Week Three at West Virginia Deputy Chief Medical Examiner's Office

Things have been going as smoothly as things can be going so far. I still make mistakes, but I've been improving my speed and accuracy at performing the autopsies. As for myself, the time seems to fly when I'm working on a body. If I watch another person perform an autopsy, I can feel my legs weighing me down and I need to sit before gravity takes over. On the other hand, if I'm the one who's working, once I've gotten into my 'mode' my arms and body are moving so fast that I don't feel the need to sit.

This reminds me of the two basic functions that PA students at WVU perform during the autopsy rotation. The two duties are evisceration and organ dissection. Today, I'll do my best to explain evisceration, especially for those who haven't studied anatomy before. This subject may turn off some of you due to the nature of cutting into the human body, so if you feel uncomfortable it would be best to stop reading.

In short, evisceration of a body involves opening it and removing the organs. After the medical examiner has completed their assessment of the external features of the body and samples of vitreous fluid (from the eyes), subclavian blood and urine have been taken, the body is ready to be opened.

A wooden block is placed underneath the body just below the shoulders to prop up the chest. This helps blood from flowing over the shoulders and giving you a better angle to access the body cavities. The first incisions are made with a scalpel and start at both shoulders (near the acromion processes) and converge at the bottom of the chest where the ribs connect to the sternum (near the xiphoid process). From here, a single long incision continues down the abdomen towards the belly button. The cut continues around the belly button all the way towards the pubic bone, just above the genitals. These cuts look like a giant Y on the body.

Skin, fat and muscle needs to be pulled back (reflected) from the chest cavity. Initially the tissues will be quite adherent and you may not have a good grip to pull back the tissue. If it's difficult for me I like to use forceps to grasp the tissue so I don't have to cut with the scalpel blade so close to my fingers. After the first bit of tissue has been sliced free I can grip it with my whole hand, but if it's still slippery using a paper towel gives you a better grip. Tissue also needs to be reflected upwards towards the neck. But, because the skin here is thinner you need to be careful that you don't cut a hole though it. You also need to be careful that you don't accidentally put a cut into the trachea as you are freeing the tissue.

The same thing about reflection can be said about the abdominal cavity. But, because there are no bones over your belly, as soon as you cut through you are into the cavity. The stomach, liver and intestines are lying right underneath, so you need to be careful not to cut into them when you are cutting through the abdominal wall.

With most of the skin reflected, you need to find a way to get into the chest cavity. Your ribs are of course made of bone, but towards the front where they meet your sternum they are made of cartilage. This allows your chest to expand and contract when you breathe. A scalpel can't cut through bone very easily, but it can cut through cartilage with little effort. The cartilage is whiter than the bone, so all that needs to be done is use the scalpel and cut down the ribs where they are white. The cartilage begins to disappear towards where your clavicles meet your sternum (manubrium), so you may have to use an oscillating saw.

The oscillating saw is used to cut through bone. Think of a power drill, but instead of a drill it has a serrated blade for a head and it vibrates back and forth incredibly fast. Against soft tissues it doesn't cut very well, but it can go through bone like a hot spoon though ice. While cutting through bone (especially the skull) it gives off a lot of bone dust and the room fills with a burning smell despite all of the ventilation.

Once the cuts through the ribs have been made you can use a scalpel again to free it and remove the chest plate. Immediately visible will be both lungs and the heart encased in its sac. You can check to see if the thymus remains, but in many adults it has been replaced by fat. If it is there you can cut it out. The lungs need to be moved out of the way so you can see how much fluid (pleural fluid) is contained within the cavities. After that you are ready to open the sac that contains the heart (the pericardium). The sac also contains its own fluid so you need to move the heart out of the way and take a look at it. To remove the heart, you can grasp it in your hand, pull it as far as possible out of the chest, then using your scissors cut across all of the vessels at the base. Your first cut will probably be through the inferior vena cava and when you cut into it blood inside the heart will fall out into the pericardial sac and make your life a little harder by obscuring where you need to cut. Even if you can't see well, as long as you cut far enough away from the heart across the vessels you should be able to free it.

Next will be to remove the lungs. Each lung is attached at its hilum adjacent to the heart. Here is where the bronchi and vessels from and to the heart enter and emerge. As with the heart, you can usually pull each lung out of the chest cavity and cut across the vessels.

At the belly, you will see the huge liver and below that a curtain of fat overlying the intestines. This is the omentum and it can be cut off. The next step is to remove the intestines all in one piece. Removing the intestines can be a little tricky for a number of reasons. First, you need to be careful that you don't accidentally poke it because the contents will ooze or spill out and you'll have a big mess on your hands. Also, the intestines are a common place for adhesions to develop and they will definitely hamper your efforts to remove them. To start, you need to find where the small intestines 'disappear' into the body fat and clamp it. This location is known as the Ligament of Treitz. It's location is just below the stomach. Once you have placed two clamps onto it, you can cut between the clamps without fear that the contents will spill out. Now, you can begin the process of removing the intestines. The way to do it is to pull on your free end and use your scalpel or scissors to cut at the fat and mesentery wherever it becomes taught. If you do so, the intestines should get freed cut by cut and elongate. Where the small intestines enter into the large intestines becomes a bit more difficult because it is usually held down by more fat and mesentery here. You can find the appendix here and remove it as you continue freeing the large intestines. Eventually you'll follow the intestines all the way to the rectum. Here you need to use your hands to remove as much surrounding fat and connective tissue so that you are left with just the 'hose' of rectum attached to the anus. All that's left is to cut across it and you are finished with the intestines.

You can now take the time to remove the bladder, prostate/uterus and the remaining rectum as a single piece. The bladder is located closer to the front (anterior) wall and you can use your fingers to free it from much of the surrounding fat. As with the rectum, you'll use a knife and cut as far down as possible to free the bladder and everything else attached to it.

The next organ is probably the most difficult to handle, the liver. It's huge and slippery, but it fortunately doesn't have too many attachments. While trying your best to avoid accidentally cutting into the liver you can use scissors to free it from the diaphragm and cut across the vessels that enter and exit the liver. On the back side of the liver (posteriorly) is the gallbladder and you'll need to be careful to not accidentally cut into it. You can remove the liver with the gallbladder attached to it. Just handle it carefully so it doesn't fall onto the morgue floor.

Now you have better access to the spleen. Looking down at the body, it's located on the right (left side from the point of view of the body). The spleen is delicate and will rip easily, so you shouldn't be too rough in removing it. It should be attached by the artery and vein that pierce it as well as some ligaments that attach it to the stomach. When you're cutting, be careful not to accidentally cut into the stomach.

Before cutting out the kidneys you should go for the adrenal glands that sit on top of each. They are not always located on top though. Often they will be in between the kidney and the spine. The adrenal glands often blend in to the surrounding fat, but you know that you're in the right spot if you cut into them because of their stripped yellow/brown appearance. When there's a lot of fat then it can be more difficult to find them.

The kidneys are easy to remove once you know how. They are surrounded by a capsule (Gerota's fascia) and if you just cut across the capsule (it's ok to cut into the kidneys a little bit) then you can use your fingers to 'dig' around the kidney beneath the capsule. The kidneys are attached at the hilum (similar to the lungs) and all you need to do is cut across those vessels.

From here I like to cut off the diaphragm. It's best to just use a scalpel and cut it away from the lateral and posterior walls of the last ribs. You just need to be careful not to accidentally puncture the stomach.

The neck is a delicate area and there are special morgue technicians who will cut this area for us to avoid any headaches with the funeral homes. They cut around the trachea and esophagus up into the jaw. They use their scalpel to free the tongue and then remove the entire piece with tongue attached at the end. From here we free the esophagus from the aorta all the way down to the stomach and remove the whole thing intact. It's quite a sight to see the GI tract all the way from the tongue down to the duodenum removed completely intact and continuous.

Now, the aorta can be accessed and removed. A cut is made where the aorta divides at the pelvis into the common iliac arteries and with a pair of forceps and scalpel the aorta is pulled upwards and cut free.

The medical examiners like to also remove a piece of muscle and bone marrow. The easiest place to get the muscle is from the psoas major muscle, but you might know this muscle better as the tenderloin or where filet mignon comes from. The bone marrow actually is most easily taken from a lumbar vertebra. A hand saw is used to cut a wedge down out of the vertebra and that thin wedge contains a good sample of bone marrow.

The last place to look is the head. The brain needs to be looked at and removed. To do this, a cut is made from left to right (because I'm left-handed) across the skull starting from just behind the ears. This cut is done so that the person can still be viewed at a funeral without having to see any incisions. The scalp needs to be freed from the skull and a combination of careful scalpel cuts and pulling with your fingers will get the job done. The front half of the scalp will be pulled over the face and the back half will be pull back down behind and underneath the head.

With the skull exposed you can begin cutting into it with the oscillating saw. This part takes some patience because you need to cut perpendicular to the bone while holding a fairly heavy, vibrating power tool. You need to cut around the skull such that a 'cap' is able to be pulled of. This stage is the most noisy and perhaps one of the more smelly steps.

Eventually, the cap can be removed and the brain exposed. The brain will be attached at the brain stem and a variety of nerves will need to be cut through. Also, the covering of the cerebellum (the tentorium cerebelli) needs to be cut through to free the cerebellum. The brain can then be removed intact in one piece.

From here there is only one last thing that we PA students need to do. That is to remove the pituitary gland. The pituitary gland is located in the middle of the skull at it's base and it's surrounded on all sides by bone (except for where it attaches to the brain). The bony throne that it sits on is the sella turcica and the posterior bony wall can be broken. Using a scalpel to remove the rest of the covering membrane (the diaphragma sellae) will allow you to gently grasp the pituitary with forceps and remove it.

The above sums up the evisceration process and hopefully gave you all an idea of how organs are typically removed. Despite the 'brutal' nature of the evisceration process, you will be even more surprised to know that these bodies will be fixed up by the funeral homes so that you can't even tell an autopsy was performed in the first place. The autopsy evisceration may not evoke the most pleasant of thoughts, but it truly is an art.