Development of a new skin incision for conduct of conventional autopsy

The conventional autopsy (a scientific tool to investigate the cause of death) remains “the gold standard” for advancement of medical knowledge (Burton and Underwood 2007). But its method is associated with many misconceptions and myths (Byard and Khong 1997). This has led to a drastic fall in the rate of pathological or clinical autopsies throughout the world. The most common reasons for refusal to give informed consent for autopsy include the fear of mutilation of the dead body, religious beliefs, and concerns about delays in funeral and removal of organs or body parts (Oluwasola et al. 2009).

The skin incision is an integral part of autopsy process to open the body. The reconstitution of the dead body produces visible defect (disfigurement) that becomes more pronounced with the use of additional confirmatory or releasing incisions.

An extensive search on PubMed reveals paucity of data on methods of skin incision for autopsy. Over the years, a few types (mainly three) of incisions are being recognized in forensic science.

The current study is aimed at the development of a new skin incision for autopsy (hereafter referred as “universal skin incision”) for conduct of conventional autopsy. The idea is to minimize apparent disfigurement of dead body, reduce time consumption, and obviate the need of additional confirmatory or releasing incisions.

The results were evaluated using empirical evidence in terms of length of skin incision, need for additional releasing or confirmatory incisions, operational area for assessment, visibility of reconstituted skin incision on the front aspect of the dead body, spillage of body fluids, and time for suturing skin incision with regard to the conventional incisions, i.e., I, Y, modified Y, and fourth incision. It was observed that the length of incision of our suggested incision on the front aspect of the dead body for anterior approach is less (equal to the length of the torso) than that of the fourth incision. The conventional incisions (I, Y, and modified Y) are shorter in length by width of the torso across inguinal ligaments. There is no need of additional incisions over the front and back of the neck along with the torso while adopting our suggested incision or fourth incision as compared to the autopsy conducted through conventional incisions. With the use of our suggested incision and fourth incision, the operational area for assessment of the neck and torso is about 100% without giving extra incisions, as is invariably required while performing autopsy through conventional incisions. After suturing, our suggested incision and fourth incision are not visible from direct front view of the neck and torso except at the right shoulder and inguinal region whereas sutured conventional incisions are visible on the front surface of the dead body. After reconstituting the dead body, spillage of fluids from the chest and abdominal cavities is almost nil while conducting autopsy with our suggested incision and fourth incision which is a common problem with conventional incisions. Time taken to suture is less in our suggested incision as compared to fourth incision, because of its shorter course, and the need of suturing the abdominal muscle flap is not required.

The widely practiced conventional methods for skin incision to be made during autopsy process have been discussed in books devoted to forensic pathology. But while adopting one of the conventional methods of skin incision, separate incisions are invariably required for the assessment of soft tissue injury on the back and to open the spinal canal during autopsy. Further additional confirmatory (for differentiating bruise from hypostasis) or releasing incisions are required for complete exposure of the front of the neck (i.e., along the inferior border of the lower jaw and over the collar bones) and pelvic cavity (i.e., along the course of inguinal ligaments). On reconstitution of the dead body, sutured conventional incision on the front aspect of the body along with additional incisions leads to the visible artifacts over the skin surface, i.e., apparent disfigurement (mutilation) of the dead body. Therefore, these incisions are cosmetically ineffective and scare the legal heirs of the dead body.

Our proposed method for skin incision provides complete exposure of the whole circumference of the neck, thorax, and abdomen with single incision line; thereby, the operational area for autopsy assessment is almost 100%. This aspect of our incision method is in corroboration with the use of fourth incision (Patowary 2010).

On reconstitution of the dead body after autopsy with any of conventional skin incisions, there is seepage of extravasated body fluids which leads to inconvenience during transportation to the attendants of the deceased. Adoption of the fourth incision method decreases the chance of seepage to almost nil as the abdominal cavity is closed first by stitching the rectus and then the flap of skin is replaced back covering it completely (Patowary 2010).

In our method of skin incision, seepage is nil too. However, there is no need to stitch the muscular flap of the anterior abdominal wall due to double breast advantage as the free end of the muscular flap is reflected back opposite to the line of skin closure.

In conventional methods, stitches made on the body for closing are seen on the front aspect of the body whereas in consonance with the fourth incision in our method too, the stitches except in the front of the shoulder and inguinal region are not apparent from the front or back view of the dead body.

The fourth incision consumes time, 10 min more for opening the body and 15 min more for closing, than in “I-shaped incision” (Patowary 2010).

In contrast, our method of skin incision is shorter in length that is equal to the length of the torso of the deceased as compared to fourth incision, and further, there is no need to stitch the muscular flap separately. Thereby, the extra time taken by fourth incision is almost curtailed by our method.

The current work presents a simple procedure of skin incision for the assessment of the neck, the front as well as back of the chest, and the abdomen and discusses its advantages on the basis of existing methodologies. The technique preserves the whole flap on the front and back of the neck, chest, and abdomen, and it does not interfere with the rest of the autopsy procedure. After dissection, reassessment of the wound tract in stab and firearm injury is easier and is convenient for surgical death cases too, as the proposed skin incision is not interfering with iatrogenic surgical incisions.

Our method is friendly for autopsy surgeons and legal heirs, as it is cosmetically effective and advocates single incision. Its routine application is both feasible and useful for autopsy on female corpse, cases of death due to custodial torture, trauma on back, surgical death cases, or fatal pressure over the neck. However, any new scientific method needs its unbiased validation of its procedure and outcome in light of the different aspects of doers and beneficiaries.

The sutured conventional skin incision on the front of the body along with sutured additional incisions leads to apparent disfigurement of the corpse. Though a new cosmetically effective fourth incision is advocated, it is time consuming. Our method of skin incision is time friendly as well as cosmetically effective and provides 100% operational area for autopsy surgeon to assess the head, neck, chest, and abdomen with single incision. To prove our new method of skin incision as a universal one, its validation in terms of different surgical (autopsy surgeons) and observer’s (legal heirs of the dead body) components is required to remove any bias regarding its noticed advantages.