UDLCO summary: The conversations suggest how alumni group support can go a long way toward meeting challenges by individual alumni in remote settings and finally also reiterate how autopsies are still valued for their primary role in the cellular histopathology clarifying diagnostic uncertainty during life and after death.
Conversational Transcripts:
[25/09, 18:47] CBBLE moderator: Needed some information help from anyone here particularly who has experience with conducting pathological autopsies ( @ and others ) as we are going to conduct a pathological autopsy for the first time in our institution ever since it began 20 years back.
As the patient was admitted with me with suspected disseminated Tuberculosis (not confirmed) and the relative has been kind enough to let us do the autopsy, it's upon me to organise it and I may even have to perform the procedure if I don't find anyone else willing to do it tomorrow. Other than PGI I guess nowhere else pathologists may be getting the opportunity to do it so their reluctance to perform it is understandable.
Our admin has been supportive in the sense that they have agreed to let me do it.
The patient relatives are also very supportive and the body is in our mortuary in cold storage till we do the procedure tomorrow morning.
Need to know what are the common essential logistic requirements one would need to carry it out in terms of
1) instruments
2) Organs to be removed
3) Legal formalities
4) Any other points
regards
[25/09, 18:52] TS: Great initiative 👍Speak to R and SJ. If don't know their no you can DM me....
[25/09, 18:53] SM: U can call Dr ... in ...
We do at ...
Not as many as in...
[25/09, 18:54] SM: I spoke to her
She is out of station
But she is willing to help u on phone
I will share ph number
[25/09, 18:56] SM: Appreciate your interest
[25/09, 19:03] DRN : I have done a few autopsies in ... patients
1. Consent
2. A few blades, good skin scissors, skin duturind needles and skin forceps, twine thread.
3. Lots of formalin containers
4. Microbiology swabs
5. A round saw or a knife to go through sternum
6. Strong gloves, gown, cap and mask
Open with single long incision from xiphisternum via chest to pubis
First examine the organs in chest and abdomen
Sample whatever organs you wish - lungs, nodes, Liver, kidney...
Intestines need lots of water to wash out contents and feces ..
Typically, brain is not opened.
No need to remove whole organs...
Sew up and clean body. Wrapt in white sheet.
Tie ID tag to the toes.
Hand over to family.
Offer free morgue van service to patients home to carry body
[25/09, 19:09] CBBLE: Thanks
This was very useful. 🙏
[25/09, 19:45] CBBLE moderator: The round saw or knife for the sternum sounds like it will be difficult to procure.
Can we remove the abdominal organs first with a scalpel and then cut the diaphragm and dissect out the chest viscera through the abdominal route?
The 61 year old patient had a large cavitating lesion on her left lobe infiltrating into the pleura that is of particular interest and I had even done an fnac of it that showed some inflammatory infiltrates and was negative for AFB
[25/09, 19:46] DRN: You can cut through the costochondral junctions - they yield to a surgical blade easily...no saw needed
[25/09, 19:47] CBBLE moderator: Alright that sounds good.
[25/09, 19:48] DRN: You have to extend the sternal notch incision laterally for about 4 to 6 inches to reach the c-c junctions
[25/09, 21:12] PS: Very interesting discussion on autopsy
[25/09, 21:48] KP: A rokitansky manoeuvre
[25/09, 22:09] BRS: No need.
You can directly divide the diaphragm through rhe abdomen and remove all the thoracic organs.
When we acquired our laparoscope first, I did a few laparoscopic autopsies and removed all the organs through a small incision.
[25/09, 22:31] DRN: Laparoscopic autopsies:
- less morbidity
- No mortality (already dead)
- aesthetically appealing
[25/09, 22:32] PS: Anaesthetist not needed
[26/09, 06:37] CBBLE moderator: Thanks.
I searched for this and it appears that,
"The Rokitansky method involves removing the body organs all at once. That is, the heart, lungs, liver, kidneys and spleen etc are removed in one block and then dissected on the autopsy table."
Unquote
[26/09, 06:39] CBBLE moderator: Here's meta AI's take on the same (but again difficult to say if it's confabulating
or not)👇
The Rokitansky autopsy method, named after Carl Freiherr von Rokitansky (1804-1878), is a historical technique for performing autopsies.
*Rokitansky's method:*
This method involves:
1. In situ dissection: Organs are dissected in their natural positions, without removal from the body.
2. Regional examination: The body is examined region by region, starting from the thorax, then the abdomen, and finally the head and extremities.
3. Minimal incisions: Small incisions are made to access organs, aiming to preserve the body's integrity.
*Key features:*
1. Focus on pathological anatomy
2. Emphasis on in situ examination
3. Minimal tissue disruption
*Historical significance:*
Rokitansky's method revolutionized autopsy practices in the 19th century, shifting focus from mere organ removal to understanding disease processes and pathological changes.
*Limitations and evolution:*
The Rokitansky method has largely been replaced by more modern techniques, such as:
1. Virchow's method (named after Rudolf Virchow): involves evisceration and separate examination of organs.
2. Modern autopsy protocols: incorporate advanced imaging, toxicology, and molecular analysis.
*References:*
1. Rokitansky, C. (1849). "A Manual of Pathological Anatomy." (Translated by W. E. Swaine)
2. "Rokitansky's Autopsy Method" (Journal of Clinical Pathology, 1974)
3. "The Evolution of Autopsy Techniques" (American Journal of Clinical Pathology, 2018)
Would you like more information on autopsy techniques or historical developments in pathology?
[26/09, 06:45] CBBLE moderator:
Laparoscopic autopsies could be an amazing breakthrough in medical education!
Large numbers of autopsies are refused due to the fear of the body getting disfigured before final ceremonial rites.
Laparoscopic autopsies could address this issue and scale the number of pathological autopsies in the 700 odd medical colleges in the country as we are all aware that subsequent CPCs from real autopsies can go a long way to generating better insights into disease and currently hasn't taken off due to reasons where relatives may feel harassed having to subject their loved one's bodies for a disfiguring procedure but could agree if it's streamlined in the above manner laparoscopically?
[26/09, 06:54] KP: The Rokitansky technique is standard in ... path department.
[26/09, 07:00] DRN: Interesting... Anything on afterlife also?
[26/09, 07:00] CBBLE moderator: Oh didn't click on that link but let me check it out
[26/09, 07:04] CBBLE moderator: Checked that link now.
Nothing on afterlife but quite a bit on afterdeath and to quote:
"In 1742 John Bruhier documented fifty-two examples of supposed live burial, in his book Dissertation de l'incertitude des signes de la mort, This fed the public's fears of premature burial, and placed growing pressure on doctors to come up with more reliable 'signs of death' as a diagnostic tool. German doctors concluded that putrefaction was the only reliable indicator of death."
Unquote
[26/09, 08:50] PS: This is clear and correct
Virchow ( old method) removed organs out individually and examined them / dissertation on table
Imagine how they stuffed all back .
Rokitansky : dissected in situ - inside body . Organ still attached to body .
This is right I feel
[26/09, 11:04] CBBLE moderator: Autopsy in progress:
[26/09, 15:54] BRS: A lot of logistic problems with laparoscopic autopsy
1. Who should do it?
Laparoscopic surgeon or pathologist/forensic specialist trained in laparoscopy or best - both together.
2. When to do?
Best soon after death.
Frozen bodies do not yield to pneumatic inflation that is absolutely essential for proper visualization.
Bloating of hollow viscera with postmortem putrefactive gases is a serious problem if punctured inadvertently.
3. How much?
Target biopsies or in situ removal of whole organs that will require long enough incisions anyway?
Different protocols are obviously needed from traditional open autopsies.
Intracranial structures cannot be accessed.
And lastly - has the value of a routine autopsy diminished in the era of high resolution imaging of solid organs and possible accessibility any tubular structure in the body?
"Dead men tell no tales" may not be accepted by William Boyd but many people nowadays do including Late Prof ... and he did not allow me to do even a pilot study of Lap autopsies.
[26/09, 16:13] CBBLE moderator:
Regarding the last point:
As long as we don't have imaging equipment to look into tissues at a cellular level, we will still need to remove those tissues either in life or after death to ascertain the cause.
Even now with all advances in imageology we still can just visualise gross pathology and not histopathology.
Here's the macro view of lung we removed today during autopsy, which wouldn't have been feasible during life and even now we await what the histopathology shall bring👇
Administrative support for mycobacterial culture sensitivity:
[30/09, 16:13] CBBLE moderator: What about the pus from the lower lobe lung abscess? Could it be sent for tubercular culture sensitivity testing?
[30/09, 16:14] DP: No sir
Because it has been fixed in formalin
[30/09, 16:14] DP: Left lower lobe showing cavity.
[30/09, 16:17] DP: Grossly intestine is showing tubercles.
[30/09, 16:18] DP: Microscopy slides will be given tomorrow afternoon sir as it took more time for fixation.
[30/09, 16:19] CBBLE moderator: Thanks. I thought we removed the pus from it at that time and it was collected to be sent for AFB culture sensitivity as archived in the video here 👇
[30/09, 16:20] CBBLE moderator: It will be very interesting to see what the histopathology of both these intestines as well as the lung shows
[30/09, 16:20] DP: Yes sir
[30/09, 16:21] CBBLE moderator: The culture would have been important to check out the sensitivity pattern and if the treatment regimen we had started was likely to be useful
[30/09, 16:24] DP: Yes sir. We shouldn't have kept in formalin.we should have sent on the day itself immediately after dissection.
[30/09, 16:29] CBBLE moderator: Yes even during the dissection I raised this point and I was told by your assistants that the pus was being collected to be sent
[30/09, 16:41] DP: the pus collected during autopsy was sent sir today after doing cytology. But fluid came during dissection of lung was not sent sir.
[30/09, 16:43] CBBLE moderator: Can the pus be sent for tubercular culture sensitivity?
[30/09, 16:53] DP: Ok sir
If pus is available, I will send it to ... laboratory for further analysis tubercular culture sensitivity test for academic purpose.
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