Anatomical Science International

, Volume 91, Issue 1, pp 1–7 | Cite as

History and future of human cadaver preservation for surgical training: from formalin to saturated salt solution method

  • Shogo Hayashi
  • Munekazu Naito
  • Shinichi Kawata
  • Ning Qu
  • Naoyuki Hatayama
  • Shuichi Hirai
  • Masahiro Itoh
Review Article


Traditionally, surgical training meant on-the-job training with live patients in an operating room. However, due to advancing surgical techniques, such as minimally invasive surgery, and increasing safety demands during procedures, human cadavers have been used for surgical training. When considering the use of human cadavers for surgical training, one of the most important factors is their preservation. In this review, we summarize four preservation methods: fresh-frozen cadaver, formalin, Thiel’s, and saturated salt solution methods. Fresh-frozen cadaver is currently the model that is closest to reality, but it also presents myriad problems, including the requirement of freezers for storage, limited work time because of rapid putrefaction, and risk of infection. Formalin is still used ubiquitously due to its low cost and wide availability, but it is not ideal because formaldehyde has an adverse health effect and formalin-embalmed cadavers do not exhibit many of the qualities of living organs. Thiel’s method results in soft and flexible cadavers with almost natural colors, and Thiel-embalmed cadavers have been appraised widely in various medical disciplines. However, Thiel’s method is relatively expensive and technically complicated. In addition, Thiel-embalmed cadavers have a limited dissection time. The saturated salt solution method is simple, carries a low risk of infection, and is relatively low cost. Although more research is needed, this method seems to be sufficiently useful for surgical training and has noteworthy features that expand the capability of clinical training. The saturated salt solution method will contribute to a wider use of cadavers for surgical training.


Cadaver Embalming Formaldehyde Organ preservation Solutions Training techniques 



This paper is based on the winning lecture of encouragement award of the JAA at the 120th annual meeting of the Japanese Association of Anatomists held at Kobe Convention Center on 22 March 2015. This work was supported by the Japan Society for the Promotion of Science (JSPS) KAKENHI Grant Numbers 26463257 and 26670254. The special ST session for our previous study (Hayashi et al. 2014) was held with support from the Ministry of Health, Labour and Welfare, Japan. The authors declare that they have no conflicts of interest. The authors wish to thank Ms. Yuki Ogawa, Ms. Miyuki Kuramasu, and Ms. Keiko Kuwana for excellent secretarial assistance and Mr. Koichi Koyama for excellent technical assistance.


  1. Akbar-Khanzadeh F, Vaquerano MU, Akbar-Khanzadeh M, Bisesi MS (1994) Formaldehyde exposure, acute pulmonary response and exposure control options in a gross anatomy laboratory. Am J Ind Med 26:61–75CrossRefPubMedGoogle Scholar
  2. Ali J, Ahmed N, Jacobs LM, Luk SS (2008) The advanced trauma operative management course in a Canadian residency program. Can J Surg 51:185–189PubMedCentralPubMedGoogle Scholar
  3. Anastakis DJ, Regehr G, Reznick RK et al (1999) Assessment of technical skills transfer from the bench training model to the human model. Am J Surg 177:167CrossRefPubMedGoogle Scholar
  4. Anderson SD (2006) Practical light embalming technique for use in the surgical fresh tissue dissection laboratory. Clin Anat 19:8–11CrossRefPubMedGoogle Scholar
  5. Balta JY, Cronin M, Cryan JF, O’Mahony SM (2015a) Human preservation techniques in anatomy: a 21st century medical education perspective. Clin Anat 28:725–734Google Scholar
  6. Balta JY, Lamb C, Soames RW (2015b) A pilot study comparing the use of Thiel- and formalin-embalmed cadavers in the teaching of human anatomy. Anat Sci Educ 8:86–91CrossRefPubMedGoogle Scholar
  7. Benkhadra M, Faust A, Ladoire S et al (2009) Comparison of fresh and Thiel’s embalmed cadavers according to the suitability for ultrasound-guided regional anesthesia of the cervical region. Surg Radiol Anat 31:531–535CrossRefPubMedGoogle Scholar
  8. Benkhadra M, Gerard J, Genelot D et al (2011a) Is Thiel’s embalming method widely known? A world survey about its use. Surg Radiol Anat 33:359–363CrossRefPubMedGoogle Scholar
  9. Benkhadra M, Bouchot A, Gerard J et al (2011b) Flexibility of Thiel’s embalmed cadavers: the explanation is probably in the muscles. Surg Radiol Anat 33:365–368CrossRefPubMedGoogle Scholar
  10. Binawara BK, Rajnee CS, Mathur K, Sharma H, Goyal K (2010) Acute effect of formalin on pulmonary function tests in medical students. Pak J Physiol 6:8–10Google Scholar
  11. Blum F (1893) Der Formaldehyd als Härtungsmittel. Z Wiss Mikrosk 10:314–315Google Scholar
  12. Brenner E (2014) Human body preservation—old and new techniques. J Anat 224:316–344CrossRefPubMedGoogle Scholar
  13. Chia SE, Ong CN, Foo SC, Lee HP (1992) Medical students’ exposure to formaldehyde in a gross anatomy dissection laboratory. J Am Coll Health 41:115–119CrossRefPubMedGoogle Scholar
  14. Coleman R, Kogan I (1998) An improved low-formaldehyde embalming fluid to preserve cadavers for anatomy teaching. J Anat 192:443–446PubMedCentralCrossRefPubMedGoogle Scholar
  15. Cosman P, Hemli JM, Ellis AM et al (2007) Learning the surgical craft: a review of skills training options. ANZ J Surg 77:838–845CrossRefPubMedGoogle Scholar
  16. De Crop A, Bacher K, van Hoof T et al (2012) Correlation of contrast- detail analysis and clinical image quality assessment in chest radiography with a human cadaver study. Radiology 262:298–304CrossRefPubMedGoogle Scholar
  17. Eisma R, Wilkinson T (2014) From “silent teachers” to models. PLoS Biol 12:e1001971PubMedCentralCrossRefPubMedGoogle Scholar
  18. Eisma R, Mahendran S, Majumdar S, Smith D, Soames RW (2011) A comparison of Thiel and formalin embalmed cadavers for thyroid surgery training. Surgeon 9:142–146CrossRefPubMedGoogle Scholar
  19. Eisma R, Lamb C, Soames RW (2013) From formalin to Thiel embalming: what changes? One anatomy department’s experiences. Clin Anat 26:564–571CrossRefPubMedGoogle Scholar
  20. Fessel G, Frey K, Schweizer A et al (2011) Suitability of Thiel embalmed tendons for biomechanical investigation. Ann Anat 193:237–241CrossRefPubMedGoogle Scholar
  21. Giger U, Fresard I, Hafliger A, Bergmann M, Krahenbuhl L (2008) Laparoscopic training on Thiel human cadavers: a model to teach advanced laparoscopic procedures. Surg Endosc 22:901–906CrossRefPubMedGoogle Scholar
  22. Goyri-O’Neill J, Pais D, Freire de Andrade F et al (2013) Improvement of the embalming perfusion method: the innovation and the results by light and scanning electron microscopy. Acta Med Port 26:188–194PubMedGoogle Scholar
  23. Gunst M, O’Keeffe T, Hollett L et al (2009) Trauma operative skills in the era of nonoperative management: the trauma exposure course (TEC). J Trauma 67:1091–1096CrossRefPubMedGoogle Scholar
  24. Hammer N, Löffler S, Bechmann I, Steinke H, Hädrich C, Feja C (2015) Comparison of modified thiel embalming and ethanol-glycerin fixation in an anatomy environment: potentials and limitations of two complementary techniques. Anat Sci Educ 8:74–85CrossRefPubMedGoogle Scholar
  25. Hart J (1990) Cadaver preservation and dissection. Eur J Plast Surg 13:75–78Google Scholar
  26. Hassan S, Eisma R, Malhas A, Soames R, Harry L (2015) Surgical simulation flexor tendon repair using Thiel cadavers: a comparison with formalin embalmed cadavers and porcine models. J Hand Surg Eur Vol 40:246–249CrossRefPubMedGoogle Scholar
  27. Hayashi S, Homma H, Naito M et al (2014) Saturated salt solution method: a useful cadaver embalming for surgical skills training. Medicine 93:e196PubMedCentralCrossRefPubMedGoogle Scholar
  28. Hess O (1901) Der Formaldehyd: Seine Darstellung, Eigenschaften Und Seine Verwendung als Conservierungs-, Therapeutisches Und Desinfectionsmittel [The formaldehyde: Its preparation, properties, and its use as conservations, therapeutic and disinfectant] (in German). Marburg: ElwertGoogle Scholar
  29. Holland JP, Waugh L, Horgan A, Paleri V, Deehan DJ (2011) Cadaveric hands-on training for surgical specialties: is this back to the future for surgical skills development? J Surg Educ 68:110–116CrossRefPubMedGoogle Scholar
  30. Hölzle F, Franz EP, Lehmbrock J et al (2012) Thiel embalming technique: a valuable method for teaching oral surgery and implantology. Clin Implant Dent Relat Res 14:121–126CrossRefPubMedGoogle Scholar
  31. Hubbell DS, Dwornik JJ, Alway SE, Eliason R, Norenberg RE (2002) Teaching gross anatomy using living tissue. Clin Anat 15:157–159CrossRefPubMedGoogle Scholar
  32. International Agency for Research on Cancer (2006) Monographs on the evaluation of carcinogenic risks to humans. Formaldehyde, 2-butoxyethanol and 1-tert butozypropan-2-ol. Monograph 88, World Health Organization IARCGoogle Scholar
  33. Jacobs LM, Burns KJ, Kaban JM et al (2003) Development and evaluation of the advanced trauma operative management course. J Trauma 55:471–479CrossRefPubMedGoogle Scholar
  34. Janczyk P, Weigner J, Luebke-Becker A, Kaessmeyer S, Plendl J (2011) Nitrite pickling salt as an alternative to formaldehyde for embalming in veterinary anatomy—a study based on histo- and microbiological analyses. Ann Anat 193:71–75CrossRefPubMedGoogle Scholar
  35. Jansen S, Kirk D, Tuppin K, Cowie M, Bharadwaj A, Hamdorf JM (2011) Fresh-frozen cadavers in surgical teaching: a gelatine arterial infusion technique. ANZ J Surg 81:880–882CrossRefPubMedGoogle Scholar
  36. Japanese Association of Anatomists (2012) Guidelines for cadaver dissection in education and research of clinical medicine (in Japanese). Kaibogaku Zasshi 87:21–23Google Scholar
  37. Jaung R, Cook P, Blyth P (2011) A comparison of embalming fluids for use in surgical workshops. Clin Anat 24:155–161CrossRefPubMedGoogle Scholar
  38. Kang PS, Horgan AF, Acheson AG (2009) Laparoscopic surgery training: try fresh-frozen cadavers. BMJ 338:b2426CrossRefPubMedGoogle Scholar
  39. Kerckaert I, Van Hoof T, Pattyn P, D’Herde K (2008) Endogent: centre for anatomy and invasive techniques. Anatomy 2:28–33CrossRefGoogle Scholar
  40. Kriebel D, Myers D, Cheng M, Woskie S, Cocanour B (2001) Short-term effects of formaldehyde on peak expiratory flow and irritant symptoms. Arch Environ Health 56:11–18CrossRefPubMedGoogle Scholar
  41. Lakchayapakorn K, Watchalayarn P (2010) Formaldehyde exposure of medical students and instructors and clinical symptoms during gross anatomy laboratory in Thammasat University. J Med Assoc Thai 93:S92–S98PubMedGoogle Scholar
  42. Leblanc F, Senagore AJ, Ellis CN et al (2010a) Hand-assisted laparoscopic sigmoid colectomy skills acquisition: augmented reality simulator versus human cadaver training models. J Surg Educ 67:200–204CrossRefPubMedGoogle Scholar
  43. Leblanc F, Champagne BJ, Augestad KM et al (2010b) A comparison of human cadaver and augmented reality simulator models for straight laparoscopic colorectal skills acquisition training. J Am Coll Surg 211:250–255CrossRefPubMedGoogle Scholar
  44. Lewis CE, Peacock WJ, Tillou A et al (2012) A novel cadaver-based educational program in general surgery training. J Surg Educ 69:693–698CrossRefPubMedGoogle Scholar
  45. Logan B (1983) The long-term preservation of whole human cadavers destined for anatomical study. Ann R Coll Surg Engl 65:333Google Scholar
  46. Macchi V, Munari PF, Brizzi E et al (2003) Workshop in clinical anatomy for residents in gynecology and obstetrics. Clin Anat 16:440–447CrossRefPubMedGoogle Scholar
  47. Mayer RG (2012) Embalming: history, theory, and practice, 5th edn. McGraw-Hill, New YorkGoogle Scholar
  48. McLeod G, Eisma R, Schwab A et al (2010) An evaluation of the Thiel embalmed cadavers for ultrasound based regional anaesthesia training and research. Ultrasound 18:125–129CrossRefGoogle Scholar
  49. Ministry of Health, Labour and Welfare (2007) Amendment of ordinance on prevention of hazards due to specified chemical substances in December 2007 (formaldehyde, 1,3-butadiene, diethyl sulfate) (in Japanese).
  50. Mitchell EL, Sevdalis N, Arora S et al (2011) A fresh cadaver laboratory to conceptualize troublesome anatomic relationships in vascular surgery. J Vasc Surg 55:1187–1197CrossRefPubMedGoogle Scholar
  51. Ocel JJ, Natt N, Tiegs RD, Arora AS (2006) Formal procedural skills training using a fresh-frozen cadaver model: a pilot study. Clin Anat 19:142–146CrossRefPubMedGoogle Scholar
  52. Prasad Rai B, Tang B, Eisma R et al (2012) A qualitative assessment of human cadavers embalmed by Thiel’s method described used in laparoscopic training for renal resection. Anat Sci Educ 5:182–186CrossRefPubMedGoogle Scholar
  53. Reed AB, Crafton C, Giglia JS, Hutto JD (2009) Back to basics: use of fresh cadavers in vascular surgery training. Surgery 146:757–763CrossRefPubMedGoogle Scholar
  54. Reznick RK, MacRae H (2006) Teaching surgical skills—changes in the wind. N Engl J Med 355:2664–2669CrossRefPubMedGoogle Scholar
  55. Richins CA, Roberts EC, Zeilmann JA (1963) Improved fluids for anatomical embalming and storage. Anat Rec 146:241–243CrossRefPubMedGoogle Scholar
  56. Rosen JM, Long SA, McGrath DM, Greer SE et al (2009) Simulation in plastic surgery training and education: the path forward. Plast Reconstr Surg 123:729–738CrossRefPubMedGoogle Scholar
  57. Schramek GG, Stoevesandt D, Reising A et al (2013) Imaging in anatomy: a comparison of imaging techniques in embalmed human cadavers. BMC Med Educ 13:143PubMedCentralCrossRefPubMedGoogle Scholar
  58. Sharma M, Horgan A (2012) Comparison of fresh-frozen cadaver and high-fidelity virtual reality simulator as methods of laparoscopic training. World J Surg 36:1732–1737CrossRefPubMedGoogle Scholar
  59. Shiwani MH (2010) Fresh-frozen cadaver: a model for laparoscopic surgery training. J Coll Physicians Surg Pak 20:425–426PubMedGoogle Scholar
  60. Stefanidis D, Yonce TC, Green JM et al (2013) Cadavers versus pigs: which are better for procedural training of surgery residents outside the OR? Surgery 154:34–37CrossRefPubMedGoogle Scholar
  61. Supe A, Dalvi A, Prabhu R et al (2005) Cadaver as a model for laparoscopic training. Indian J Gastroenterol 24:111–113PubMedGoogle Scholar
  62. Tanaka K, Nishiyama K, Yaginuma H et al (2003) Formaldehyde exposure levels and exposure control measures during an anatomy dissecting course (in German). Kaibogaku Zasshi 174:185–195Google Scholar
  63. Thiel W (1992) Die Konservierung ganzer Leichen in natürlichen Farben [The preservation of the whole corpse with natural color] (in German). Ann Anat 174:185–195CrossRefPubMedGoogle Scholar
  64. Thiel W (2002) Ergänzung für die Konservierung ganzer Leichen nach [Supplement to the conservation of an entire cadaver according to W. Thiel] (in German). Ann Anat 184:267–269CrossRefPubMedGoogle Scholar
  65. US Environmental Protection Agency (1999) Integrated risk information system (IRIS) on formaldehyde national center for environmental assessment. Office of research and development. WashingtonGoogle Scholar
  66. Whitehead MC, Savoia MC (2008) Evaluation of methods to reduce formaldehyde levels of cadavers in the dissection laboratory. Clin Anat 21:75–81CrossRefPubMedGoogle Scholar
  67. Wilke HJ, Werner K, Haussler K et al (2011) Thiel-fixation preserves the non-linear load-deformation characteristic of spinal motion segments, but increases their flexibility. J Mech Behav Biomed Mater 4:2133–2137CrossRefPubMedGoogle Scholar
  68. Wolff KD, Kesting M, Mucke T, Rau A, Holzle F (2008) Thiel embalming technique: a valuable method for microvascular exercise and teaching of flap raising. Microsurgery 28:273–278CrossRefPubMedGoogle Scholar
  69. Wolkoff P, Nielsen GD (2010) Non-cancer effects of formaldehyde and relevance for setting an indoor air guideline. Environ Int 36:788–799CrossRefPubMedGoogle Scholar
  70. Yang JH, Kim YM, Chung HS et al (2010) Comparison of four manikins and fresh-frozen cadaver models for direct laryngoscopic orotracheal intubation training. Emerg Med J 27:13–16CrossRefPubMedGoogle Scholar

Copyright information

© Japanese Association of Anatomists 2015

Authors and Affiliations

  1. 1.Department of AnatomyTokyo Medical UniversityShinjuku-KuJapan
  2. 2.Department of Anatomy, School of MedicineAichi Medical UniversityAichiJapan

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