Organ removal involves the following techniques –
Virchow’s technique: Organs are removed one by one. Cranial cavity is exposed first, followed by thoracic, cervical and abdominal organs.
Rokitansky’s technique: It involves in situ dissection in part, combined with en block removal.
Lettulle’s technique: Cervical, thoracic, abdominal and pelvic organs are removed en masse and dissected as organ block.
The greater omentum lying across the small intestine is pushed upwards across the liver. The upper part of the small intestine is grasped in the left hand, and followed upwards until it disappears retroperitoneally to become the duodenum. The mesentery is penetrated with the point of the knife at the duodenojejunal flexure, and two pieces of string are passed through the hole.
They are then brought upwards and tied separately and tightly around the gut. The gut is divided between these two ligatures. The coils of the intestine are pulled forwards by the left hand and the mesentery is cut close to the mesenteric border of the gut until the ileocaecal valve is reached.
The caecum is mobilized, and the ascending colon pulled forwards and medially by the left hand, and its attachments with the posterior abdominal wall are cut with the knife up to the hepatic flexure. The omentum is pulled down and the transverse mesocolon is cut through with a knife, until the splenic flexure is reached.
Then descending colon is freed in a similar manner until the sigmoid is also free. The upper part of the rectum is mobilized and cut through between two ligatures below the brim of the pelvis. The whole of the small and large intestine is removed from the abdominal cavity.
Next in Organ removal procedure, the axillary bundles which lie behind the clavicles and first rib are cut, by passing the knife upwards on each side from the thoracic cavity into the neck. Pleural adhesion between the lungs and the chest wall if any, should be cleared of by fingers or knife.
Slip the fingers of both hands between the lateral portion of one lung and the inner side of the chest wall. The left hand works up to the apex, the right down to the base, and they meet at hilum. The neck structures are grasped en masse in the left hand and pulled downwards, cutting the structures on the front of the spinal column to the level of the diaphragm. After this, the thoracic organs are put back in the thorax.
The stomach and spleen are pulled medially by the left hand and the diaphragm is removed by cutting through its attachment to the ribs on both sides. The thoracic organs are pulled down by gentle traction on the neck structures and the cruciate ligament which attaches the diaphragm to the spine is cut. The organs are then put back into the thorax.
The spleen and the tail of the pancreas are held in the left hand, and dissection is carried behind them to the mid line. The diaphragmatic surface of the spleen is held in the palm, and the vessels at the hilum are cut after they have been inspected. The liver is pulled medially and the knife is passed behind it to free it from attachments.
The peritoneum and fat are cut just outside the lateral border of the kidney which is then grasped in the left hand and mobilized by dissection behind it to the mid line, freeing it from the anterior surface of the iliopsoas muscle. The ureter is identified and freed all the way down to its entry to the bladder. Both kidneys are then taken in the left hand, and the knife is carried down the mid line behind the aorta to the pelvis.
The knife is passed around the side wall of the pelvis, dividing the lateral attachments of the bladder, each side of the pelvis being dissected downwards to the mid-line. The anterior surface of the bladder is freed with the fingers from the pubic bone.
The femoral vessels are cut at the level of the brim of the pelvis. The contents are pulled upwards and the urethra and vagina divided as low as possible. The whole block of thoracic and abdominal organs are pulled forward and removed en masse.
The atlanto-occipital joint should be examined by moving the head on the spine, to note any fracture- dislocation. Examine the cervical spine for fractures. The so-called “UNDERTAKER’S FRACTURE” is caused due to the head falling backwards forcibly after death, which tears open one of the inter vertebral disc usually around C-6 and C-7, due to which subluxation of the lower cervical spine occurs.
The thoracic and lumbar spine should be examined by pushing a hand under the body to raise up the spine forward, which will show any abnormal movement at the site of fracture. The cervical spine can be tested by manual manipulation. To detect fractures of the sacroiliac joints or of the pelvic bones, the pelvis should be squeezed from side to side by pressure on each iliac crest.
EXAMINATION OF ORGANS before Organ removal
The en masse chest and abdominal organs are kept on a wooden board with posterior surface upwards and the tongue facing the operator.