Anat Sci Int (2016) 91:1–7
DOI 10.1007/s12565-015-0299-5
REVIEW ARTICLE
History and future of human cadaver preservation for surgical
training: from formalin to saturated salt solution method
Shogo Hayashi1 • Munekazu Naito2 • Shinichi Kawata1 • Ning Qu1
Naoyuki Hatayama1 • Shuichi Hirai1 • Masahiro Itoh1
Received: 18 July 2015 / Accepted: 18 August 2015 / Published online: 1 September 2015
 Japanese Association of Anatomists 2015
Abstract 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 compli-
cated. 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
& Shogo Hayashi
shogo@tokyo-med.ac.jp
1
Department of Anatomy, Tokyo Medical University, 6-1-1
Shinjuku, Shinjuku-Ku, Tokyo 160-8402, Japan
2
Department of Anatomy, School of Medicine, Aichi Medical
University, Aichi, Japan
•
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.
Keywords Cadaver
Embalming
Formaldehyde

Organ preservation
Solutions
Training techniques
Surgical training and human cadaver models
Expertise in dissection, tissue handling, and suturing are
difficult tasks to learn in an operating room and even more
difficult to learn theoretically (Reed et al. 2009). Tradi-
tionally, surgical training (ST) meant on-the-job training
with live patients in an operating room. However, the
practice of surgery has changed dramatically (Cosman
et al. 2007), and the traditional apprenticeship approach is
now shifting toward training in laboratories before
embarking on living patients (Shiwani 2010). The two
main driving forces behind these changes have been
advances in medical technology and greater public
expectations (Cosman et al. 2007). First, surgical tech-
niques are constantly advancing; thus, surgeons require
training and practice to achieve mastery of the new pro-
cedures (Cosman et al. 2007; Hayashi et al. 2014). Mini-
mally invasive techniques, such as microsurgery, fiber-
optic endoscopy, laparoscopic and arthroscopic surgery,
and interventional radiology, have broadened the range of
therapeutic options. Although each technique requires a
different set of skills, practitioners often need to be profi-
cient in a wide variety of skill categories (Cosman et al.
2007). At the same time, demanding and increasingly
informed public expects consistent patient safety during
procedures, operating efficiency, and reduced complica-
tions (Cosman et al. 2007; Jansen et al. 2011). Thus, almost
123
2 S. Hayashi et al.
all general surgical procedures and the majority of surgical
procedures in various subspecialties are being performed
using a minimal access approach. Surgeons are moving
toward scarless surgery worldwide (Shiwani 2010).
This advancement requires different training. Most ST
programs make use of various models, including inanimate
models, virtual reality, live animals, and human cadavers,
to simulate living human tissue and anatomy (Reznick and
MacRae 2006; Goyri-O’Neill et al. 2013), and the use of
cadavers for ST has been compared with that of other
methods, such as live animals and low- and high-fidelity
simulators (Anastakis et al. 1999; Reznick and MacRae
2006; Cosman et al. 2007). Although human cadavers
currently represent the closest model to reality found in
clinical practice, the cost, limited availability, infection
risk, and poor compliance of cadaveric tissue restrict their
use (Reznick and MacRae 2006; Cosman et al. 2007;
Rosen et al. 2009; Goyri-O’Neill et al. 2013). Particularly
in Japan, it was conventionally considered that the ille-
gality of using human cadavers in training other than
anatomy practice could not be denied because there were
no clear guidelines (Japan Surgical Society and Japanese
Association of Anatomists 2012). Nevertheless, to provide
sufficient realism and clinical context, several authors have
suggested that the use of human cadavers is valuable in
training and development of surgical techniques (Reed
et al. 2009; Shiwani 2010; Yang et al. 2010; Eisma and
Wilkinson 2014); thus, it has become a growing trend. In
addition, in Japan, the publication of ‘‘guidelines for
cadaver dissection in education and research of clinical
medicine’’ in 2012 (Japan Surgical Society and Japanese
Association of Anatomists) clarified and confirmed that
even under current law, ST training using cadavers con-
ducted under adequate procedures and rules is lawful.
Therefore, many medical universities are now adopting ST
using human cadaver models.
Cadaver preservation methods for ST: fresh-
frozen, formalin, and Thiel’s method
An important factor when considering the use of human
cadavers for ST is their preservation (Hayashi et al. 2014).
Because realistic tissue properties are of principal interest
for clinicians when performing ST (Hammer et al. 2015), a
large number of studies have used fresh-frozen cadavers
(Macchi et al. 2003; Jacobs et al. 2003; Supe et al. 2005;
Ocel et al. 2006; Ali et al. 2008; Benkhadra et al. 2009;
Gunst et al. 2009; Kang et al. 2009; Leblanc et al. 2010a, b;
Yang et al. 2010; Mitchell et al. 2011; Holland et al. 2011;
Lewis et al. 2012; Sharma and Hogan 2012; Stefanidis
et al. 2013). Fresh-frozen cadavers initially ‘‘exhibit life-
like color, softness, and pliability’’ (Macchi et al. 2003).
123
However, they also present myriad problems, including the
requirement of freezers for storage and limited work time
(a few weeks at the most) because of rapid putrefaction
following thawing. The risk of infection from unembalmed
tissue is also significant (Anderson 2006; Reznick and
MacRae 2006; Rosen et al. 2009; Eisma and Wilkinson
2014; Hammer et al. 2015). For the abovementioned rea-
sons, the use of fresh-frozen cadavers is subject to the
restriction of facilities and situations where ST occurs.
An alternative to fresh-frozen cadavers is embalmed
cadavers (Jaung et al. 2011). The desired properties required
for successful cadaver embalming include good long-term
structural preservation of organs and tissues with minimal
distortion and prevention of over-hardening or alteration of
appearance. This needs to take place while maintaining the
flexibility of internal organs, preventing desiccation, and
limiting fungal or bacterial growth and spread within a
specific cadaver and to other cadavers in the dissection room
(Coleman and Kogan 1998). Scientists are trying to develop
an ideal embalming solution to preserve the human body.
Such a solution would preserve bodies in a condition com-
parable to that of an unembalmed cadaver, and the chemicals
used in the solution should be nonhazardous to eliminate any
health risks that persons might encounter during handling.
The embalmed cadaver should be relatively bacteria free and
the embalming solution should prevent the growth of
microorganisms that may accelerate the decomposition
process (Coleman and Kogan 1998; Balta et al. 2015a).
One of the most important chemicals used for
embalming is formaldehyde (Brenner 2014). Formalde-
hyde was first discovered by August Wilhelm von Hof-
mann in 1869 (Hess 1901), and its introduction as a
formalin fixative in 1893 was an important step in preser-
vation (Blum 1893; Binawara et al. 2010; Balta et al.
2015b). Since then, very little has changed in the basic
chemistry or technique of formalin preservation of human
cadavers (Brenner 2014), and it is still used ubiquitously
now in the twenty-first century due to its low cost and wide
availability (Benkhadra et al. 2011a; Hammer et al. 2015;
Balta et al. 2015a). The extensive use of formalin as a
preserving agent is based on the fact that formalin has
excellent bactericidal, fungicidal, and insecticidal proper-
ties, thus preventing the entry of organisms (Brenner 2014;
Balta et al. 2015a). However, the relatively high levels of
formalin harden the tissues (Hart 1990), thus its use is
generally associated with extreme rigidity (Richins et al.
1963) and has been found to severely affect the quality of
cadaveric tissue, particularly soft tissues (Wilke et al.
2011). Formalin-embalmed cadavers do not exhibit many
of the qualities of living organs, among which are color,
softness, pliability, pulsatile nature of the heart and arter-
ies, and the expansion of aerated lungs (Hubbell et al.
2002). Moreover, besides hardening, formaldehyde has
History and future of human cadaver preservation for surgical training: from formalin to…
several other disadvantages for embalming purposes
(Mayer 2012). It coagulates the blood rapidly, converts
tissues to a gray hue when it mixes with blood, fixes dis-
colorations, dehydrates tissues, constricts capillaries,
deteriorates with age, and has an unpleasant odor (Brenner
2014). While imaging techniques such as ultrasound and
radiography are preferable for a quick overview of cadaver
condition, including skeletal structures, effusion in the
body cavities, adhesion of pleura and peritoneum, and
distribution of gas content in the gut before dissection, a
report analyzing the possibilities and limitations of imaging
techniques in formalin-embalmed human cadavers
(Schramek et al. 2013) concluded that the quality of
ultrasound and radiography images was poor, although
computed tomography (CT) and magnetic resonance
imaging (MRI) images were of good quality. In particular,
in ultrasound, severe gas artifacts up to the small renal
blood vessels and in the surrounding tissue were found in
images of the examined kidneys. In radiography, the
lumbar spine and pelvic bones were poorly detectable in
anteroposterior views and structures were rarely identifi-
able in lateral views (Schramek et al. 2013). In addition,
formaldehyde is an irritant for the nose, eyes, skin, and
airways (Chia et al. 1992; Kriebel et al. 2001; Tanaka et al.
2003; Lakchayapakorn and Watchalayarn 2010; Wolkoff
and Nielsen 2010) and compromises pulmonary function
(Whitehead and Savoia 2008; Akbar-Khanzadeh et al.
1994). Furthermore, formaldehyde is classified as a prob-
able human carcinogen by the US Environmental Protec-
tion Agency (1999), as a carcinogen by the International
Agency for Research on Cancer (2006), and as a Class II
specified chemical substance by the Ministry of Health,
Labour and Welfare, Japan (2007), which highlights the
need for alternative fixatives (Hammer et al. 2015).
To reduce the formaldehyde concentration, a variety of
fixative agents have been proposed (Hayashi et al. 2014;
Balta et al. 2015a; Hammer et al. 2015). However, only a few
of these solutions have been tested for embalming purposes
(Brenner 2014), and there is a paucity of literature con-
cerning the different embalming methods for use in ST
(Whitehead and Savoia 2008; Jaung et al. 2011; Hammer
et al. 2015). One of the best embalming methods investigated
is Thiel’s method (1992, 2002) where the solutions are
composed mainly of large amounts of salts, such as ammo-
nium nitrate, potassium nitrate, and sodium sulfite, together
with small percentages (*0.6 %) of formaldehyde,
ethylenglyol, boric acid, and p-chlorocresol (Thiel 1992,
2002; Eisma et al. 2013; Hammer et al. 2015). The nitrites
and myoglobin in muscles form nitrosomyoglobin and stain
the tissue an intense red color (Hammer et al. 2015).
Ethylenglycol is related chemically to trivalent glycerin, and
is thus responsible for the soft haptics of the tissue (Thiel
1992). According to Benkhadra et al. (2011b), the flexibility
3
might be due to a considerable fragmentation of muscle
proteins caused by the boric acid, where the muscle fibers
show a cut-up ‘‘minced’’ appearance. Fessel et al. (2011)
found no major changes in collagenous tissues but reported
that Thiel-embalmed tendons did not completely represent
the biomechanical characteristics of fresh-frozen tendons.
Although Thiel’s method shows significant changes in
biomechanical properties (Benkhadra et al. 2011b; Fessel
et al. 2011) and the visible and tactile feel of Thiel-embalmed
cadavers are not necessarily close to those of living patients
(Hayashi et al. 2014), this method is praised for resulting in
soft and flexible cadavers with almost natural colors (Ben-
khadra et al. 2011a; Brenner 2014). Thiel-embalmed
cadavers have been appraised widely in various medical
disciplines (Benkhadra et al. 2011a; Brenner 2014; Eisma
and Wilkinson 2014), such as thyroid surgery (Eisma et al.
2011), laparoscopy (Giger et al. 2008; Kerckaert et al. 2008;
Prasad Rai et al. 2012), tendon repair (Hassan et al. 2015),
flap raising and microsurgery (Wolff et al. 2008), and oral
surgery (Hölzle et al. 2012), in comparison with alternative
soft embalming methods (Hammer et al. 2015). Further-
more, the flexibility of Thiel-embalmed cadavers makes
them suitable for intubation and ventilation (Eisma et al.
2013), ultrasound-guided anesthesia (Benkhadra et al. 2009;
McLeod et al. 2010), suturing, biopsies, and various forms of
endoscopies (Eisma and Wilkinson 2014). It is also reported
that chest radiographs of Thiel-embalmed cadavers with
inflated lungs are of high quality (De Crop et al. 2012). In
contrast, Thiel’s method has recently come under scrutiny
for other aspects such as histology, cost, and the chemicals
used (Hammer et al. 2015; Balta et al. 2015b). Hammer et al.
(2015) reported that neither cell membranes nor nuclei were
found in the hematoxylin–eosin-stained histology samples
obtained from Thiel-fixed tissues, which appeared to be
washed out by the fixatives, generating blurry structural
borders. On a technical level, Thiel’s solution is quite com-
plicated to make, and the process is relatively expensive,
time consuming, and difficult to perform (Wolff et al. 2008;
Hammer et al. 2015). Thiel-embalmed cadavers have also
been known to have the drawbacks of muscular disintegra-
tion and a limited time for dissection (Brenner 2014).
Moreover, some of the chemicals used to prepare Thiel’s
solution are poisonous, very flammable, explosive, extre-
mely hazardous to health, and environmentally unfriendly
(Janczyk et al. 2011; Hammer et al. 2015).
Back to the future: introducing the saturated salt
solution method in ST
The use of salt in the embalming of cadavers has a long
history. Since Egyptians reports of the successful
embalming of cadavers, and the earliest Biblical texts
123
4 S. Hayashi et al.

Fig. 1 Macroscopic and histological observations of a saturated salt solution (SSS)-embalmed human cadaver. a Thoracic cavity, heart, and
lungs after clamshell opening. b Horizontal section of the kidney. c Renal corpus section stained with hematoxylin and eosin (H&E). Bar 50 lm

referring to this practice, salt appears to have been used in
the embalming process (Mayer 2012). Ambroise Paré
(1510–1590), considered as one of the fathers of surgery, a
pioneer in surgical techniques, and an anatomist, described
that he used ‘‘common salt’’ as a component of his
embalming solution (Mayer 2012). In 1998, Coleman and
Kogan (1998) developed an embalming solution with high
salt content and low formaldehyde (0.75 %) content. Their
solution, a simple modification of the one described by
Logan (1983), consisted of formalin, isopropyl alcohol,
glycerine, phenol, and a vast amount of sodium chloride.
They argued that the high salt content retained in the
tissues prevented any further significant desiccation; thus,
cadavers were excellently preserved, they had minimal
structural distortion, their tissues were supple, there was
little desiccation, and their colors remained natural.
Moreover, common salt is readily available and is very
cheap (Coleman and Kogan 1998).
These characteristics of their saturated salt solution
(SSS) method seem to be ideal for ST. However, there
had been no follow-up report on their method (not only
for ST but also for anatomical teaching) before we
investigated the suitability of the SSS method for ST by
comparing it with other commonly used embalming

123
History and future of human cadaver preservation for surgical training: from formalin to… 5

methods (Hayashi et al. 2014). The following is a brief
summary of our study.
Six cadavers were embalmed using three methods: for-
malin (4.4 % formaldehyde), Thiel’s (0.6 % formalde-
hyde), and SSS (0.75 % formaldehyde) methods. Although
no known instance of transmission of bacterial or viral
disease has been recorded in Thiel-embalmed cadavers,
little antimicrobial testing has been performed on Thiel’s
and the SSS method (Anderson 2006). Therefore, we first
performed bacterial and fungal tests in the pharynx, rec-
tum, pleural fluids, and ascites of each cadaver embalmed
by formalin, Thiel’s, and SSS methods to investigate their
infectious risk. All cadavers showed positive growth of
microorganisms before embalming, whereas bacterial and
fungal culture tests proved that all three solutions have
sufficient bactericidal effects. Next, we held a special ST
session. As Coleman and Kogan (1998) described, the
gross anatomy of organs showed minimal structural dis-
tortion (Fig. 1a, b) and the histology of necropsy samples
confirmed the excellence of the fixation in a wide range of
tissues (Fig. 1c). Because the softness of tissues and joints
in a cadaver is an important factor for ST, the range of
motion (ROM) of the joints of each cadaver was measured.
The joints of SSS-embalmed cadavers tended to be softer
than those of formalin-embalmed cadavers but harder than
those of Thiel-embalmed cadavers, whereas there was no
significant difference in ROM between Thiel- and SSS-
embalmed cadavers. In terms of visual and tactile assess-
ment, skin incision and suture, vessel ligation and suture,
decollement, and usefulness for ST, SSS and Thiel-em-
balmed cadavers were evaluated to be similar by 14 sur-
geons. With regard to usefulness for mastering each of 21
procedures, no significant difference was found between
Thiel- and SSS-embalmed cadavers. Furthermore, the
evaluation of SSS-embalmed cadavers did not vary much
between surgeons in comparison with that of Thiel-em-
balmed cadavers. Ultrasound images of the formalin-em-
balmed cadavers were not as clear for the heart, liver, and
kidneys. However, those organs could be clearly observed
in Thiel- and SSS-embalmed cadavers, with no difference
between the two methods. In addition, in cervical regions,
the ultrasound image in SSS-embalmed cadavers was very
clear. Because the SSS method liquefies the blood, a
catheter could be inserted into the internal jugular vein.
Chest X-ray images were also so clear in the SSS-em-
balmed cadaver that the tip of the catheter could be seen in
the superior vena cava. Use of an electrosurgical knife and
autosuture-stapling devices were possible for both Thiel-
and SSS-embalmed cadavers. Furthermore, pulmonary
ventilation was also applied with both Thiel- and SSS-
embalmed cadavers (unpublished data).
Conclusions and future directions
The four preservation methods reviewed so far, i.e., fresh-
frozen, formalin, Thiel’s, and SSS methods, are summa-
rized in Table 1. The SSS method is sufficiently useful for
general ST, and certainly no less useful than any other
method (Hayashi et al. 2014). In addition, some features of
the SSS method may expand the capability of the human
cadaver model in ST. For example, the histological supe-
riority of the SSS method may make it possible for sur-
geons in training to evaluate their skills postoperatively.

Table 1 Comparison of different preservation methods for cadavers

Method Formaldehyde Cost Advantages Disadvantages
concentration

Fresh- 0% Very high initial cost Flexible joints and tissues, realistic color, Infection risk, deterioration throughout
frozen and running cost minimal tissue change, well studied usage period (on an hourly basis),
cadaver (cost per cadaver mounting of body parts when not using
inestimable) full cadaver
Formalin About 4–8 % Initially low (about Longevity, minimal infection risk, good Stiff joints and tissues, discolored,
1500 yen per histological quality, very well studied unnatural texture, poor imaging, quality,
cadaver) not suitable for insufflation or ventilation,
health hazards including carcinogenic
property
Thiel’s 0.6 % High (about 30,000 Flexible joints and tissues, almost realistic Deterioration throughout usage period (on a
method yen per cadaver) color, good imaging quality, ability to daily basis), poor histological quality,
ventilate, well studied technically difficult and need time for
embalming process
Saturated 0.75 % Low (about 3000 yen Natural color, comparatively low Somewhat rigid joints and tissues,
salt per cadaver) deterioration throughout usage period (on edematous (particularly subcutaneous
solution a monthly basis), good imaging and tissue), change in state during storage
method histological quality, ability to ventilate period, not well studied
(not well validated)

123
6 S. Hayashi et al.
However, more research is needed for the SSS method to
make it applicable for a wider range of use in surgical and
anatomical teaching. For example, edematous tissues of
SSS-embalmed cadavers are considered as an obstacle for
some types of clinical training, including echo-guided
peripheral nerve block, wherein probe handling and skin
needling may be too difficult for trainees. Furthermore,
although Coleman and Kogan (1998) reported that desic-
cation of SSS-embalmed cadavers was limited and it was
not necessary to add any additional fluid, we observed that
the water in SSS-embalmed cadavers was gradually lost on
a monthly basis. Period to dissection should be adjusted for
specific clinical needs. A method for extending the storage
period is also needed. Reduction of formaldehyde con-
centration should be addressed to gain softer tissue and
joints and to circumvent health risks.
Demand for ST will increase, and in fact is never
expected to decrease. In promoting the use of cadavers in
ST, many economical, technical, and hygienic difficulties
remain unsolved (Hayashi et al. 2014). The SSS method
will greatly assist the procedure of ST using cadavers to be
spread worldwide.
Acknowledgments 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.
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