| ABBREVIATED AUTOPSY PROCEDURE--ROKITANSKY METHOD GENERAL 1. Locate, dissect, and serially section and block adrenal glands. 2. Open entire aorta and renal arteries. Also open celiac and/or mesenteric arteries if indicated. 3. Open inferior vena cava and renal veins--other branches are indicated. 4. Peel aorta up. 5. If parathyroids are needed, dissect them at this time. 6. Cut esophagus at larynx and peel down. 7. Separate thorax from abdomen. WEIGHTS Unless otherwise indicated, weigh each major organ (lungs, heart, liver, spleen, kidneys. Also, when indicated, weigh endocrine glands, tumor masses or other structures. THORAX 1. Identify thymus if indicated. 2. In some cases of lung disease one may fill the lungs with formalin via the trachea before dissection. (Note: this may render thrombotic pulmonary emboli more difficult to recognize. also it completely destroys atelectasis.) There are at least two standard methods of dissecting and examining lungs. A single parasagittal section is most common. 3. Dissect thyroid. 4. Open larynx and trachea along posterior midline. 5. Measure transverse diameter of heart. Check valves for competency before opening if indicated. There are at least three standard methods of dissecting and examining the heart. Most common is the following: Open heart by following flow of blood. Cut right atrium from inferior vena cava to apex of the atrial appendage. Examine foramen ovale. cut along the lateral wall of right atrium, through tricuspid valve, and lateral wall of right ventricle to apex. Continue up along the right side of interventricular septum, cutting open the pulmonary valve and pulmonary artery. Open left atrium by cutting between pulmonary veins (four). Slice through posterior or lateral aspect of mitral valve and continue along left side of interventricular septum through aortic valve and aorta. (When cutting aortic valve take care to avoid pulmonary valve.) Other Methods: transverse (bread-slice) sectioning; removal of coronary arteries before opening heart, and decalcification before cutting; postmortem angiography; bisection from apex to base (for comparison with cardiac imaging in vivo). All have their uses. Trace coronaries from ostia (use probe if necessary) and open these vessels either by cross sectioning (2 mm intervals when care is important) or longitudinally. ABDOMEN 1. Locate ureters and remove kidneys, ureter, bladder, and rectum from abdominal contents. 2. Bivalve kidneys, open ureters, open bladder anteriorly (through urethra) and open rectum. Cut prostate gland in multiple transverse section. 3. Dissect the reproductive systems. In male, bivalve testes and perform the "string sign". In female, separate uterus and adnexa from abdominal organs. Open vagina. Open cervix and uterus along lateral wall. Cut oviducts incross section at their proximal, middle, and distal portions. Bivalve ovaries. 4. Remove spleen and cut one or more times in long axis. 5. Open gallbladder; follow cystic duct if indicated. 6. Dissect porta hepatis and follow and open common duct if indicated. 7. Remove liver from abdominal contents. Slice coronally once or horizontally one or more times through both lobes. 8. Expose pancreas but preserve common bile duct, ampulla, and adherent duodenum. Slice once longitudinally or multiple times transversely form head to tail. 9. Remove mesentery ligaments and omentum from stomach. Open stomach along greater curvature and open duodenum. 10. Run bowel inspect. Check appendix. CRANIAL CAVITY 1. Inspect brain, examine meninges. Check symmetry and visible or palpable lesions. Examine pituitary gland. DISSECTION OF CARDIOVASCULAR SYSTEM IN PEDIATRIC CARDIOLOGY PEDIATRIC CARDIAC SURGERY CASES METHOD 1. Remove the thoracic organs, plus larynx, trachea, thoracic aorta, esophagus, and major portion of the diaphragm "en bloc". It may also be best to include a portion of the liver about the superior part of the abdominal segment of the inferior vena cava. Avoid laceration of any of these structures. 2. Ligate the following vessels, but remember to include the connector from the tube from the formalin container in the right atrium before closing this.
formalin. 4. Place the specimen in a wide container with capacity of at least ten times the volume of the specimen. 5. Allow filling of both the airway and the cardiovascular system by gravity. Keep relations of lung and heart in anatomic position (do not allow a lung to rotate on its hilus during fixation). 6. When the specimen is fully distended the flow rates can be progressively slowed so as not to overflow the container. Distention at the beginning is most important. 7. Allow fixation overnight before dissection. This method serves two important purposes. First, it allows the best anatomic examinations, both by pathologists and after dissection. Secondly, it avoids the competitive aspect of dissection which sometimes appears when several individuals have great interest in the case. However, there are some cases where this method should not be used. For example, if bacterial culture is to be taken from a heart valve, obviously this must be obtained before fixation. In some cases it may be desirable to include more of the viscera in the injection specimen. Particularly consider cases of total anomalous pulmonary venous drainage. If the anomalous venous return from the lungs passes by way of the left innominate vein or the portal vein, all portions of these veins and their connections with the heart should be included as well. Also, in cases of isomerism (bilateral right- or left-sidedness), it may be desirable to have the entire thoracoabdominal block of organs together; this is especially important when there is interruption of the inferior vena cava. MICROSECTIONS Routine: 1. Liver 11. Prostate 2. Spleen 12. Breast 3. Bone Marrow 13. Pituitary gland 4. Lungs 14. Muscle 5. Heart & coronary arteries 15. Skin 6. Adrenals 16. Testis or ovary 7. Pancreas 17. Lymph nodes 8. Kidneys 18. Parathyroids 9. Thyroid 19. Cervix 10. Appendix 20. Endomyometrium Others: Section any abnormal areas. FIXATION One should try to keep post-mortem degeneration (autolysis) to the minimum. To follow an interesting or important and challenging gross examination with a microsection which cannot be interpreted can be one of life's greatest frustrations. Autolysis may continue after the autopsy is started if attention is not paid to sampling and fixation. Tissues autolyze at different rates and two general rules for histology apply: 1. Greater density of tissue (solid organs such as brain, liver, blood clot, adipose tissue) slows penetration of fixative. 2. Tissues with high metabolic activity (pancreas, renal proximal tubules) autolyze faster; these require prompt action. Therefore, one should not allow oneself to be surprised by autolysis in such specimens. In order to prevent continuing rot: 1. Blocks should be cut and placed in formalin as soon as reasonably possible (e.g. within 2 or 3 hours of beginning the autopsy). 2. Block should be thin, not over 4 mm in thickness for pancreas, spleen, kidney, liver, adrenal, and any pathology which may need similar treatment. And it does no good to cut an organ block 1 cm thick and expect to trim it later; rot will continue in the middle of the block event though it is in formalin. 3. There should be 10 x as much fixative solution as tissue. (Large blocks of tissue, such as a 1.5-2 cm thick cross section of an entire liver, may be preserved in large volumes; this is often desirable for various reasons.) |