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Laparoscopic Autopsy


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Laparoscopic Autopsy

  1. 1. Laparoscopic Autopsy George Ferzli MD, FACS Professor of SurgerySUNY Health Science Center at Brooklyn
  2. 2. Introductionq Autopsies were performed on more than ½ of American corpsesq Nowadays, only 10% of U.S. corpses are autopsied and mostly for cases where foul play is suspectedq Families want to leave their loved one aloneq Doctors don’t encourage it because they do not want to be second-guessed
  3. 3. Introductionq Funeral directors like to have the body within four hours of their passingq 80% of funeral directors had significant problems with embalming when conventional autopsy is performed a) carotid arteries cut too short b) scalpel penetration in visible areas c) crush injury to face and nose from reflection of flap across face
  4. 4. Introductionq Sophistication of available tests leaves little doubt as to the cause of deathq However, a federal report showed that autopsies overturned the official cause of death in 23% of cases in 2000
  5. 5. Introductionq Autopsy consent fell from 15% to 7% over 10 yearsq With the introduction of needle biopsy techniques, consent rose to 40%q We decided to compare needle biopsy vs. laparoscopic autopsy vs. open autopsy in determining the actual cause of death
  6. 6. Needle Biopsy Autopsyq Less invasive and disfiguringq Potentially safer for pathologistsq Rapidq Insensitive (67% sensitivity in determining the cause of death)
  7. 7. Laparoscopic Autopsyq Hypothesis – Laparoscopic autopsy will result in improved sensitivity in detecting cause of death compared to needle biopsy – Laparoscopic autopsy will result in improved autopsy consent rates – Laparoscopic autopsy will be a useful teaching exercise for fellows and residents
  8. 8. Equipmentq System dedicated to autopsiesq Re-usable instruments and trocarsq 0 degree / 10 mm scopeq Cameraq Monitorq Insufflatorq Video recorder
  9. 9. Protocolq Chart reviewq External examinationq Needle biopsyq Abdominal + retroperitoneal laparoscopy + thoracoscopy – endoscopic exam tailored to expected findings based on chart reviewq Open autopsy when consent is granted
  10. 10. Techniqueq Laparoscopic and thoracoscopic approachq Veress needle insufflation – 30 mm Hg pressure to overcome abdominal rigidityq Five 10 mm ports to access the abdomenq Three 10 mm ports to access the thoraxq All cases were performed on the autopsy table in the supine position
  11. 11. Trocar sites
  12. 12. Technique Abdomenq Retroperitoneal organs examined first – adrenal glands – kidneys – pancreas – aorta – vena cavaq Solid organs examined nextq Hollow organs examined last
  13. 13. Trocar sites
  14. 14. Technique Thoraxq Examine the entire thorax from the left sideq Left pulmonary artery opened – pulmonary angioscopy performed with the laparoscopeq Left lung examinedq Pericardium openedq Cardiectomy if necessaryq Right lung examined transmediastinally
  15. 15. Organs Obtainedq Kidneys q Lungsq Adrenal glands q Pericardiumq Pancreas q Heartq Spleenq Liver & Gall bladderq GI tractq Uterus & Ovariesq Bladder
  16. 16. Dataq 58 cases were performed over a two year periodq Autopsy consent rate 25%q Mean age 76.6 yr. (range 34 to 94 years)q Mean duration of laparoscopy 2.0 hr.q 20 patients subsequently underwent full autopsyq Needle autopsy performed in all cases
  17. 17. Dataq 19 patients with prior surgery – exposure limited in only fourq Complete agreement in cause of death when compared to full autopsyq Needle autopsy arrived at cause of death 73% of cases
  18. 18. Causes of Deathq Myocardial infarction (20)q Metastatic cancer (16)q Pneumonia (9)q Pulmonary embolus (1)q Intestinal infarction (2)q Intestinal perforation (2)q Esophageal variceal bleed (1)q Gangrenous cholecystitis (1)
  19. 19. Additional diagnosesq Cirrhosis and SBP (1)q Cirrhosis with multi-organ failure (1)q Uterine fibroids (6)q Diverticulosis (6)q Liver metastasesq Adrenal metastasis (1)q Colon polyps (5)
  20. 20. Missed diagnosesq Liver hemangioma (1)q Colon polyps (5)q Pulmonary embolus (1)
  21. 21. Bowel infarct
  22. 22. Calcified aortic valve
  23. 23. Cirrhosis
  24. 24. Hemopericardium
  25. 25. Benefits to Surgical Traineesq Improving basic technical skillsq Demonstrating “laparoscopic anatomy”q Allows for planning advanced procedures – vascular – colorectalq Subspecialist attendance
  26. 26. Conclusionsq Laparoscopic autopsy has contributed to improving our hospital’s autopsy rate.q Laparoscopic autopsy is acceptably sensitive to detect cause of death and incidental diseases.q Laparoscopic autopsy is a valuable teaching exercise for laparoscopic fellows and residents.
  27. 27. Surgical programs everywhereshould strongly considerlaparoscopic autopsies as part oftheir curriculum.