This document describes a study comparing laparoscopic autopsy to needle biopsy and open autopsy. Laparoscopic autopsy was found to have a higher consent rate of 25% compared to needle biopsy. It had a sensitivity of 73% in determining cause of death, compared to 67% for needle biopsy. Laparoscopic autopsy allowed examination of abdominal and thoracic organs in a minimally invasive manner. Several additional diagnoses were made with laparoscopic autopsy that were missed by needle biopsy. The document concludes that laparoscopic autopsy is an effective technique for determining cause of death and has educational benefits for surgical trainees.

1. Laparoscopic Autopsy
George Ferzli MD, FACS
Professor of Surgery
SUNY Health Science Center at Brooklyn

2. Introduction
q Autopsies were performed on more than ½ of
American corpses
q Nowadays, only 10% of U.S. corpses are
autopsied and mostly for cases where foul
play is suspected
q Families want to leave their loved one alone
q Doctors don’t encourage it because they do
not want to be second-guessed

3. Introduction
q Funeral directors like to have the body within
four hours of their passing
q 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. Introduction
q Sophistication of available tests leaves
little doubt as to the cause of death
q However, a federal report showed that
autopsies overturned the official cause
of death in 23% of cases in 2000

5. Introduction
q Autopsy consent fell from 15% to 7%
over 10 years
q 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. Needle Biopsy Autopsy
q Less invasive and disfiguring
q Potentially safer for pathologists
q Rapid
q Insensitive (67% sensitivity in
determining the cause of death)

7. Laparoscopic Autopsy
q 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. Equipment
q System dedicated to autopsies
q Re-usable instruments and trocars
q 0 degree / 10 mm scope
q Camera
q Monitor
q Insufflator
q Video recorder

9. Protocol
q Chart review
q External examination
q Needle biopsy
q Abdominal + retroperitoneal
laparoscopy + thoracoscopy
– endoscopic exam tailored to expected
findings based on chart review
q Open autopsy when consent is granted

10. Technique
q Laparoscopic and thoracoscopic
approach
q Veress needle insufflation
– 30 mm Hg pressure to overcome
abdominal rigidity
q Five 10 mm ports to access the
abdomen
q Three 10 mm ports to access the thorax
q All cases were performed on the
autopsy table in the supine position

11. Trocar sites

12. Technique
Abdomen
q Retroperitoneal organs examined first
– adrenal glands
– kidneys
– pancreas
– aorta
– vena cava
q Solid organs examined next
q Hollow organs examined last

13. Trocar sites

14. Technique
Thorax
q Examine the entire thorax from the left
side
q Left pulmonary artery opened
– pulmonary angioscopy performed with the
laparoscope
q Left lung examined
q Pericardium opened
q Cardiectomy if necessary
q Right lung examined transmediastinally

15. Organs Obtained
q Kidneys q Lungs
q Adrenal glands q Pericardium
q Pancreas q Heart
q Spleen
q Liver & Gall bladder
q GI tract
q Uterus & Ovaries
q Bladder

16. Data
q 58 cases were performed over a two
year period
q 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 autopsy
q Needle autopsy performed in all cases

17. Data
q 19 patients with prior surgery
– exposure limited in only four
q Complete agreement in cause of death
when compared to full autopsy
q Needle autopsy arrived at cause of
death 73% of cases

18. Causes of Death
q 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. Additional diagnoses
q Cirrhosis and SBP (1)
q Cirrhosis with multi-organ failure (1)
q Uterine fibroids (6)
q Diverticulosis (6)
q Liver metastases
q Adrenal metastasis (1)
q Colon polyps (5)

20. Missed diagnoses
q Liver hemangioma (1)
q Colon polyps (5)
q Pulmonary embolus (1)

21. Bowel infarct

22. Calcified aortic valve

23. Cirrhosis

24. Hemopericardium

25. Benefits to Surgical Trainees
q Improving basic technical skills
q Demonstrating “laparoscopic anatomy”
q Allows for planning advanced
procedures
– vascular
– colorectal
q Subspecialist attendance

26. Conclusions
q 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. Surgical programs everywhere
should strongly consider
laparoscopic autopsies as part of
their curriculum.