Surgical Pathology Specimen Procedures

Requests for examination of surgical material are submitted on a Pathology Requisition Form.  The form should be completed by the nurse or attending physician and include all patient identifiers,  collect date and time, specimen source and description, medical record number and all clinically relevant information.  Outpatient request forms are must also include all billling instructions, insurance information, diagnosis code(s) and ordering physician. 

GMH patient care units may obtain pathology forms directly from Bulk Stores.  Outreach laboratory clients and physician offices should contact Laboratory Customer Service to request additional forms. 

Surgical tissues are accessioned in the laboratory daily from 7:00 a.m. to 5:30 p.m. and assigned a surgical case number.  Histotechnologists make multiple trips to the operating room during the day so that any specimens submitted prior to 5:00 p.m. will be ready for microscopic interpretation the following day.  If you have questions, call  Anatomic Pathology directly at 704-834-2884.

Gross and microscopic description as well as the diagnosis for most surgical specimens submitted will be reported and printed to the patient care unit within 24 hours of specimen arrival in the laboratory.  The physician will be notified of specimens for which reporting may be delayed due to additional preparation or studies required.

Specimen Handling                                                                                                                                               Careful attention must be paid to the size of the specimen in relation to the size of the container.  Large specimens must not be forced into small containers or adequate fixation will not result.  Tiny specimens, likewise, should not be placed into overly large containers.  The danger of loss of such specimens upon opening the container is great.  Attention must also be paid to the amount of fixative to the size of specimen.  As a general rule, submit most routine surgical specimens in a container with an adequate amount of fixative to cover the entire specimen. 

Only one specimen should be submitted per container.  Multiple specimens on a case should be numbered and further labeled on the requisition and container to identify the particular specimen and body site from with it was obtained. 

Specimen Labeling and Transport                                                                                             Specimens must be properly labeled upon submission to the Pathology department.  The label should be tightly affixed to the specimen container, not the lid and include the following:

• Patient Full Name
• Medical Record Number
• Date & Time of Collection
• Specimen Source & Description 

Specimens must be delivered to the Pathology department in tightly sealed spill and leak-proof containers.  Specimen containers for courier pickup must also be placed in sealed plastic specimen bags for transport.  Requisition forms should be folded and placed in the outer pocket of the specimen bag.  Specimen label identifiers must match the requisition form.  

Frozen Section

Frozen sections or any specimen requiring immediate attention should be submitted fresh.  Frozen sections should be scheduled to insure immediate availability of a pathologist.   Scheduling is accomplished by adding the words "Frozen Section" on the surgery schedule for the appropriate case, and notifying the pathology secretary at x2851.

Best medical practice requires the surgeon to confer with the pathologist prior to scheduling a frozen section.  This will ensure that every proper diagnostic  aid is available, to afford the best diagnostic approach at the time of initial biopsy, for example, special fixative, imprint, cultures,  x-ray findings, etc.  All frozen section cancellations should be promptly reported to the pathology secretary.

The specimen should be transported to the lab in the fresh state immediately after collection (NO Formalin or fixative ).  The specimen may be wrapped in gauze moistened with saline.  The pathologist will provide a verbal report to the operating surgeon when results are available.

Kidney Stone Analysis (Calculus) 

The stone must be submitted to the Histology department of the laboratory.  The specimen should have a pathology requisition attached that identifies the patient and specimen.  Submit specimen to the laboratory in a dry state (NO Formalin).

A Calculus Analysis should be ordered in the computer using test code STNA ( in Invision, alpha browse on  Cal).   Specimens are referred to a reference laboratory.  

Muscle Biopsy

Skeletal muscle biopsies are submitted in saline and must be hand-carried to the laboratory within 20 minutes of the time placed in saline.  Muscle biopsy specimens submitted in saline must be handed personally to a laboratory employee. 

Contact a pathologist prior to obtaining the sample.

Skin Biopsy for Rocky Mountain Spotted Fever

The specimen should be collected in sterile saline.   Submit specimen to the Pathology department with an attached pathology requisition that identifies the patient and notes that the specimen is in saline for the RMSF test.  The specimen must be handed to a technician in the pathology department.  The pathology department will then handle the preparation for having the test performed.  Specimen must be refrigerated if  there is delay in referring  the specimen.

Tissue for Chromosome and Cytogenetic Studies

Specimens should be submitted fresh ( NO Formalin, fixative or saline).  The sample must be delivered and handed personally to a laboratory employee.   Contact a pathologist immediately when the specimen is obtained.  Tissue samples for chromosome analysis and cytogenetic studies are sent to a reference laboratory.

Renal Biopsy                                                                                                                                                                                          The specimen should be transported to the laboratory with NO fixative.  Specimen must be handed to a laboratory employee.  Contact a pathologist when the specimen is obtained.  If possible, notify the Histology Department the day prior to procedure so that preparations may be arranged in advance for specimen transport to the reference laboratory.  

Review of Referred Surgical Material
Upon request, the laboratory will prepare and mail the proper correspondence requesting loan of surgical and autopsy material pertinent to the management of patients hospitalized at GMH.  Physicians who request these services must make available to the laboratory complete and detailed information concerning the exact location and date of the patient's prior hospitalization.

Transmission of Surgical Material to Other Hospitals
It is sometimes necessary that surgery material and slides obtained from a GMH patient for diagnostic or therapeutic purposes be sent to another hospital to which the patient has been transferred or readmitted.  All such material will be forwarded through the Department of Laboratory Services.   In these cases, we will forward available surgical material along with a copy of the pathology report. 

Removal of Material From the Department
Surgical specimens, whether gross or microscopic, may be removed from the laboratory department for research, study, or teaching.  All such material must be signed out by the requesting physician and his intentions concerning the material must be noted.  This is not required to preclude study of these materials, but to enable the laboratory to locate and track specimens should the need arise.