3. Evisceration Techniques & Autopsy Procedures

Connolly (Atlas): Ch. 4 (internal exam sections), Ch. 6 (Special Dissection Procedures) Di Maio (Handbook): Ch. 1 (III: forensic autopsy vs external exam; VII: morgue handling)

Do all medicolegal deaths require a complete autopsy?

No. The extent of the autopsy varies depending on the circumstances of the case.

Which medicolegal deaths generally require a complete autopsy?

All homicides.

What structures and specimens are included, at minimum, in a complete forensic autopsy?

Brain, larynx with hyoid, thoracic and abdominal viscera, blood, urine, bile, and vitreous humor (when available).

Which body regions may require additional examination beyond a standard forensic autopsy?

Any region relevant to the case, such as the legs in selected investigations.

In what circumstance may a limited forensic autopsy be appropriate?

In a well-documented self-inflicted gunshot wound to the head when a complete autopsy is unnecessary.

What information should be documented when a body arrives at the morgue?

The decedent's name (on the toe tag and body bag), date and time of arrival, who transported the body, who received it, a unique case number, and an identification photograph.

Why is a unique case number assigned when a body arrives at the morgue?

To maintain positive identification and ensure all documentation and evidence remain linked to the correct case.

Which procedures should NOT be performed before the forensic pathologist examines the body?

Do not undress, wash, embalm, or fingerprint the body.

When should radiographs (X-rays) be obtained before an autopsy?

In cases such as gunshot wounds, trauma in adolescents, retained hardware, explosions, or whenever foreign bodies or skeletal injuries are suspected.

Why is trace evidence collected before clothing is removed or the body is cleaned?

To prevent the loss or contamination of fragile evidence.

What should be done after clothing is removed and trace evidence is collected?

Photograph the body, then clean it and perform a second examination for injuries.

Why is the body reexamined after it has been cleaned?

Cleaning may reveal wounds or other findings that were hidden by blood, dirt, or other debris.

What are the minimum photographs that should be taken of a wound?

One photograph showing the wound in relation to surrounding body landmarks and one close-up photograph of the wound.

What identifying items should be included in forensic wound photographs?

The case identification number and a measurement scale (ruler).

When should a color ruler be included in a forensic photograph?

When accurate assessment of wound color is important.

Why are laboratory tests performed during a forensic autopsy?

To help determine the cause and manner of death, identify contributing factors, and exclude other possible causes of death.

What are the most common laboratory studies performed during a forensic autopsy?

Toxicology, histology, neuropathology, microbiology, serology, and test firings (when applicable).

Why are two complete sets of fingerprints obtained during a forensic autopsy?

To ensure accurate identification and provide a permanent identification record.

In which type of case are palm prints routinely obtained in addition to fingerprints?

Homicide cases.

Where should the body block be placed before beginning a standard autopsy?

Under the shoulders and/or neck to extend the body and facilitate the Y-incision.

What is commonly used instead of a body block during a fetal autopsy?

A rolled towel placed beneath the body.

Where does the standard Y-incision begin on a male?

At each acromion process, extending to the sternum and then down the midline to the pubis, curving around the umbilicus.

Why is a U-incision commonly used in female autopsies?

To avoid cutting through the breasts while still providing adequate exposure of the thoracic and abdominal cavities.

What are the landmarks for a U-incision in a female autopsy?

It begins at each acromion, curves beneath the breasts to meet at the sternum, then continues down the midline around the umbilicus to the pubis.

Why is the sternum (chest plate) retracted during the internal examination?

To expose the thoracic cavity for inspection of the heart, lungs, mediastinum, and pleural cavities.

Which neck vessels are ligated (tied off) before organ removal?

The major cervical vessels, including the common carotid arteries and internal jugular veins.

Why are the neck vessels ligated before evisceration?

To prevent leakage of blood and embalming fluid and to preserve normal anatomy during organ removal.

What should be assessed immediately after opening the thoracic cavity?

The pleural cavities for abnormal fluid, adhesions, pneumothorax, or hemothorax.

What observations should be recorded when pleural or other body cavity fluid is present?

The volume, color, clarity, and whether blood clots are present.

Why should the edges of the cut rib cage be covered with a towel during an autopsy?

To protect the prosector from the sharp cut edges of the ribs.

In a normal adult autopsy, should the thymus be readily visible?

No. A prominent thymus in an adult should be noted because it may be abnormal.

Why is the pulmonary artery opened during the internal examination?

To evaluate for pulmonary thromboemboli.

What is a hemopericardium?

The presence of blood within the pericardial sac.

What is the ligament of Treitz?

The suspensory ligament marking the junction of the duodenum and jejunum.

Why is the ligament of Treitz an important landmark during evisceration?

It identifies where the proximal small intestine should be divided during gastrointestinal tract removal.

Why are both ends of the bowel tied off before removal?

To prevent leakage of intestinal contents and contamination of the body cavity.

Why are the bowel ends clamped before they are divided?

To control intestinal contents and facilitate safe removal of the gastrointestinal tract.

What is the general sequence of the internal examination after the Y-incision?

1. Reflect the sternum (chest plate) anteriorly.

2. Inspect the thoracic cavity in situ.

3. Assess and document pleural fluid (volume, color, clots) and pleural surfaces.

4. Inspect the pericardial sac and note any hemopericardium.

5. Ligate the major neck vessels before organ removal.

6. Open the pulmonary arteries and examine for pulmonary emboli (differentiate antemortem vs. postmortem clot).

7. Identify the ligament of Treitz (duodenojejunal junction).

8. Clamp, ligate, and divide the bowel on both sides to prevent spillage.

9. Proceed with evisceration according to the chosen technique.

What is the Letulle method of evisceration?

An en masse technique in which all cervical, thoracic, abdominal, and pelvic organs are removed together as one intact organ block (in toto).

Which evisceration method removes all organs as a single organ block?

The Letulle (en masse) method.

What is the primary advantage of the Letulle method?

It preserves the normal anatomic relationships between organs, allowing evaluation of disease or injury involving multiple organ systems.

Why is the Letulle method considered safer for the prosector?

Because most of the organ dissection is performed outside the body cavity after the organ block has been removed.

What are the advantages of the Letulle method?

• Rapid preparation of the body for the funeral home. • Preserves organ relationships. • Greater safety for the prosector. • Most dissection occurs outside the body cavity.

What are the disadvantages of the Letulle method?

• Examination of individual organs takes longer. • The large organ block may require assistance to remove and dissect.

Which evisceration method is best for preserving anatomic relationships between organs?

The Letulle (en masse) method.

Which evisceration method is generally preferred when preservation of organ relationships is more important than rapid examination of individual organs?

The Letulle (en masse) method.

What is the general sequence for separating the organ block during the Letulle method?

1. Place the organ block with the posterior surface facing up.

2. Open the inferior vena cava from the distal end to the diaphragm.

3. Open the descending aorta and major branches posteriorly.

4. Examine the vessels for patency and intimal abnormalities.

5. Reflect the thoracic aorta downward while leaving the abdominal aorta attached.

6. Open the esophagus posteriorly and inspect it.

7. Separate and weigh the adrenal glands.

8. Divide the thoracic and abdominal organ blocks while preserving the esophagus.

How should the organ block be positioned before dissection?

With the posterior surface facing upward.

Which major vein is opened first during dissection of the organ block?

The inferior vena cava, beginning distally and continuing to the diaphragm.

Which arteries are opened during organ block dissection?

The descending thoracic aorta, abdominal aorta, iliac arteries, and renal arteries.

What should be evaluated after opening the aorta?

The intimal surface, vessel patency, and the presence of dissections, ruptures, or aneurysms.

Why is the abdominal aorta left attached to the retroperitoneal tissues initially?

To maintain the orientation of the abdominal organs until abdominal dissection is completed.

How is the esophagus opened during organ block dissection?

Along its posterior aspect.

What abnormalities should be assessed when examining the esophagus?

Fistulas, lesions, and neoplasms.

Why are the adrenal glands separated and weighed individually?

Because they are examined separately for pathology and are routinely weighed as individual organs.

Why should the adrenal glands be placed in formalin immediately after removal?

Because they are fragile and undergo rapid autolysis.

Where is the organ block divided to separate the thoracic organs from the abdominal organs?

Between the inferior aspect of the pericardium and the superior aspect of the diaphragm.

Which vessel is transected when separating the thoracic and abdominal organ blocks?

The inferior vena cava.

Which structure remains attached to the abdominal organ block during separation?

The diaphragm.

Which structure should NOT be transected when separating the thoracic and abdominal organ blocks?

The esophagus.

What is the general sequence for examining the lungs during an autopsy?

1. Separate the lungs at the carina and divide the pulmonary arteries and veins near the hilum.

2. Examine for pulmonary thromboemboli.

3. Weigh each lung.

4. Inspect the pleural surfaces.

5. Palpate the lung parenchyma.

6. Inflate the lungs with formalin and cover with a formalin-soaked paper towel for at least 1 hour.

7. Serially section the lungs at 1–2 cm intervals.

8. Examine the lung parenchyma and airways for abnormalities.

Why are the lungs examined for pulmonary thromboemboli early in the dissection?

To identify emboli before the pulmonary vasculature is disturbed by further dissection.

What should be inspected on the external surface of the lungs?

The pleural surfaces for abnormalities such as adhesions, plaques, hemorrhage, or lesions.

Why is the lung parenchyma palpated before sectioning?

To detect masses, areas of consolidation, fibrosis, or other abnormalities that may not be immediately visible.

Why are the lungs inflated with formalin before sectioning?

To preserve the normal architecture of the alveoli and improve histologic and gross examination.

How long should the lungs remain inflated with formalin before sectioning?

At least 1 hour.

At what intervals should the lungs be serially sectioned?

Approximately every 1–2 cm.

Why is a midcoronal cut through the bronchus performed?

To identify centrally located bronchogenic carcinomas.

Why are horizontal slices of the lungs useful?

They correlate with cross-sectional imaging studies such as CT scans.

What should be evaluated within the lung parenchyma after sectioning?

Lesions, consolidation, scarring, and other abnormalities.

What should be examined after evaluating the lung parenchyma?

The airways.

What is the general sequence for examining the anterior and mediastinal organs?

1. Examine the mediastinum.

2. Sample any abnormal lymph nodes.

3. Open the brachiocephalic veins and superior vena cava to evaluate for thrombi.

4. Open the aortic arch and its major branches anteriorly.

5. Remove the larynx and trachea.

6. Inspect the thyroid gland in situ.

7. Remove, weigh, and section the thyroid gland.

8. Inspect for the parathyroid glands.

9. Open the larynx and trachea along the posterior aspect.

What should be examined first when evaluating the anterior mediastinum?

The mediastinum itself, including any abnormal masses or lymph nodes.

When should mediastinal lymph nodes be sampled?

Whenever they appear enlarged or otherwise abnormal.

Which major veins are opened during examination of the mediastinum?

The brachiocephalic veins and the superior vena cava.

Why are the brachiocephalic veins and superior vena cava opened?

To evaluate for thrombi.

How is the aortic arch opened during the mediastinal examination?

Anteriorly, including its major branches.

What should be evaluated before removing the thyroid gland?

Whether the thyroid is intact and whether either lobe or the entire gland is absent.

After removal, how should the thyroid gland be examined?

Remove it from the thyroid cartilage, inspect for the parathyroid glands, weigh it, serially section it, and document any abnormalities.

Why are the parathyroid glands inspected during thyroid dissection?

To identify their presence and evaluate for abnormalities.

How are the larynx and trachea opened?

They are opened longitudinally along the posterior aspect.

Why may the thyroid cartilage need to be cracked during laryngeal examination?

To allow complete opening and visualization of the larynx.

What is the general sequence for examining the heart during an autopsy?

1. Remove blood clots and trim the great vessels to approximately 1 cm above the valves.

2. Weigh the heart.

3. Dissect the pericardial tissue.

4. Clean and expose the great vessels.

5. Examine the coronary arteries.

6. Serially section the ventricles horizontally from the apex toward the valves.

7. Inspect for infarcts and measure ventricular wall thickness.

8. Section the papillary muscles longitudinally.

9. Open the atria and ventricles along the direction of blood flow.

10. Measure the valve circumferences.

How should the great vessels be trimmed before weighing the heart?

Trim the great vessels to approximately 1 cm above the valves after removing blood clots.

When should the heart be weighed?

After blood clots have been removed and the great vessels have been trimmed.

How are the coronary arteries examined during a routine autopsy?

They are serially cross-sectioned at 2–3 mm intervals.

When may the coronary arteries be opened longitudinally instead of by serial cross-sections?

When there is no evidence of coronary atherosclerosis.

Why are the coronary arteries serially sectioned?

To evaluate for atherosclerosis, thrombosis, or luminal narrowing.

How is the myocardium serially sectioned?

The ventricles are cut horizontally at approximately 1 cm intervals beginning at the apex and progressing toward the valve leaflets.

What should be evaluated after serially sectioning the myocardium?

Myocardial infarcts and ventricular wall thickness.

Why are the papillary muscles cut longitudinally?

To evaluate for myocardial infarction involving the papillary muscles.

How are the cardiac chambers opened?

Along the normal direction of blood flow.

Why are valve circumferences measured?

To evaluate for valvular stenosis or dilation.

What is the normal direction of blood flow through the heart?

Right atrium → Tricuspid valve → Right ventricle → Pulmonary valve → Pulmonary artery → Lungs → Pulmonary veins → Left atrium → Mitral valve → Left ventricle → Aortic valve → Aorta.

What characteristics distinguish an antemortem thrombus?

Firm, friable, attached to the vessel wall, dark red with Lines of Zahn.

What characteristics distinguish a postmortem clot?

Gelatinous, not attached to the vessel wall, with yellow 'chicken-fat' and dark red 'currant-jelly' layers.

What is the key feature that distinguishes an antemortem thrombus from a postmortem clot?

An antemortem thrombus is attached to the vessel wall, whereas a postmortem clot is not.

What is the general sequence for examining the kidneys and ureters during an autopsy?

1. Identify the ureters along each side of the midline.

2. Open each ureter longitudinally with scissors from the renal pelvis to the entrance of the bladder.

3. Measure the ureteral lumen and examine the mucosa.

4. Remove each kidney by blunt dissection between the renal capsule and the perinephric fat.

5. Remove the renal capsule.

6. Clean the kidneys of surrounding fat and weigh them.

7. Bivalve each kidney through the coronal plane.

8. Examine the cortex, medulla, renal pyramids, and renal pelvis.

Where do the ureters run anatomically?

Along each side of the midline from the renal pelvis to the urinary bladder.

How are the ureters opened during an autopsy?

Longitudinally with scissors from the renal pelvis to the entrance of the bladder.