Step 1. Specimen Orientation
If the surgical pathology report is the end result of the dissection, specimen orientation might be regarded as a road map by which to reach that ultimate destination. With orientation, an other-wise confusing conglomerate of tissue is placed in its proper clinical and anatomic context and appreciated as a structural unit. Then a proper course of dissection can be chartered. Without orientation, specimen dissection can proceed speedily but may never reach its desired aims.
Orientation is usually thought of in terms of the structural anatomy of the specimen. While these anatomic considerations certainly are im-portant, a specimen must also be understood in terms of its clinical context. No specimen should be dissected in a ‘‘clinical vacuum’’; rather, a strategy for the dissection of any specimen should be directed by the clinical history. For example, a uterus removed for leiomyomas is handled very differently from one removed for cervical cancer. Fortunately, clinical orientation usually does not require a full review of the patient’s medical chart. Instead, a pertinent clinical history can often be succinctly communicated through a requisition form . The requisition form should accompany every surgical speci-men. It identifies the patient and the type of specimen, provides relevant clinical history, and alerts the prosector to specific biohazards. Referring physicians are responsible for provid-ing this clinical information. Sometimes the infor-mation on the requisition form may not be complete, or a case may be so complex that addi-tional clinical information is required. These situ-ations may necessitate a review of the medical chart, evaluation of imaging studies, and/or direct communication with the requesting clini-cian. Do not be shy or timid; if in doubt, call the clinician.
The anatomic orientation is best appreciated at the outset of the dissection while the specimen is still intact. The further the dissection progresses, the more difficult it can become to reconstruct and orient the specimen. Even when the specimen is entirely intact, orientation is not always a sim-ple task. Unlike the surgeon viewing the speci-men as it is situated in the patient, the prosector frequently cannot fully appreciate the anatomic context of the isolated specimen lying on the cut-ting table. Nonetheless, two steps can be taken to overcome this obstacle and confidently orient the specimen: appreciation of anatomic landmarks and communication with the surgeon.
Anatomic landmarks can be thought of as consistent features (a shape, a contour, a struc-ture, etc.) that serve to indicate a specific structure or designate a position. For example, the uterus can be correctly oriented by the relative posi-tions of its peritoneal reflections, and the orienta-tion of the eye may be guided by the insertion of a specific extraocular muscle. Before proceeding with any dissection, the prosector should be fa-miliar with the anatomy of a specimen and should be able to recognize and interpret its unique ana-tomic landmarks. Toward this end, an anatomy atlas should be within easy reach of the cutting table.
Sometimes, even with the guidance of an anat-omy atlas, the prosector may not be able to orient the specimen. Either the specimen is too complex, or it simply does not possess any useful anatomic landmarks. In these instances, commu-nication with the surgeon takes on a very im-portant role. This communication may take one of several forms. Sometimes a surgeon will use tags, sutures, and/or an accompanying diagram to designate important structures or locations on a specimen. At other times, specimen orientation may require direct communication with the surgeon.