INDIVIDUAL ORGAN REMOVAL
In this procedure, the individual organs are removed sequentially and dissected immediately after removal. This technique is effective for normal or diffusely diseased organs but has disadvantages, as relationships between organs are lost due destructive nature of evisceration. This method has been developed over the years to avoid adverse situations while inspecting organs in situ.
The procedure begins with examination through the peritoneal, pleural, and then pericardial cavities, which are cut, opened and inspected, with the organs separated and removed from those areas.
First, the abdominal wall is inspected, and then the cavity and finally the fluid is removed, measured and documented. The abdominal organs are inspected and palpated before being dissected and removed. It is suggested that gastrointestinal tract starting from appendix is inspected first, along with mesenteric lymph nodes. Next spleen, liver, kidneys and finally pelvic organs are examined. The pancreas can be examined by separating attachment of greater omentum between stomach and transverse colon.
The thoracic cavity is examined after removing the sternal plate. At first, the pleural cavities are inspected thoroughly and any collection, if present, measured. If chest wall is adherent with fibrous band it should be documented before being separated by blunt dissection.
The anterior mediastinal soft tissue is examined next. In adults, thymus is atrophic and any gross pathological changes needs to be documented. Pericardium is inspected before being cut open. Any collection of fluid, blood or clots from the pericardial sac is collected and measured.
After examination of all cavities and collection of blood for further investigation, as required, the heart is removed by lifting the apex and severing from attached large vessels namely, inferior vena cava, superior vena cava, pulmonary veins, pulmonary arteries and finally aorta. The heart is freed for further detail examination.
If pulmonary thromboembolism is suspected, the pulmonary artery should be dissected initially, by cutting with scissors just above the origin from right ventricle.
Next, the lungs are freed from hilar attachments by lifting forward and outward, out of pleural cavity, holding the root by the non-cutting hand and cut is made through primary bronchus, vessels and pleura.
Neck structure can be dissected in situ or can be removed similar to en-bloc evisceration. The soft tissue over the neck attachments are dissected and freed from the lateral and posterior aspects of the upper esophagus and trachea. During in situ dissection, the posterior wall of the pharynx is dissected, next to the uvula, to examine pharynx. The tonsils are incised and esophagus is cut open from the posterior wall of trachea to inspect mucosal surface of trachea as well as esophagus. The Thyroid gland can be dissected by giving longitudinal incisions over the lateral aspects of thyroid gland.
Before dissection of individual organs from abdominal cavity, all organs are inspected in situ, removed and all collections measured. Presence of diffuse adhesions of peritoneal structures makes it better to eviscerate en-bloc.
The order of removal of abdominal organs depends on the pathological condition and preference of dissector. It is more convenient to remove normal organ first and leave pathological organs, which may require careful dissection. As a routine, spleen is removed first, and then followed by gastrointestinal tract, liver, pancreas, kidneys and adrenal glands with ureters. Finally, the aorta is dissected in situ.
Spleen is removed by gentle manipulation to avoid tearing of its capsule. It is lifted from the abdominal cavity and cut from its hilar structures.
The gastrointestinal tract is inspected from the stomach to the rectum, including the mesentery and lymph node. The gastro-intestinal tract should be dissected after complete separation from abdominal cavity and cut open in a sink. First, the duodenum is mobilized around second to third part and cut with scissors. The flow of bile through Ampulla of Vater is assessed by squeezing the gall bladder. Once the free flow of bile has been established, gastrointestinal tract starting from sigmoid colon is removed. The colon is pulled forward so that the mesocolon can be released from its attachment. The sigmoid colon is then pulled medially and mesentery incised. This incision is extended inferiorly as far as possible to reach the rectum before moving proximal. Care must be taken at splenic flexure if the spleen has not been removed. The transverse colon is detached from the stomach by tearing its attachment to the hepatic flexure, ascending colon, caecum and around the appendix. From Terminal ileum, a cut is made through the mesentery, close to the small bowel and extended proximally to reach the duodenum. Once the entire intestinal tract has been freed, the rectum is released by cutting as low as possible, after massaging all of the intestinal contents back into the sigmoid.
To remove the liver, hepatic hilar structures are divided, by stretching the hepatoduodenal ligament. The hepatic artery, followed by the common bile duct and portal vein are cut. The distal portion of esophagus is ligated to prevent spillage of stomach contents, and transected to mobilize the liver. Next, the liver is pushed forward by passing the left hand between the right lobe of the liver and the diaphragm. The liver is grasped by placing the thumb under the lower anterior border and insert the remaining fingers into the long incision for grip. The liver is lifted and released after cutting hepatoduodenal ligament. Hepatogastric ligament, inferior vena cava, falciform ligament, coronary ligaments, soft tissue between the liver and right kidney, avoiding any damages to adrenal glands. Liver is removed from the abdominal cavity and dissected.
The pancreas is dissected from its attachment by lifting the stomach and cutting all the soft tissue around the pancreas. Stomach along with a portion of duodenum is removed by cutting proximal to the ligation over the esophagus.
Now only the genitourinary tract and large abdominal vessels are left in the abdominal cavity. The kidneys and adrenal glands may be removed together or separately. Kidneys and adrenal glands are located by palpation, then with use of forceps and scissors adrenal gland is separated from the upper pole of kidney. Peri-renal fat is removed from by blunt dissection. Then the kidneys are lifted anteriorly to expose the ureters, which are cut along their course to the bladder.
The thoracic aorta is cut in situ, along its ventral surface into the iliac arteries. Renal arteries are cut open on both sides from the aorta.
The Virchow (individual organ) technique is summarized as
- Inspect the abdominal and pleural cavities.
- Open the pericardium and remove the heart. Remove the left and then the right lungs. Assess the pharynx, esophagus, trachea, parathyroid glands, and thyroid gland.
- Remove the spleen. Assess biliary tract patency. Remove the intestines. Open the stomach. Remove the liver. Remove the pancreas. Shell out the left and right kidneys and adrenal glands. Trace the ureters.
- Dissect the pelvic structures.
- Inspect and open the large arteries and veins.