch to aid in evaluation of possible arch malformations.

In cases requiring a more detailed vascular dissection—for example, when indicated by the medical history or by initial autopsy findings such as infarcts, organ atrophy or hypoplasia, primary vascular pathology such as stenosis or occlusion, or the need to demonstrate patency of surgical anastomoses—it may be best to perform the dissection of the pertinent vasculature before removing organs from the autopsy block. Those equipped for postmortem angiography might consider the use of this technique in their dissection plan (see Chapter 8 ).

Open the esophagus along its posterior aspect, and examine it for fistulous communications, mucosal lesions, or abnormalities in the submucosa, such as varices or neoplasms ( Fig. 4-13 ). Reflect it to the level of the diaphragm. Next, remove the adrenal glands by exposing their bed beneath the posterior aspects of the hemidiaphragms. Identify the glands by palpation. Failing that, begin carefully dissecting away the suprarenal fat, starting at the superior pole of the kidneys. The adrenal glands may be difficult to locate in patients with excessive abdominal fat, with hypoplastic glands secondary to corticosteroid therapy, or with altered anatomy related to extensive retroperitoneal fibrosis or tumor metastasis. In such cases, the adrenal glands can be located by dissection of the venous drainage of these organs retrograde from the inferior vena cava.

After locating the adrenal glands, remove them carefully, trim any adherent fat, and weigh them ( Fig. 4-14 ). Sometimes the adrenal glands are so soft and friable from postmortem autolysis that it is better to remove them with their investing adipose tissue and trim them after fixation. Solid organ weights change little with fixation ( Table B-2 , Appendix B ) compared with the error introduced by adherent tissues. In any case, do not slice them until they are adequately fixed because the fragile medulla would become distorted. 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. Separate the neck and thoracic organs from the abdominal organs by cutting between the inferior aspect of the pericardium and the superior aspect of the diaphragm, thereby transecting the inferior vena cava in the short distance between the hepatic veins and right atrium. Leave the diaphragm with the abdominal block. Take care not to transect the esophagus accidentally.

Examination of the Neck and Thoracic Organs

Lungs

Remove the lungs, transecting the bronchi at the carina and then the pulmonary arteries and veins near the hilus of the lung unless you plan to perfuse through the artery ( Fig. 4-15 ). Examine the cut ends of the pulmonary arteries for any thromboemboli that could become dislodged with handling of the lungs. Weigh the lungs, inspect their pleural surfaces, and palpate the pulmonary parenchyma. Routinely, we inflate lungs through the bronchi with formalin by simple gravity perfusion with a plastic tube running from a container of fixative positioned approximately 1 m above the specimen. Apparatuses for perfusion at constant, regulated pressure are also easily constructed. Consider perfusing the lungs with formalin through the pulmonary arteries if mucus plugs might have contributed to the patient's death. In either case, clamp the perfused orifice after complete inflation, add fixative to the container, and cover the lungs with a paper towel moistened with fixative to prevent drying of the pleural surfaces. Set aside the perfused lungs for at least 1 hour. Attending to the lungs early in the case allows adequate fixation before slicing and does not result in a delay in the communication of the gross pathologic findings. Many pathologists examine the lungs fresh by cutting sequentially along the arteries, airways, and veins. If you elect to do so, the method of McCulloch and Rutty is best for examination of fresh lungs. Some pathologists compromise, inflating one lung and cutting one fresh. However, we feel that it is difficult to assess subtle parenchymal changes in the fresh lung.

We cut formalin-inflated lungs in 1- to 2-cm parasagittal slices. Coronal slices, including a midcoronal cut through the main stem bronchus, may demonstrate a central carcinoma to advantage. The only advantage of horizontal sections is that they correlate with prior cross-sectional imaging. For slicing lungs, a sharp knife with a long blade is a necessity. Although one can cut the lungs freehand, an acrylic plastic (Plexiglas) cutting board with knife slots on two opposite sides permits finer control ( Fig. 4-16 ). After slicing the lungs, the prosector examines the lung parenchyma with eyes and fingers to identify abnormalities and areas of consolidation or scarring. The larger airways and vessels are opened as needed to complete the examination.