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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 43-47

Soft-fixed embalming: Our experiences


1 Associate Professor, Department of Anatomy, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Assistant Professor, Department of Anatomy, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
3 Professor and Head, Department of Anatomy, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
4 Professor Emeritus, Department of Anatomy, Eras Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India
5 Assistant Professor, Department of Anatomy, Eras Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India

Date of Submission28-May-2020
Date of Decision31-Jul-2020
Date of Acceptance22-Aug-2020
Date of Web Publication10-Sep-2020

Correspondence Address:
Eti Sthapak
Department of Anatomy, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJCA.NJCA_2_20

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  Abstract 


Background: There is an increased need for surgical skills training which does not involve patients in the first exposure. Clinicians and surgeons prefer honing their psychomotor skills on cadavers. Standard formalin embalming, however, does not provide a very realistic model, so an alternative approach needs to be sorted out in the form of soft-fixed embalmed cadavers to provide realistic model for such procedures. Aim: This study aimed to evolve new methods of soft embalming, which provide better cadavers for surgical training. Objectives: (1) To provide long-term structural preservation of tissues, viscera, and body and prevent fungal and bacterial growth. (2) To explore the use of glutaraldehyde solution for arterial embalming. (3) To obtain cadavers with soft consistency of muscle and tendon and maintain joint mobility. (4) To provide lifelike quality of soft-fixed cadavers for cadaveric surgical workshops. Materials and Methods: Only those bodies which were received within 12 h of death were used for soft embalming. The solution for soft embalming contained glutaraldehyde, glycerin, methanol, cetrimide, and eosin for arterial and formalin solution for cavity embalming. The cadavers were embalmed and then preserved in a deep freezer (−70°C to −80°C) for at least 30 days. After that, the cadavers were preserved in an immersion tank which contained 10% formalin diluted in water. Results: Soft-fixed embalmed cadavers were better for all aspects of training. Soft-fixed cadavers exhibited a greater degree of flexibility and color retention compared to that of traditional formalin-fixed cadavers. The preference was particularly pronounced in aspects that require flexibility of tissues such as for flap raising. Conclusions: Soft-embalmed cadavers provide a more realistic model for training of surgical skills.

Keywords: Cadaver, embalming, glutaraldehyde, soft-fixed embalming


How to cite this article:
Pasricha N, Sthapak E, Bhatnagar R, Siddiqui M S, Jaiswal S. Soft-fixed embalming: Our experiences. Natl J Clin Anat 2020;9:43-7

How to cite this URL:
Pasricha N, Sthapak E, Bhatnagar R, Siddiqui M S, Jaiswal S. Soft-fixed embalming: Our experiences. Natl J Clin Anat [serial online] 2020 [cited 2020 Oct 27];9:43-7. Available from: http://www.njca.info/text.asp?2020/9/2/43/294746




  Introduction Top


The medical world is experiencing an explosion in the introduction of new surgical technologies and consequent expansion in the instrumentation that accompanies such procedures. Thus, clinicians require training and practice to achieve mastery of the new procedures. There is an increased need for surgical skills training which does not involve patients. Clinicians are increasingly collaborating with their colleagues in anatomy departments to perform and practice procedures on cadavers.[1],[2] In this scenario, cadaveric workshops enhance surgical and clinical skills by providing hands-on training.[3],[4] Thus, it is extremely important to fix and preserve cadavers properly to facilitate effective learning. Standard formalin embalming cadavers do not provide a very realistic model for skills training in cadaveric workshops. Keeping this in mind, we explored the options of soft-embalmed cadavers to provide better models for such procedures.[5],[6],[7] The soft-embalmed cadavers have many features of living body, particularly with regard to color, tissue consistency, and flexibility.[8]

The first of the new “soft-embalming” solutions was developed at Cambridge by Bari Logan and his team in 1985 – The Cantabrian solution.[9] This replaced much of the formalin solution with methanol, to retain the flexibility of the specimen. Thiel's soft-embalming solution was developed in 1992 by Prof Thiel at Graz Institute of Anatomy, Austria. Thiel solution-embalmed cadavers have been widely appraised and used for postgraduate hands-on workshops for several medical disciplines.[10] The other chemical solutions used for soft embalming are the Coleman and Kogan saturated salt solution (1998), the Larsen solution (2007), the modified Laskowsky solution (2007), the Al-Hayani Shellac mixture (2011), Goyri-o-neill embalming solution (2013), Hayashi saturated salt solution (2014), Gosomji saturated salt solution 2018, and the Natekar and De Souza glutaraldehyde solution (2014),[11],[12],[13],[14],[15],[16],[17] Natekar and De Souza observed that glutaraldehyde as the principal component of the embalming fluid was very effective in the preservation of cadavers for surgical dissections.[17] We used Natekar's method for soft embalming with our own modifications and observed that these cadavers were very useful for surgical demonstrations during cadaveric workshops and were well accepted by the surgeons for their flexibility and lifelike qualities. This inspired us to share our experiences on soft embalming, which can help others to prepare better cadavers for surgical training.

Aim

This study aimed to evolve new methods of soft embalming which provide better cadavers for surgical training.

Objectives

  1. To provide long-term structural preservation of tissues, viscera, and body and prevent fungal and bacterial growth
  2. To explore the use of glutaraldehyde solution for arterial embalming
  3. To obtain cadavers with soft consistency of muscle and tendon and maintain joint mobility
  4. To provide lifelike quality of soft-fixed cadavers for cadaveric surgical workshops.



  Materials and Methods Top


Ten cadavers were embalmed by using our modification of Natekar's method of soft-embalming technique for orthopedic and plastic surgery workshops beginning from September 2014. The bodies obtained within 12 h after death were preserved in a cooling cabinet which maintained 2°C–4°C temperature.

Exclusion criteria

Bodies received >12 h after death, with burns or trauma, decomposed bodies, and extremely obese bodies.

Inclusion criteria

Bodies received within 12 h of death, without burn or trauma.

Procedure

The bodies were transferred on the embalming table and disinfected with topical disinfectant solution. The surface disinfectant was allowed to remain on the bodies for 15–30 min. After topical disinfection, the bodies were washed with water and soap.

Arterial embalming

A 2–3 cm incision was made in the femoral triangle, and the femoral artery was cannulated. The cannula was connected to the container kept 3–4 feet above the body for embalming by gravity method and was left in place overnight to inject approximately 6–10 L of arterial fluid [glutaraldehyde solution as shown in [Figure 1] and [Table 1]. In the gravity method, “A rise of one foot gives a fluid pressure of approximately one-half (0.43) pound.”[18] The average temperature in our region ranged from 15.9°C to 34°C through the year, with the average temperature being 25.7°C, with precipitation ranging from 2 to 305 mm in the monsoon season. Apart from this, around 2–3 L of arterial fluid (glutaraldehyde solution) was also injected near the joints.
Figure 1: Chemicals used for arterial embalming

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Table 1: Chemical composition of arterial and cavity fluids

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Cavity embalming

Cavity embalming was performed after arterial embalming. In the body cavities (abdomen, thorax, and cranium), approximately 4–5 L formalin solution [Table 1] was given.

Thereafter, the bodies were kept in a deep freezer at −70°C to −80°C for at least 30 days. After that, the cadavers were preserved in an immersion tank which contained 10% formalin diluted in water.

Our modifications (not mentioned in Natekar's method) to ensure proper fixation of bodies were as follows:

  1. Cavity embalming along with arterial embalming
  2. Glutaraldehyde solution was given near the joints by injection
  3. The bodies were kept in a deep freezer (period ranging from 15 to 30 days to obtain complete fixation with glutaraldehyde) after embalming because glutaraldehyde delivers more end point permanent fixation but penetrates and diffuses the tissue slowly
  4. After complete fixation and embalming was obtained with glutaraldehyde, the bodies were shifted to the immersion tank with formalin 10%.



  Observation and Results Top


Soft-fixed cadavers exhibited a greater degree of flexibility and color retention compared to that of traditional formalin-fixed cadavers. It was observed that the cadavers were very supple, showed lifelike appearance, with no rigidity and hardness. These soft-fixed cadavers were successfully used in cadaveric surgery workshops. The skin elasticity was retained with lifelike flexibility of all joints including metacarpophalangeal and interphalangeal joints [Figure 2] and [Figure 3]. No fungal growth or pungent smell was observed. The same cadavers were used multiple times over a period of >5 years without need for defrosting or refreezing.
Figure 2: Photograph of soft-embalmed cadaver showing elasticity of skin

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Figure 3: Photograph of a soft-embalmed cadaver showing flexibility of different joints

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Even though we have a limited experience of only ten cadavers, the surgeons who worked on the soft-fixed cadavers were very satisfied with the quality for all aspects of training [Figure 4]. The preference was particularly pronounced in aspects that required flexibility of tissues such as flap raising and joint dissections during orthopedic surgeries. Even 5 years after the cadavers were soft fixed, their skin elasticity and joint flexibility are still maintained.
Figure 4: Photograph of a soft-embalmed cadaver being used in a plastic surgery workshop

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  Discussion Top


Cadaveric preservation can be categorized broadly by three different methods.[19] The first method is conventional embalming in which formalin is used as a preservative agent.[18] Cadavers preserved by this method are mainly used in gross anatomy teaching for undergraduate and postgraduate students. The advantages of the conventional preservation include low cost, long usage duration, and that the cadaver can be conveniently kept in room temperature. The significant disadvantages of this method include joint stiffness and tissue rigidity.[19] To reduce this problem, fresh frozen cadavers are used. For obtaining such cadavers, they are immediately kept in a deep freezer at −20°C to 40°C. The advantages of these cadavers include that their tissue consistency and range of motion of joints are similar to the living beings.[20],[21] The disadvantages of these cadavers include that they can be used in a short duration only and there is a concern of microbial contamination and bio-safety issues. To overcome these problems, “soft cadaveric preservation” was introduced using the Thiel's method. In the Thiel's method, the tissues of cadaver are maintained in a soft, lifelike quality and joints can move freely. The main disadvantages include very high cost per cadaver preparation and a long time interval between fluid infusion and complete preservation.[22],[23]

The “soft cadavers,” better called “live dead,” provide better dissection and learning of clinical and surgical skills and technologies, thus preventing unnecessary iatrogenic harm to patients during learning of these procedures. The soft-embalmed cadavers should ideally have no detectable odor; a lifelike flexibility of body parts; excellent color preservation of muscles, viscera, and vasculature; superior antimicrobial preservation properties; the joints should remain freely movable; and the peritoneal cavity should be inflated for laparoscopic procedures.[13],[24] To fulfill these objectives, various methods of embalming and embalming fluid have evolved,[25],[26] which have their own advantages and disadvantages.

Glutaraldehyde was first successfully synthesized by Harries and Tank in 1908.[12] Interest in glutaraldehyde peaked in the early 1960s, when several investigations found it to have outstanding disinfection and sterilization capabilities. It has two functional aldehyde groups which are capable of reacting with protein over a wider pH range than other aldehydes and has relatively low volatility, less odor, and low toxicity. The European Commission in 2010 banned the use of glutaraldehyde, but research proves that it is less toxic and less carcinogenic, it is a lesser irritant, and it has lower overall exposure impact during embalming operations than formaldehyde.[27] In our experience too, the smell and irritant effects of formalin were experienced to a lesser degree with these soft-fixed cadavers.

Glutaraldehyde in contrast to formaldehyde is a slow diffuser but delivers a rapid and irreversible final reaction with proteins. Therefore, glutaraldehyde delivers more end point permanent fixation but perfuses the tissue slowly, whereas formaldehyde perfuses the tissue rapidly but only forms irreversible fixation.[12],[27] This forms the basis of our modification [comparisons elucidated in [Table 2]. We reasoned that because glutaraldehyde perfuses slowly, after glutaraldehyde arterial injection, we deep froze the body for a month to allow for proper fixation while allowing for lesser chances of putrefaction in lower degree of temperature. A modification over the Natekar's method we did was to not keep the body immediately in formalin solution. We reasoned that to allow for effective soft-embalmed body, it should not be kept in formalin immediately after arterial embalming as formalin is a rapid fixator. We did not prolong the time in the deep freezer beyond 1 month once sufficient fixation was obtained as there were financial issues involved in retaining the deep freezer for more than a month's time. In addition, once fixation was obtained with glutaraldehyde embalming and deep freezing for a month or so, even after keeping it in formalin, the skin elasticity and joint flexibility of the bodies were well preserved. The only issue was that the color of the skin was not maintained very well after immersion in the formalin tank. This procedure presents a number of significant advantages over the traditional methods of embalming. By soft-fixing cadavers using glutaraldehyde solution, our cadavers exhibited a greater degree of flexibility compared to that of formalin-fixed cadavers. Because of more lifelike texture and color of structures, dissections are of high quality, improving learning in dissection laboratory. Appreciating the action of muscles at joints especially in the extremities was facilitated by the flexibility of cadavers.
Table 2: Comparison with the Theil's and Natekar's methods

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Limitations

The small sample size and our inability to note histological changes are the shortcomings of this study.


  Conclusions Top


We experienced that cadavers embalmed by glutaraldehyde had sufficient antimicrobial protection, their joints remained flexible, and their soft-tissue quality was acceptable for cadaveric surgical workshops. With our technique, in contrast to other known methods of soft embalming, after the initial preservation, there was no need for costly deep freeze maintenance. The soft-embalmed cadavers thus obtained provided a more realistic model for training of surgical skills.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.[28]



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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