Virchows Archiv

, Volume 474, Issue 2, pp 149–158 | Cite as

Implementation of modern tools in autopsy practice—the way towards contemporary postmortal diagnostics

  • Rupert LangerEmail author
  • Alexandra Tröhler
  • Beat Schnüriger
  • Mafalda Trippel
  • Annika Blank
  • Yara Banz
  • Daniel Candinas
  • Aurel Perren
  • Alessandro Lugli
Original Article


Medical, legal, and socioeconomic issues have contributed to the decline of autopsy rates. Pathology-related factors, however, with changing clinical duties on the one hand and decreasing interest and lack of substantial technical developments in this field on the other, may have contributed to this condition as well. We present our experience of a restructuring project that culminated in the introduction of a modernized postmortal diagnostic (PMD) unit: Workflows of PMD procedures and space organization were restructured according to LEAN management principles method. Classical autopsy suites were transformed into postmortal operating rooms. A PMD pathologist staff was designated to perform postmortal operative diagnostics (i.e., using laparotomy and thoracotomy approaches) with the intention of gradually replacing classical autopsy procedures. Postmortal minimal invasive diagnostics (PMID) using laparoscopy and thoracoscopy were successfully implemented with the expertise of clinical colleagues. Reorganization of workflow reduced turn-around times for PMD reports from a median of 33 days to 15 days. Short-term analysis revealed that this combined effort leads to a slight increase in the number of adult postmortal examinations 1 year after the introduction of this project. A change of culture in postmortal diagnostics may contribute to a better reputation of postmortal examinations from the perspective of clinicians, the general public, and affected relatives of the deceased. It may also serve to demonstrate that the pathology community is keen not only to preserve but also to further develop this valuable tool for medical quality control and education.


Autopsy Postmortal diagnostics Minimally invasive LEAN management 



The authors greatly appreciate the enthusiastic contribution of the autopsy assistants Patrycja Imiela, Sascha Häusler, and René Vögtli and our residents (Viktor H. Koelzer, MD, Gregor Rieger, MD, Bastian Dislich, MD, Monique Niklaus, MD, Claudia Jaccard, MD, and Ronan Gabriel, MD) to this project. We also thank Mrs. Carolin Hammer for her tremendous support during the implementation of the LEAN measurements.


RL and AL conceived and designed the study, and wrote, edited, and reviewed the manuscript. AT and BS researched and analyzed data, and wrote, edited, and reviewed the manuscript. MT, AB, YB, DC, and AP analyzed data, and edited and reviewed the manuscript. All authors gave final approval for publication. RL takes full responsibility for the work as a whole, including the study design, access to data, and the decision to submit and publish the manuscript.

Compliance with ethical standards

The project was approved by the Ethics Committee of the canton of Bern (KEK 236/15).

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    van den Tweel JG, Wittekind C (2016) The medical autopsy as quality assurance tool in clinical medicine: dreams and realities. Virchows Arch 468:75–81CrossRefGoogle Scholar
  2. 2.
    Burton JL, Underwood J (2007) Clinical, educational, and epidemiological value of autopsy. Lancet 369:1471–1480CrossRefGoogle Scholar
  3. 3.
    Turnbull A, Osborn M, Nicholas N (2015) Hospital autopsy: endangered or extinct? J Clin Pathol 68:601–604CrossRefGoogle Scholar
  4. 4.
    Blokker BM, Weustink AC, Hunink MGM, Oosterhuis JW (2017) Autopsy rates in the Netherlands: 35 years of decline. PLoS One 12:e0178200CrossRefGoogle Scholar
  5. 5.
    Chariot P, Witt K, Pautot V, Porcher R, Thomas G, Zafrani ES, Lemaire F (2000) Declining autopsy rate in a French hospital. Arch Pathol Lab Med 124:739–745Google Scholar
  6. 6.
    Erlmeier F, Weichert W, Knüchel R, Andruszkow J (2017) Erwachsenenobduktionen im letzten Jahrzehnt in Deutschland. Pathologe 38:430–437CrossRefGoogle Scholar
  7. 7.
    Rodewald A-K, Bode P, Cathomas G, Moch H (2017) Klinische Obduktionen in der Schweiz. Pathologe 38:416–421CrossRefGoogle Scholar
  8. 8.
    Liker J (2004) The Toyota Way [Electronic Resource]: 14 Management principles from the world’s greatest manufacturer. McGraw-Hill Education Ltd., New YorkGoogle Scholar
  9. 9.
    Knowles S, Barnes I (2013) Lean laboratories: laboratory medicine needs to learn from other industries how to deliver more for less. J Clin Pathol 66:635–637CrossRefGoogle Scholar
  10. 10.
    Womack JP, Jones DT (2015) Lean solutions: how companies and customers can create value and wealth together. Free Press, New York (reprint)Google Scholar
  11. 11.
    Cankovic M, Varney RC, Whiteley L, Brown R, D'Angelo R, Chitale D, Zarbo RJ (2009) The Henry ford production system: LEAN process redesign improves Service in the Molecular Diagnostic Laboratory. J Mol Diagn 11:390–399CrossRefGoogle Scholar
  12. 12.
    Hewer E, Hammer C, Fricke-Vetsch D, Baumann C, Perren A, Schmitt AM (2018) Implementation of a ‘lean’ cytopathology service: towards routine same-day reporting. J Clin Pathol 71:395–401CrossRefGoogle Scholar
  13. 13.
    Blank A, Dawson H, Hammer C, Perren A, Lugli A (2017) Lean-management im Pathologielabor. Pathologe 38:540–544CrossRefGoogle Scholar
  14. 14.
    Rubin M, Hirano H (1996) 5S for operators: 5 pillars of the visual workplace. Productivity, PortlandGoogle Scholar
  15. 15.
    Virchow RLK (1880) A description and explanation of the method of performing post-mortem examinations in the dead-house of the Berlin Charité hospital, with especial reference to medico-legal practice, from the Charité-Annalen [tr. by TP Smith]Google Scholar
  16. 16.
    Ayoub T, Chow J (2008) The conventional autopsy in modern medicine. J R Soc Med 101:177–181CrossRefGoogle Scholar
  17. 17.
    Sonderegger-lseli K, Burger S, Muntwyler J, Salomon F (2000) Diagnostic errors in three medical eras: a necropsy study. Lancet 355:2027–2031CrossRefGoogle Scholar
  18. 18.
    Bieri U, Moch H, Dehler S, Korol D, Rohrmann S (2015) Changes in autopsy rates among cancer patients and their impact on cancer statistics from a public health point of view: a longitudinal study from 1980 to 2010 with data from Cancer Registry Zurich. Virchows Arch 466:637–643CrossRefGoogle Scholar
  19. 19.
    Shojania KG, Burton EC, McDonald KM, Goldman L (2003) Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. JAMA 289:2849–2856CrossRefGoogle Scholar
  20. 20.
    Silfvast T, Takkunen O, Kolho E, Andersson LC, Rosenberg P (2003) Characteristics of discrepancies between clinical and autopsy diagnoses in the intensive care unit: a 5-year review. Int Care Med 29:321–324CrossRefGoogle Scholar
  21. 21.
    Thurnheer R, Hoess C, Doenecke C, Moll C, Muntwyler J, Krause M (2009) Diagnostic performance in a primary referral hospital assessed by autopsy: evolution over a ten-year period. Eur J Int Med 20:784–787CrossRefGoogle Scholar
  22. 22.
    Roulson J, Benbow EW, Hasleton PS (2005) Discrepancies between clinical and autopsy diagnosis and the value of post mortem histology; a meta-analysis and review. Histopathology 47:551–559CrossRefGoogle Scholar
  23. 23.
    Kuijpers CCHJ, Fronczek J, van de Goot FRW, Niessen HWM, van Diest PJ, Jiwa M (2014) The value of autopsies in the era of high-tech medicine: discrepant findings persist. J Clin Pathol 67:512–519CrossRefGoogle Scholar
  24. 24.
    Wittschieber D, Klauschen F, Kimmritz A-C, von Winterfeld M, Kamphues C, Scholman H-J, Erbersdobler A, Pfeiffer H, Denkert C, Dietel M, Weichert W, Budczies J, Stenzinger A (2012) Who is at risk for diagnostic discrepancies? Comparison of pre- and postmortal diagnoses in 1800 patients of 3 medical decades in east and West Berlin. PLoS One 7:e37460CrossRefGoogle Scholar
  25. 25.
    Connolly AJ, Finkbeiner WE, Ursell PC, Davis RL (2015) Autopsy pathology: a manual and atlas. Elsevier Health SciencesGoogle Scholar
  26. 26.
    Levy B (2015) Informatics and autopsy pathology. Surg Pathol Clin 8:159–174CrossRefGoogle Scholar
  27. 27.
    Raab SS, Grzybicki DM, Condel JL, Stewart WR, Turcsanyi BD, Mahood LK, Becich MJ (2008) Effect of Lean method implementation in the histopathology section of an anatomical pathology laboratory. J Clin Pathol 61:1193–1199CrossRefGoogle Scholar
  28. 28.
    Serrano L, Hegge P, Sato B, Richmond B, Stahnke L (2010) Using LEAN principles to improve quality, patient safety, and workflow in histology and anatomic pathology. Adv Anat Pathol 17:215–221CrossRefGoogle Scholar
  29. 29.
    Alshieban S, Al-Surimi K (2015) Reducing turnaround time of surgical pathology reports in pathology and laboratory medicine departments. BMJ Qual Improv Rep 4Google Scholar
  30. 30.
    Fryer EP, Traill ZC, Benamore RE, Roberts ISD (2013) High risk medicolegal autopsies: is a full postmortem examination necessary? J Clin Pathol 66:1–7CrossRefGoogle Scholar
  31. 31.
    Karat AS, Omar T, von Gottberg A, Tlali M, Chihota VN, Churchyard GJ, Fielding KL, Johnson S, Martinson NA, McCarthy K, Wolter N, Wong EB, Charalambous S, Grant AD (2016) Autopsy prevalence of tuberculosis and other potentially treatable infections among adults with advanced HIV enrolled in out-patient care in South Africa. PLoS One 11:e0166158CrossRefGoogle Scholar
  32. 32.
    Castillo P, Martínez MJ, Ussene E, Jordao D, Lovane L, Ismail MR, Carrilho C, Lorenzoni C, Fernandes F, Bene R, Palhares A, Ferreira L, Lacerda M, Mandomando I, Vila J, Hurtado JC, Munguambe K, Maixenchs M, Sanz A, Quintó L, Macete E, Alonso P, Bassat Q, Menéndez C, Ordi J (2016) Validity of a minimally invasive autopsy for cause of death determination in adults in Mozambique: an observational study. PLoS Med 13:e1002171CrossRefGoogle Scholar
  33. 33.
    Avrahami R, Watemberg S, Daniels-Philips E, Kahana T, Hiss J (1995) Endoscopic autopsy. Am J Forensic Med Pathol 16:147–150CrossRefGoogle Scholar
  34. 34.
    Avrahami R, Watemberg S, Hiss Y (1995) Thoracoscopy vs conventional autopsy of the thorax. A promising perspective. Arch Surg 130:956–958CrossRefGoogle Scholar
  35. 35.
    Avrahami R, Watemberg S, Hiss Y, Deutsch AA (1995) Laparoscopic vs conventional autopsy. A promising perspective. Arch Surg 130:407–409CrossRefGoogle Scholar
  36. 36.
    van der Linden A, Blokker BM, Kap M, Weustink AC, Riegman PHJ, Oosterhuis JW (2014) Post-mortem tissue biopsies obtained at minimally invasive autopsy: an RNA-quality analysis. PLoS One 9:e115675CrossRefGoogle Scholar
  37. 37.
    Breeze ACG, Jessop FA, Set PAK, Whitehead AL, Cross JJ, Lomas DJ, Hackett GA, Joubert I, Lees CC (2011) Minimally-invasive fetal autopsy using magnetic resonance imaging and percutaneous organ biopsies: clinical value and comparison to conventional autopsy. Ultrasound Obstet Gynecol 37:317–323CrossRefGoogle Scholar
  38. 38.
    Ernst LM (2015) A pathologist’s perspective on the perinatal autopsy. Semin Perinatol 39:55–63CrossRefGoogle Scholar
  39. 39.
    Sebire NJ, Weber MA, Thayyil S, Mushtaq I, Taylor A, Chitty LS (2012) Minimally invasive perinatal autopsies using magnetic resonance imaging and endoscopic postmortem examination (“keyhole autopsy”): feasibility and initial experience. J Matern Fetal Neonatal Med 25:513–518CrossRefGoogle Scholar
  40. 40.
    Menendez C, Castillo P, Martínez MJ, Jordao D, Lovane L, Ismail MR, Carrilho C, Lorenzoni C, Fernandes F, Nhampossa T, Hurtado JC, Navarro M, Casas I, Santos Ritchie P, Bandeira S, Mocumbi S, Jaze Z, Mabota F, Munguambe K, Maixenchs M, Sanz A, Mandomando I, Nadal A, Goncé A, Muñoz-Almagro C, Quintó L, Vila J, Macete E, Alonso P, Ordi J, Bassat Q (2017) Validity of a minimally invasive autopsy for cause of death determination in stillborn babies and neonates in Mozambique: an observational study. PLoS Med 14:e1002318CrossRefGoogle Scholar
  41. 41.
    Roberts ISD, Benamore RE, Benbow EW, Lee SH, Harris JN, Jackson A, Mallett S, Patankar T, Peebles C, Roobottom C, Traill ZC (2012) Post-mortem imaging as an alternative to autopsy in the diagnosis of adult deaths: a validation study. Lancet 379:136–142CrossRefGoogle Scholar
  42. 42.
    Sonnemans LJP, Kubat B, Prokop M, Klein WM (2018) Can virtual autopsy with postmortem CT improve clinical diagnosis of cause of death? A retrospective observational cohort study in a Dutch tertiary referral centre. BMJ Open 8:e018834CrossRefGoogle Scholar
  43. 43.
    Westphal SE, Apitzsch J, Penzkofer T, Mahnken AH, Knüchel R (2012) Virtual CT autopsy in clinical pathology: feasibility in clinical autopsies. Virchows Arch 461:211–219CrossRefGoogle Scholar
  44. 44.
    Westphal SE, Apitzsch JC, Penzkofer T, Kuhl CK, Mahnken AH, Knüchel R (2014) Contrast-enhanced postmortem computed tomography in clinical pathology: enhanced value of 20 clinical autopsies. Hum Pathol 45:1813–1823CrossRefGoogle Scholar
  45. 45.
    Murken DR, Ding M, Branstetter BF, Nichols L (2012) Autopsy as a quality control measure for radiology, and vice versa. Am J Roentgenol 199:394–401CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Institute of PathologyUniversity of BernBernSwitzerland
  2. 2.Department of Visceral Surgery and MedicineInselspital University Hospital BernBernSwitzerland

Personalised recommendations