EDAN

The incisions used to undertake the internal examination vary according to the circumstances and among pathologists. The safest procedure, the one most likely to identify the injuries of particular forensic interest while at the same time minimising artefact, commences with the scalp. The incision commences immediately behind the ear and passes through the mid-temporal regions to the same point behind the other ear. The scalp is then reflected forwards to the orbital ridges and backwards to the deep occipital region. The skull cap is then removed, preferably leaving the dura intact. The dura is incised, exposing the brain, which is then removed. The removal of the brain at this stage of the autopsy will assist drainage of blood from the head and neck and so minimise possible artefactual bruising during dissection of the neck. The dura over the base of the skull is then removed. The incisions behind the ears are continued down the anterolateral aspects of the neck across the mid-clavicle to the midline just below the sternal notch. At the midline the incision continues down to the symphysis pubis, skirting the umbilicus.

The skin of the neck is then reflected in the subcutaneous plane at least to the mandible, and possibly to the inferior margins or the orbit when the determination of the presence, or accurate delineation, of facial injuries is of particular significance. The skin of the chest and abdomen is likewise reflected in the subcutaneous plane to maximise the detection of bruises in these areas. The peritoneum is then incised in the midline and the anterior abdominal musculature is freed from the costal margins so that the abdominal contents are fully exposed. The skin of the chest having been reflected, the pectoral muscles are then freed from their costal and clavicular attachments exposing the ribs. At this point the pleural cavities can be assessed for the presence of air between the lungs and the chest wall (a pneumothorax). Several techniques can be employed including aspiration of pleural contents through a water trap, opening part of an intercostal space under water and dissecting the intercostal musculature to inspect the parietal pleura directly for the presence of visible surface lung markings. After the pathologist has checked for pneumothoraces, the sternocleidomastoid muscle is then reflected from its sternal and clavicular attachments. The sternoclavicular joints are incised and the ribs are cut, allowing removal of the sternum with attached portions of ribs and costal cartilages. At this point the surface of the mediastinum and the lining of the chest can be examined and any fluids in the pericardium (the sack around the heart) or within the pleura cavities can be measured and collected.

Should the examination of the neck be of particular importance, the thoracic organs can then be released below the thoracic inlet, allowing blood to drain from the neck to minimise artefactual bruising during the in situ neck dissection. The strap muscles of the neck can then be reflected, and the hyoid bone and thyroid cartilage can be inspected, having been subjected to minimal interference by the prosector. When such a detailed examination of the neck is not of particular importance, the removal of organs can proceed directly. The oral contents are freed by removing the floor of the mouth from its mandibular attachments. The pharynx is then dissected from its prevertebral attachments and the structures of the neck dissected away from the cervical vertebrae, making a conscious decision whether to include the carotid arteries. (In appropriate circumstances, leaving the external carotid arteries intact may be a consideration in relation to subsequent embalming.) The common and internal carotid arteries are then explored.

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There are various techniques which can now be used to remove and subsequently examine the internal organs. The three main variations are as follows:

(1) Examining the organs in situ and then dissecting them out one by one. This technique basically follows that elaborated and used by Rudolph Virchov in the 19th century.

This technique is rarely used today. However, it may still have some value in situations where only a limited autopsy is permitted by law. A further modification of this procedure involves the taking of biopsies of major body organs while they remain in situ. In the case of high-risk cases where transmission of infectious disease is a substantial hazard of the autopsy, such an approach may be reasonable. However, the biopsy autopsy allows for only a very small part of the body organs to be examined with a consequent severe reduction in the amount of information that can be obtained. (2) Removing groups of organs that are anatomically related to each body cavity and functionally related to specific body systems (ie, cardiovascular system–heart and great vessels; pulmonary system–lungs, trachea, larynx and diaphragm). These organ clusters or dissection blocks are removed together and dissected without disturbing their anatomical relationship. This technique is sometimes referred to as the modified Virchov procedure. The five principal groups of organs removed comprise:

(a) the central nervous system;

(b) the small and large intestines together with the mesentery;

(c) the contents of the thorax and neck including the tongue, larynx, trachea, oesophagus, heart, thoracic aorta and lungs;

(d) the stomach, duodenum, liver, biliary apparatus, pancreas and spleen; and (e) the kidneys, ureters, bladder, rectum and internal genitalia.

The modified Virchov technique is widely used by pathologists today. It is more commonly used in hospital autopsy practice but is equally applicable to forensic case work. Its principal advantage is that it allows the pathologist to examine more of the internal organs while they are still in the body and so still retain their attachments to the walls of the body cavities. Upon opening the chest and abdominal cavities, the small bowel (jejunum and ileum) and large bowel, excluding the rectum, is removed, allowing greater exposure of the remaining abdominal organs in situ within the abdominal cavity. This permits direct visualisation of the relationship of any penetrating injury to the skin of the abdomen with injuries to the internal organs, evidence which may be lost if all the internal organs are removed en masse.

The next step involves dissection of the front of the neck, as described above. The tongue is released from the floor of the mouth and brought down through the underside of the lower jaw (mandible). The soft palate is separated from the hard palate and all of the soft tissues of the anterior and lateral compartments of the neck, including the oropharynx and larynx, are dissected free from the cervical spinal column. Next the lungs are reflected forwards allowing the posterior chest wall and the diaphragm to be examined in relation to any disease or injury to the heart, mediastinum and lungs. At this point the oesophagus may be tied off to prevent loss of gastric contents, the lower thoracic aorta and oesophagus and inferior vena cava transected and the neck tissues and chest cavity contents removed.

To remove the remainder of the abdominal contents, the bowel mesentary is then dissected from the anterior wall of the aorta up to the level of the coeliac axis. The spleen, pancreas and liver are then mobilised and removed as one block with the mesentary and stomach, leaving the diaphragm intact in the body.

Finally the kidneys are reflected medially from each side and the pelvic peritoneum is freed from the pelvic wall and the iliac arteries and veins, urethra, rectum (and vagina or prostate) cut so as to enable removal of the entire pelvic contents in continuity with the aorta, bladder, ureters and kidneys. In cases of suspected genital injury, the external genitalia, anus and

perineum may be removed in continuity with this block using a modified version of the surgical procedure of abdomino-perineal resection. With removal of the five organ blocks, dissection of each can take place in a similar manner to the third technique described below.

(3) Removal of the contents of the neck, the thorax and the abdomen together with the aorta and diaphragm, in one large mass in a technique that has been attributed to Rokitansky and later to Leutille. The technique is commonly employed in forensic autopsies.

Mobilisation of the neck structures is followed by the freeing of the diaphragm from its attachments. The pelvic organs can be manually separated as a whole from their bony attachments and then incised at the pelvic floor. Then, preferably with assistance, the organs can be removed as a whole by finally incising the attachments to the vertebral column. The bulk of the “pluck” can be reduced substantially by removing the small and large bowel first. This is simply done by cutting through the proximal jejunum (taking care to secure both incised ends of the jejunum if the contents are important for toxicological or microbiological analysis) and freeing it, the ileum and colon by cutting the root of the mesentary or preferable the mesentary adjacent to the bowel wall. The tissue mass is routinely dissected beginning posteriorly and working forwards. This technique preserves the relationships of organs enabling the whole length of the aorta and oesophagus, stomach and intestines to be examined intact and in relation to the surrounding organs.

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In general, whatever the method used, it must be systematic and planned. All organs must be weighed in grams and the weights must be recorded. Abnormalities in the orientation and relationship of the various organs to their neighbours should be noted. In recording findings, accurate descriptions should be made of what is actually seen rather than interpretations or assumptions made about the lesion or abnormality. Before completing the autopsy, the prosector must ensure that all necessary specimens for laboratory and toxicological analysis, as well as all photographs and/or x-ray films which may be of assistance, have been taken. When there is doubt concerning the findings, whole organs should be retained for further study or for consultation with others.

The physical autopsy is not complete until the body of the deceased person has been restored to a state where the family as part of their funeral tradition can view it. The technical and scientific staff who are employed in assisting in this task are usually highly skilled and experienced. They are aware of the needs of the funeral industry and a number will also be qualified embalmers. In all cases the aim is to restore the outward appearance of the deceased to that visible before death. In deaths from severe trauma, specialised restorative techniques may be required to repair areas of the body damaged before the autopsy. Similarly, if large amounts of structurally significant tissue has been collected for investigation or for transplantation, such as the spinal column or the pelvis, more extensive restorative work will be required. In most cases relatively little restoration is required because the routine procedures employed in a standard autopsy are intrinsically non-disfiguring.

Reconstruction of the head and neck including the face are critical tasks which, because of the sensitivity given to facial injuries, must be carried out with utmost attention to detail. Given that a complete and thorough dissection of the face is not inconsistent with satisfactory reconstruction of a body after autopsy, there should be no reluctance on the part of the pathologist to carrying out such a dissection. When dissection of the face is limited to the soft tissues only, little alteration in facial outline should be expected. However, where the dissection involves not only the soft tissues but also the facial skeleton, then restoration of facial shape and form can be more difficult. In this situation it may be prudent for the

pathologist to obtain photographs of the body prior to autopsy and also photographs of the individual in life prior to cranio-facial injury and death.

In document UNIVERSIDAD DE EL SALVADOR FACULTAD DE INGENIERIA Y ARQUITECTURA ESCUELA DE INGENIERIA DE SISTEMAS INFORMÁTICOS (página 132-142)