Note the orientation of the specimen. Describe the serosal surface (color, adhesions, exudate, perforation).
Open the specimen along the antimesenteric border, gently evacuate the fecal content, and take photographs if appropriate.
Measure the length of the specimen and the average circumference, noting any areas of dilatation or narrowing. If you can identify different regions of bowel (e.g. terminal ileum, cecum), measure these segments individually.
Describe the mucosal surface (color, perforation, ulcer, diverticulosis, plaque, stricture, polypoid lesions). Measure lesions and their distances to the resection margins. Measure the wall thickness in normal and abnormal areas.
If infarct is suspected, cross-section the mesenteric vessels and look for vascular calcification, emboli or thrombi.
Pin to a board mucosal side up and submerge in formalin for a few hours or overnight.
Note the presence or absence of the appendix and process as in Appendectomy.
Proximal and distal resection margins: representative perpendicular sections if < 1 cm from abnormalities; cross section if > 1cm away.
Lesions: sections should be taken perpendicular to the direction of the mucosal folds.
Inflammatory bowel disease: minimum of 5 sections or one section per 10 cm of specimen length. Include ulcers, pseudopolyps, and junction with normal-appearing areas.
Ischemic bowel: 5 sections of bowel. Include junction with normal-appearing areas. If infarct is suspected, take several cross-sections of mesenteric vessels.
Traumatic perforation: 3 perpendicular sections at edge of perforation. Include serosal exudate.
Diverticulosis: minimum of 2 diverticula (more if resection was specifically done for diverticulitis) with adjacent fat. Identify any mesenteric abscesses, serosal inflammation, or perforations.
Uninvolved areas: 1-3 blocks. If the resection margins are free of lesions in specimens with localized pathology (e.g. traumatic perforation, diverticulosis), they will count as the “uninvolved areas” and additional sections are not needed.
Lymph nodes: entirely submit any identified (but you do not need to search as vigorously as you would if neoplasm were present).
Appendix: tip, proximal margin and 1 cross-section, if present.
Dictation Template 1: Bowel Resection for Diverticulitis
Received without fixative/in formalin, labeled _____ and “_____”, is a __ cm (unoriented) segment of colon. The stapled end has a circumference of __ cm, and the open end has a circumference of __ cm. The serosa is _____ (color, smooth, focally/diffusely covered with adhesions/exudate). There is a __ x __ cm mural defect located __ cm from the _____ margin, corresponding to a perforated diverticulum. __ (#)/numerous diverticula are identified throughout the colon, ___ cm from the nearest (___) margin. The wall thickness ranges from __ to __ cm. The uninvolved mucosa is tan with normal-appearing folds. The pericolonic fat shows ____. ___ possible lymph nodes are identified. Representative sections of the specimen are submitted as follows:
# ___ = open margin; 1 pieces.
#___= stapled margin; 1 piece.
#___ - __ = diverticula; __ pieces in each.
#___ - ___ = inflamed diverticula with serosal surface; 1 piece in each.
#___ - ___ = fibrotic / firm areas in pericolonic fat; __ pieces in each.
#___ - ___= lymph nodes; __ pieces in each.
__ blocks, __ H&E
Dictation Template 2: Bowel Resection for Ischemia
Received without fixative/in formalin, labeled _____ and “_____ “, is a __ cm (unoriented) segment of small bowel with a small/abundant amount of attached mesenteric fat. A surgical suture marks the proximal/distal end. The serosal surface is _____ (color, dusky, hemorrhagic, covered with adhesions, fibrotic) over a __ cm area located ___ cm from the distal margin and __ cm from the proximal margin. The remainder of the serosa is _____. The bowel is opened to reveal a ___ cm segment of _____ (color, hemorrhagic, flattened, ulcerated) mucosa involving the ____ (e.g. proximal, distal, mid portion). The ____ change involves ___ (e.g. inner layers) / is transmural. The wall is __ cm in thickness in this area, contrasting with a thickness of __ cm elsewhere. The remaining mucosa is _____ (color, appearance of folds, congested). No discrete nodule or polyp is identified. Cross sections of the mesenteric vessels reveal ____ (e.g. vascular stenosis, calcification, firm blood clot in mesenteric blood vessels). There is no/is a perforation __ cm from the distal/proximal end with associated serosal exudate/fibrosis/hemorrhage. __ (number) mesenteric lymph nodes range from __ to __ cm. ___ possible lymph nodes are identified. Representative sections of the specimen are submitted as follows:
# ___ = proximal margin; __ pieces.
#___= distal resection margin; __ piece.
#___ - __ = diverticula; __ pieces in each.
#___ - #___ = segment with possible ischemia / perforation; ___ piece in each.
#___ - ___ = junction with uninvolved mucosa; __ pieces in each.