Opening the trunk

The body is opened using a Y-shaped incision from shoulders to mid-chest and down to the pubic region, making a slight deviation to avoid the umbilicus (navel). The incision is very deep, extending to the rib cage on the chest, and completely through the abdominal wall below that.

The incisions are carried down to the skull, the rib cage and breastbone, and the cavity which contains the organs of the abdomen. The scalp and the soft tissues in front of the chest are then reflected back. Again, the pathologist looks around for any abnormalities.

With the Y incision made, the next task is to peel the skin, muscle, and soft tissues off the chest wall. This is done with a scalpel. When complete, the chest flap is pulled upward over the patient's face, and the front of the rib cage and the strap muscles of the front of the neck lie exposed.

An electric saw or bone cutter is used to open the rib cage. One cut is made up each side of the front of the rib cage, so that the chest plate, consisting of the sternum and the ribs which connect to it, are no longer attached to the rest of the skeleton. When the breastbone and attached rib cartilages are removed, they are examined. Often they are fractured during cardiopulmonary resuscitation. The chest plate is pulled back and peeled off with a little help of the scalpel, which is used to dissect the adherent soft tissues stuck to the back of the chest plate. After the chest plate has been removed, the organs of the chest (heart and lungs) are exposed (the heart is actually covered by the pericardial sac).

Before disturbing the organs further, the prosector cuts open the pericardial sac, then the pulmonary artery where it exits the heart. He sticks his finger into the hole in the pulmonary artery and feels around for any thromboembolus (a blood clot which has traveled through the heart to the pulmonary artery, lodged there, and caused sudden death).

The abdomen is further opened by dissecting the abdominal muscle away from the bottom of the rib cage and diaphragm. The flaps of abdominal wall fall off to either side, and the abdominal organs are now exposed.

Removing the organs of the trunk

Then the pathologist must decide in what order to perform the rest of the autopsy. The choice will be based on a variety of considerations.

The most typical method of organ removal is called the "Rokitansky method. The dissection begins at the neck and proceeds downward, so that eventually all the organs of the trunk are removed from the body in one bloc. The first thing the diener does is to identify the carotid and subclavian arteries in the neck and upper chest. He ties a long string to each and then cuts them off, so that the ties are left in the body. This allows the mortician to more easily find the arteries for injection of the embalming fluids.

A cut is them made above the larynx, detaching the larynx and esophagus from the pharynx. The larynx and trachea are then pulled downward, and the scalpel is used to free up the remainder of the chest organs from their attachment at the spine. The diaphragm is cut away from the body wall, and the abdominal organs are pulled out and down. Finally, all of the organs are attached to the body only by the pelvic ligaments, bladder, and rectum. A single slash with the scalpel divides this connection, and all of the organs are now free in one block and can be further explored on a dissecting table.

Removing the brain

The diener takes the body block out from under the patient's back and places it under the back of the head. This elevates the head so that it is positioned as if it were on a very thick, stiff pillow. The diener uses a scalpel to make an incision across the head, joining the bony prominences just below and behind the ears. Like with the trunk incisions, this one is deep, all the way to the skull. The skin and soft tissues are now divided into a front flap and a rear flap. The front flap is pulled (this takes some strength) forward (like being "scalped") over the patient's face, thus exposing the top and front of the skull. The back flap is pulled backwards over the nape of the neck. The whole top hemisphere of the skull is now exposed.

The diener takes an electric saw and makes cuts around the equator of the cranium. This cut must be deep enough to cut all the way through the skull, but not so deep that the brain is cut . Typically, the cut is not totally straight but has a notch so that the skull top (calvarium) will not slide off the bottom half of the skull after everything is sewn back up. After this cut, the calvarium is removed and set aside. As the calvarium is lifted off, there is a very characteristic sound that is sort of a combination of a sucking sound and the sound of rubbing two halves of a coconut together.

The outer layer of the meninges (the coverings of the brain), called the dura, stays with the calvarium, so that the top of the brain is now fully exposed. After the chore of getting to it, it is a relatively easy matter to get the brain out. There are no tough ligaments that hold the brain in, so really all that needs to be done is to cut the spinal cord and the dural reflections that go between the cerebellum and cerebrum.

Since the brain is very soft and easily deformable, it is not manipulated at the time of the autopsy. Instead, it is usually suspended in fixative (a 10% solution of formaldehyde gas in buffered water) for two weeks or longer so that the later dissection will be clean, neat, and accurate. The action of formaldehyde is to "fix" the tissue, not only preserving it from decay, but also causing it to become much firmer and easier to handle without deforming it. The reason that it is suspended by string is to prevent it from having a flattened side from lying in the bottom of the jar (the brain is heavier than water and therefore sinks).

Examination of the organs of the trunk

After any organ is removed, the pathologist will save a section in preservative solution and submit the tissue to the histology lab, to be made into microscopic slides. When these are ready, they will examine the sections, look at the results of any lab work, and draw their final conclusions. The rest of the organ goes into a biohazard bag, which is supported by a large plastic container.

The pathologist weighs the major solid organs (heart, lung, brain, kidney, liver, spleen, sometimes others) on a grocer's scale. The smaller organs (thyroid, adrenals) get weighed on a chemist's triple-beam balance.

At the dissection table, the prosector typically dissects and isolates the esophagus from the rest of the chest organs. This is usually done simply by pulling it away without help of a blade (a technique called "blunt dissection"). The chest organs are then cut away from the abdominal organs and esophagus with scissors. The lungs are cut away from the heart and trachea and weighed, then sliced like loaves of bread into slices about one centimeter thick. A long (12" - 18"), sharp knife, called a "bread knife" is used for this.

The heart is weighed and opened along the pathway of normal blood flow using the bread knife or scissors. The coronary arteries are examined by making numerous crosscuts with a scalpel.

The larynx and trachea are opened longitudinally from the rear and the interior examined. The thyroid gland is dissected away from the trachea with scissors, weighed, and examined in thin slices. Sometimes the parathyroid glands are easy to find, other times impossible.

The bloc containing the abdominal organs is turned over so that the back side is up. The adrenal glands are located in the fatty tissue over the kidneys and are removed, weighed, sliced, and examined by the prosector.

The liver is removed with scissors from the rest of the abdominal organs, weighed, sliced with a bread knife, and examined. The spleen is similarly treated. The liver is cut at intervals of about a centimeter, using a long knife. This enables the pathologist to examine its inner structure.

The lungs are almost never normal at autopsy. The lungs are pink when the dead was a non-smoker. Dissecting the lungs can be done in any of several ways. All methods reveal the surfaces of the large airways, and the great arteries of the lungs. Most pathologists use the long knife again while studying the lungs. The air spaces of the lungs will be evaluated based on their texture and appearance. The pathologist will inspect and feel them for areas of pneumonia and other abnormalities. The pathologist weighs both lungs together, then each one separately. Afterwards, the lungs may get inflated with fixative.

The intestines are stripped from the mesentery and opened over a sink under running water, so that all the feces and undigested food flow out. As one might imagine, this step is extremely malodorous. The resultant material in the sink smells like a pleasant combination of feces and vomitus. The internal (mucosal) surface of the bowel is washed off with water and examined.

The stomach is then opened along its greater curvature. The pancreas is removed from the duodenum, weighed, sliced and examined. The duodenum is opened longitudinally, washed out, and examined internally. The esophagus is similarly treated.

The kidneys are removed, weighed, cut lengthwise in half, and examined. The urinary bladder is opened and examined internally. In the female patient, the ovaries are removed, cut in half, and examined. The uterus is opened along either side (bivalved) and examined. In the male, the testes are typically not removed if they are not enlarged. If it is necessary to remove them, they can be pulled up into the abdomen by traction on the spermatic cord, cut off, cut in half, and examined.

The aorta and its major abdominal/pelvic branches (the renal, celiac, mesenteric, and iliac arteries) are opened longitudinally and examined.