Surgical pathology grossing (sampling, cut in, depending on the terminology) went a long way from using simple kitchen like tables to contemporary grossing, or gross dissection, stations. The definition of the grossing table will remain as a generic term although the modern grossing tables actually are complicated engineering construction with exhaust features and additional accessories (shelves, sprays, computers, etc.). They are really stand-alone specimen processing stations and their development goes in this direction. In practice, definitions of grossing table and grossing station are used interchangeably.
Grossing tables and equipment have a scarce representation in literature, except in two volume manual Modern Surgical Pathology (1). There is a discrepancy between understandably plentiful representation on companies’ websites, in catalogs, brochures or advertisings flyers and assessment by professional users. This article does not intend to fill this gap, but is rather focusing on the perspective of the grossing station’s specialization.
Perhaps, some grossing stations historical data would be of interest.
Founded by J. Gordon Short, MD, board certified pathologist, Brevis Corporation (Salt Lake City,UT) introduced the first workstation for gross examination of surgical specimens in 1978. By 1988, Dr. Short developed the original bench-top Grosslab™ Workstation and made arrangements with Lipshaw Manufacturing Corporation inDetroit,MIto manufacture and market it. In 1991, Shandon purchased Lipshaw and relocated all operations toPittsburgh,PA. They continued to manufacture and market the original Grosslab™ Workstation as the Grosslab™ V Pathology Workstation. By this time, Dr. Short had also developed the original stand-alone Grosslab™ Senior Pathology Workstation. Arrangements were made again with Shandon to manufacture and market Grosslab™ Senior Workstations. During the mid 1990s, the Grosslab™ V and Grosslab™ Senior Pathology Workstations were redesigned by Shandon Lipshaw /Shandon Inc. inPittsburghto improve corrosion resistance and ventilation. The Grosslab™ V was renamed Grosslab™ Junior.
Since then all grossing stations variants are, in general, similar with small deviation from the basic model. Only an experienced eye can distinguish these clones and only careful reading of specifications can catch some differences.
In theUSA, grossing stations are manufactured by many companies. Among them are: Mopec Inc., Oak Park, MI; TBJ Inc. Chambersburg, Pa; Thermo Fisher Scientific, Waltham, Ma; Sakura Finetek USA, Torrance, Ca; Mortech Manufacturing Co, Azusa, Ca. These companies have basic models, like for example, Thermo Fisher Scientific has Thermo Scientific Shandon Gross-Star™ Pathology Workstations and Workbenches and numerous modifications of them which serve to customize to local laboratory conditions.
In Europe, grossing stations are manufactured by Propath company inBelgium. The design is similar to theUSAstations, but the size is smaller and much less variants.
All basic models include the obligatory set of features as ventilation (outside backdraft, downdraft or self-contained system with replaceable filters), table elevation (various ranges between 32”-45.5”), and sink with hand spray and a disposer. Most offer foot-pedal or proximity-sensing hand-free controls and table rinse (Thermo Fisher Scientific, Sakura). The modern grossing station includes tape recording dictation units and additional arms for computers.
This article is not in aim to single out any of the companies. Their stations differ in quality of stainless steel surfacing, size of the sink, convenience of shelves or sink handles, seamless welding, quality of plumbing, and, of course, the size of actual working grossing table surface.
Two main requirements drive the development of grossing stations:
convenience and safety. The first should contribute to productivity; the second must meet safety concerns and government regulations.
The development of the basic Grosslab™ workstation coincided with society’s attention to safety issues at the working place, especially to formaldehyde exposure. During the 1980s, there was a politically charged, even with involvement of US Court of Appeals for theDistrict of Columbiain 1987, dispute between U.S. Environment Protection Agency (EPA), Occupational Safety and Health Administration (OSHA), College of American Pathologists (CAP), Formaldehyde Institute, DuPont and labor unions on formaldehyde’s occupational exposure evaluation (2). Now the engineering controls for histology, pathology, and anatomy laboratories are focused on local exhaust ventilation to meet OSHA’s certain parameters.
The modern grossing stations definitely serve the purpose to be in compliance with regulations of exposure to formaldehyde and other chemical in the grossing room. In general, they are convenient for routine work in grossing rooms with adjustments of height of the table, accessible water, and shelves for supplies.
However, since the first grossing stations were introduced, surgical pathology has changed in many directions. Although the principles of grossing remain the same, the conditions of the performance are different.
First, the amount of specimens, and biopsies among them, is increased dramatically. Many specimens require ancillary studies.
Second, the turn around time (TAT) pressure changed the technology of processing substantially, especially with introduction microwave assisted processing. A completely different mode of loading the tissue processing equipment (conventional and micro wave processors) is now establishing. Broader interpretation of “rush” specimens also contributed to changes in style of tissue processing.
Third, safety conditions are different. Most of biopsies arrive in the laboratory in containers with prefilled fixative or in the fresh state. This means that the contact with 10% formalin is substantially diminished. However, fresh specimens pose definite biohazard.
Fourth, surgical pathology became more specialized with subspecialty groups in large laboratories. Specialization inevitably brings in practice standard processing protocols with standard kits of instruments and gadgets.
All these circumstances should be taken into account while planning grossing equipment for surgical pathology. Perhaps, there are some local custom- made grossing tables which meet specific laboratory needs, but they are not published in open literature. Specialization in the grossing table design is knocking on the door, but not loud enough. There is no conceptual approach to specialized grossing station that is at the level of modern surgical pathology grossing room requirements.
This author has spent two decades working at the different types of grossing stations, most of the time with the Grosslab™ Senior. While using a variety of instruments and gadgets (3, 4), I became gradually unsatisfied with all of them. I wish I had at least two types of specialized grossing tables: one for bone grossing and another for grossing biopsies.
Bone Grossing Table (BGT)
The most evident type of specialized grossing table appears to be a grossing station for bone grossing. It is determined by definite specifics in bone grossing which distinguish it from other grossing procedures.
Our book Grossing Bones: Principles, Techniques, and Instruments (Amazon.com) discusses the subject in detail.
Biopsy Grossing Station (BGS)
hile the Bone Grossing Table only follows the rational implementation of grossing bones requirements, specialized equipment for grossing biopsies should reflect the modern tendencies in the surgical pathology. In biopsies, grossing is much broader than just sampling (cut-up). It includes different actions of biopsy triage by priorities of timing, workflow consideration, and ancillary studies. The main methodological principle is in triage specimens in subspecialties: dermatopathology, gastroenterology, gynecology, urology, hematology, and other depending on laboratory profile.
Figure 2. A tray for grossing biopsies
Figure 2 presents the overcrowded tray which I used for biopsies grossing as a basic set up of the working place. Filtration kits, ink, pads, pipettes, blades, forceps, etc. are begging to disperse them for efficient and accurate grossing processing in many trays with specific selection of instruments and gadgets.
The traditional grossing dissection station is not suited for effective biopsies grossing in the modern surgical pathology. New requirements need a different approach to the station’s design.
The concept of Biopsy Grossing Station (BGS)
1. Smooth workflow is the dominant notion in the concept of Biopsy Grossing Processing Station. It is provided by large open- from- all- sides workspace for simultaneous processing of biopsies in subspecialties with prioritizing after triage according to institutional protocols.
2. Each subspecialty has its particularity that requires standard selection of instrument and gadgets.
For example, dermatopathology specimens need a variety of inking, precise cutting, and careful orientation.
Or gynecology require gadgets for completes of submission, inking, and orientation.
Specialized trays can be used as processing/cutting boards for a subspecialty. Biopsies grossing should be separated from so-called routine specimens. From practical point of work organization a special tray can be reserved for small specimens, like tendons, prostate chips, heart valves, etc.
3. Specifics of biopsies grossing as completeness of submission, fine skill cutting, and precise orientation require additional instruments and gadgets, including a visual presenter manipulation board.
4. Minimizing extraneous tissue (“floaters”) by providing conditions for cleaning working instruments, for instant and continuous cleaning of working space.
5. Prevention of specimen misidentification by computerized bar-coding of biopsies requisites.
The optimal design for Biopsy Grossing Station
The island type of the disposition of the grossing dissection station appears to be optimal for Biopsy Grossing Station. Positioning the station in the middle of the grossing room opens more options for its utilization for multiple functions that is in the core of modern biopsy grossing processing.
Immediately an island kitchen comes to mind. The vast majority of new homes buyers like them. There are numerous island kitchen variants even with a triangle of sink/stove/refrigerator.
Surprisingly, most of the manufacturing companies, except Sakura FinetekUSA(Model GL 135), do not offer an island configuration grossing station for surgical pathology on their websites, although they are included in catalogs (Thermo Fisher Scientific, TBJ Inc). According to the Sakura Finetek’s specification drawing (Model GL 135), the island configuration would allow grossing from either side. That entails a location in the middle of the room or the short length against the wall. However, the company has not manufactured any.
Figure 3 presents Sakura Finetek drawing of island grossing station.
Mortech Manufacturing Inc. offers a backdraft/downdraft necroscopy table (model 1036/273) without connection to a room’s wall. Mopec Inc. has two downdraft ergonomic grossing stations (MK100, MK 200) with multiple accesses. TBJ Inc. also has developed an island style grossing station (Fig. 4)
Figure 4. Island style grossing station (TBJ. Inc.)
The Propath company (Belgium) also offers double- side downdraft workstations. They have manufactured them since 1990s. In 2000, Thermo Shandon (now part of Thermo Fisher Scientific) developed an island station … forFrance. The island configuration of grossing station is not a novelty, but is not in the demand in theUSA.
Why has not been the island configuration of a grossing station implemented? We cannot attribute this fact only to rigidity of customer’s thinking and habits. What gains the grossing process will have from this configuration? Why do we need to go from the typical unit that goes against the wall? Why the access from either side is necessary? And there are some consequences in deviation from the traditional at wall location. The island stations take up more floor space with fewer variants in effective ventilation, and there are some plumbing difficulties. It seems that the answer is in absence of a different methodological approach that requires departure from the standard grossing station design.
What does make the Biopsy Grossing Station different from the standard grossing station?
A/ Provided by at least two accesses to the station, the larger (more than 82” long and 36 “ wide) working space has the advantage of placing simultaneously different specialized trays with processing boards for specimens of different subspecialties, as well as separately for priority (“rush”) specimens. It gives more opportunities of streamlining the workflow to meet requirements of turn around time (TAT).
B/ The island/peninsula configuration allows laboratory aids to actively participate in grossing for technical support. If the protocol is established for incremental loading of the tissue processor, it can be carried out by histology technicians or laboratory aids without disturbing grossing process.
C/ Every biopsy grossing processing station should be equipped with a manipulation board to provide higher quality of grossing. Incorporated in the grossing station, a manipulation board with a visual presenter (ELMO type) connected to the LCD monitor enables efficient sampling of different kind specimens, especially miniscule biopsies. It can be indispensible for the precise biopsy orientation. The visual presenter can be connected to PC with interface and internet connection. The manipulation visual presenter board can be used as part of digital imaging in anatomical pathology with broader applications. There should be a place reserved for a dissecting microscope if the facility practices kidney biopsies.
D/The sink should be placed in the centre of the station to have immediate access to the running water facets. The traditional grossing station places the sink at one of the end, but the Biopsy Grossing Station is substantially larger that requires the sink in the middle or two sinks from both ends of the table.
Specimen contamination, so-called “floaters”, is not so rare in grossing, especially in the increased amount of biopsies in modern laboratories. Specialized grossing station can provide space for cleaning the instruments, including by establishing special gadgets. For example, as an improvised metallic brush under permanent stream of water can be used for cleaning a forceps (Figure 5). More details are at the link “Instruments and Gadgets.” (8)
Figure 5. Metal brush for forceps cleaning under the steam of water.
Periodical cleaning during the day and at the end of work should be provided by obligatory spray. The additional devices, like visual presenter board, can be disconnected, removed and cleaned separately.
Perimeter rinsing is not a good idea at the biopsy grossing table because they might be prone to accidental starting due to thermal sensor that may cause loosing irreplaceable biopsy materials.
E/ Prevention of formaldehyde and other laboratory hazards overexposure is the significant part of the grossing station design. In the case of island configuration the optimal type of ventilation appears to be downdraft combined with self contained filters which are widely used by many grossing stations. The prefilled formalin containers and specimens processed in fresh state definitely diminish formaldehyde exposure in the modern surgical pathology laboratory. In this situation, the most effective backdraft ventilation does not have its preference as this type of ventilation has for standard grossing stations.
However, downdraft ventilation can have some construction difficulties in island configuration design of a grossing station. Perforated working space, as usually downdraft is designed, is not acceptable for biopsies grossing because by accident the irreplaceable material can be lost. But the island configuration should not be taken literally. It can be a “peninsula” variant just to have adjacency to a wall for bellows connections of the ventilation. The advantage of a larger working space and accessibility will remain. There are suggestions for “peninsula” configuration of necroscopy tables , but they are far from surgical pathology grossing table requirements.
Thermo Fisher Scientific offers an island/peninsula workstation for dissection of specimens and small animals necroscopy. It has a canopy for shelving and two sinks for waste formalin collection on both sides (Thermo Fisher Scientific 2008/2009 “Anatomical Pathology- Products and Services Catalog, Part No. M 53003).
Both examples demonstrate that technical difficulties for island/peninsula configuration are solvable as far as design of Biopsy Grossing Station is concerned. It is possible to achieve effective ventilation with downdraft around the perimeter of recessed work surfaces although effective downdraft ventilation cannot be achieved if perforations or slots are entirely eliminated from grossing station tabletops. Back draft or canopy ventilation would be required. These considerations could support a peninsula design of the Biopsy Grossing Station. Peninsula configuration can be also more preferable for two sinks on opposite sides of the table, because space must be available for drain line routing and connection to the facility’s plumbing tie-in.
Prefilled biopsy containers do not require formalin collection and other bulky features which accompany the standard grossing station. The sink should be large enough for cleaning the trays/ processing boards, but not deep. A usual disposer is not necessary.
There might be other differences with the regular grossing station.
The preferable sitting position of the grossing person while doing biopsies makes hydraulics for the elevation of the table unnecessary (the high of the chair is better to adjust). Accessible storage for constant change of soiled and formalin soaked waste is obligatory. This storage should be securely closed and located in the reach of the grossing person.
Shelves or additional accessories should be designed to keep instruments and numerous gadgets for filtration, inking, etc. Technical support for efficient registration of grossing data (computer module, scanner, dictation equipment) should be placed on movable hinged arms.
The table 2 summarizes main distinctive features of the Biopsy Grossing Station. There are curtain advantages in comparison with a regular at wall grossing station.
Table 2. Distinctive features of Biopsy Grossing Station
|Grossing tabletop||Large working space (82” long x 36 wide)||Specialized trays as cutting boards|
Manipulation board with visual presenterConfigurationIsland/peninsulaAccess from both sidesSinkIn the middle or both endsAccess to water flow for instant cleaning of instrumentsShelvesCanopy styleEasy access storage for numerous instruments and gadgetsVentilationDowndraft/backdraft slots around perimeter of recessed work surfacesEffective fumes capture with comfortable airflow and minimal noise level
This article does not provide a specific drawing of a Biopsy Grossing Station which requires engineering qualification that the author obviously does not have. The goal is to justify its necessity, to discuss the possibility of the development of such equipment, and lay out the main features of the station.
For now, the modern design of an island kitchen workbench can serve as a remote “prototype.” Perhaps, it can hint at some possibilities to deviate from the standard grossing station design.
Is not the proposed development of specialized Bone Grossing Table and Biopsy Grossing Station impractical and ahead of its time? Most surgical pathology laboratories across the nation do not have the volume of cases that would make it cost-effective to have a dedicated grossing table just for bones and biopsy specimens. The vast majority of small labs have been able to handle the work for many years with no untoward effects.
There is an egg and chicken situation. A manufacturer cannot do without an order of a professional, but a professional ought to know that such project is methodologically justified and is technically feasible. Manufacturers follow the demand. A pathologist remarked: “If the market existed for a specialized grossing station for biopsies, believe me, they would already be selling them like hotcakes!” The difficult part is to persuade surgical pathology practitioners that “good enough” realism of working with familiar equipment collides with the requirement of modern surgical pathology.
The separation of a biopsy grossing table (model BTOCV) and a dissection station (model CTIBT) for larger specimens is already made by Propath (Belgium). The units can be positioned under a right angle or in one line. By essence, this is not the specialization that is proposed in the presented materials, rather customization. The biopsy table is small and lacks many features (even a sink) necessary for efficient grossing. However, the notion of allocation biopsy grossing to a separate working place has been carried out in metal.
While an increase in productivity is difficult to calculate, the quality improvements, and this is the most important, are more evident. It is the place where specialization meets standardization for quality optimization.
Specialization opens more opportunities for standardization. The technical procedures should be standardized as much a possible.
The subspecialty oriented trays as cutting boards with the diversified and standard set of instruments and gadgets can assure correctness of sampling technique, completeness of submission, and certain specimen orientation for embedding and microtomy. For example, completeness of submission requires a collection of gadgets which are different in gynecology and gastroenterology. Filtration of a bone marrow clot is technically different from endocervical curettage specimen. Orientation gadgets in dermatopathology are different from used in gastroenterology. Subspecialty trays contribute to efficiency and quality of grossing. The tray for consultation is an important part of the station. This underestimated detail of processing can improve quality of grossing and provide real pathologist’s supervision.
Biopsy grossing station can provide more working space for specialized kits, for example Biopsy Inking Kit and Filtration Kit for Surgical Pathology (see at the link Equipment, Instruments & Gadgets). Specialized kits can substantially contribute to productivity and quality of grossing biopsies.
The presence permanently on hand, ELMO like manipulation board with an LSD monitor can be a step in digital grossing pathology which needs a methodological advancement to become incorporated in every day practice. As the next step, a pathologist’s consultation through the interface can be more effective while grossing. However, the proposed by some companies (MILESTONE, SPOT Imaging Solutions, a division of Diagnostic Instruments) advancement in gross digital pathology simply do not have working space on the traditional grossing table surface. Without modifications in grossing table’s design all sophisticated electronic equipment will remain for trade show demonstrations.
Specialization opens more opportunities for standardization, one of the corner stones of enhancing productivity. While the approach to grossing as a diagnostic procedure ought to be nonstandard, the technical procedures should be standardized as much a possible.
Some laboratories use assembly line practice inherited from Frederick Taylor and Henry Ford principles with the modern Lean label as an adaptation of Toyota Production System (8). Rationality of maintaining smooth and efficient production line workflow cannot be disputed even in such manual work as grossing in surgical pathology. But it requires support by appropriate equipment.
The island/peninsula configuration of the biopsy grossing station can be a new trend in station’s design. Like a car assembly line is located in the center of the plant working space, the departure from the traditional at wall location of the station provides more opportunities for work organization.
Productivity increase is one of incentive to change equipment which naturally comes with necessary investments. Among surgical pathology laboratory tasks, productivity of grossing is the most difficult for study due to the variety of modes of manual by essence processing in different laboratories and the different work force involved (pathologists, residents, pathologists’ assistants, histotechnologists, pathology assistants, laboratory assistants, and others). The study of grossing productivity requires a statistical method of measurement which is not still determined except amount of cases in and out. This parameter is too general and depends on different factors. However, the average case per day is the best measurement solution for now.
Can the specialized grossing stations influence productivity? The positive answer is not clear yet without a methodologically serious study. However, besides safer work conditions, Bone Grossing Table with its additional space for variety of instruments can definitely contribute to productivity.
Enhanced by Biopsies Grossing Station, the smooth workflow eventually will pay off in increase of productivity. It is the place where specialization meets standardization for productivity optimization. The turn around time (TAT) certainly can be improved. Without any doubt, and this is the most important, specialization of the grossing table can assure the quality of biopsy grossing, including sampling, orientation and minimization of “floaters.”
Large specialized laboratories, reference laboratories, and surgical pathology laboratories in academic institutions can be the first interested in specialized, especially for biopsy grossing, stations. The tendency of consolidation of surgical pathology laboratories will remain, and they will need a different type of equipment, like specialized grossing stations.
Specialization or customization? Most of the grossing stations manufacturing companies offer customization of their products to the laboratory’s needs and to the available space. According to their catalogs and brochures, customization is endless in variants, but in practice everything ends up with the basic model. Customization is adjustment to laboratory condition; specialization requires a different design focused on the type of specimens.
Specialization is the modern trend in surgical pathology that ought to be reflected in the grossing laboratory equipments. When the notion of specialized grossing tables becomes a commonly accepted, the architect project of new and remodeled laboratories will include them in their space design. Customization which is always a compromise would be minimized.
The trends of the specialized grossing table development are difficult to predict now. Perhaps, the biopsy grossing station will be combined with some tissue processors in one unit that makes sense from productivity considerations, especially owing to the embedding automation which is looming on the horizon of histology processing. Practice might request different types of specialized grossing tables. The presented two variants (Bone Grossing Table and Biopsy Grossing Station) are only a step in this direction.
Thanks to Todd Campbell (TBJ Inc.), Gilles Lefebvre (Sakura Finetek USA), and Ronald D. Green (ThermoFisherScientific) for generous consultations.
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A part of this article has been published in AAPA’s Newsletter, Spring Edition, 2011: 22.
The poster 192 “The Grossing Table Specialization in Surgical Pathology” was selected for oral presentation at the 2011 ASCP Annual Meeting/WASPaLM World Congress in Las Vegas in October 19, 20011.