Position of Vermiform Appendix in Indian population

Transworld Medical Journal ISSN: 23472790 Available online at www.tmjournals.com
Original Research Paper
Position of Vermiform Appendix in Indian population
Nikhil Kumar Das1, K. L. Sampath Kumar2, Pinaki Mohanty1
1Department
of Gen. Surgery, MVJ Medical College & Research Hospital, Hoskote, Bangalore, Karnataka
of Gen. Surgery, Professor of Surgery, Rajeev Gandhi Institute of Medical Sciences, Kadapa, AP
2Department
Abstract
Background: Position of vermiform appendix is variable. However the location of the tip of the appendix determines
the signs and symptoms of acute appendicitis.
Aim: To analyze the various positions of vermiform appendix in Indian population.
Method: It is a retrospective study where hospital records were analysed from 1979 2010. The study recorded the
position of vermiform appendix in 16,128 Indian patients. Basic dermatographic data collected included sex and
dietary habits of the individual. Clinical data recorded whether the patient was suffering from appendicular
pathology or not.
Results: Retrocecal position of appendix was present in 51.15%. In females, the pelvic position was the commonest
(48%). Whenever appendicular pathology was encountered, the retro-cecal position was highest at 58.1%, where as
in non-appendicular pathology, pelvic position was highest at 47.55%.
Conclusion: In Indian population the position of vermiform appendix is variable.
Key words: Worm of the intestine, retrocaecal, appendix, appendicitis, Indian population.
Introduction
The vermiform appendix is present only in human
beings, and certain anthropoid apes and the
wombat.1 It was probably first noted as early as
Egyptian
civilization
(3000BC).
During
mummification process abdominal parts were
removed and placed in jars with inscription
described the appendix as worm of the intestine.2
The vermiform appendix is considered by most as
a vestigial organ. Its importance in surgery is due
to mainly its potentiality for inflammation that
results in the clinical syndrome known as ‘acute
appendicitis’. Acute appendicitis is the most
common cause of acute abdomen in young
adolescents and it is often the first major
procedure performed by a surgeon in training.3,4
Tel.: +91‐ 73536 51331 E‐mail: [email protected] © Transworld Medical Journal. All rights reserved. Embryologically, the appendix is the continuation
of the caecum and is first delineated during the
fifth month of gestation. The appendix doesn’t
elongate as rapidly as the rest of the colon, thus
forming a worm like structure. It is the only organ
in the human body that has no constant anatomical
position, and only constant feature is its base,
which is located in the posteromedial wall of the
cecum about 2.5 cm below the ileocaecum valve,
where the taenia coli converge.
The early signs and symptoms of acute
appendicitis depend up on the location of the tip
of the appendix. Hence the interest is to know the
variation of position of Vermiform appendix.
Vermiform appendix varies considerably in length
from 01 cm to 25 cm. The tip of the appendix may
be positioned as retrocaecal, subcaecal, pelvic,
preileal, postileal and rarely subhepatic. Variations
in the position of the appendix, age of the patient
and degree of inflammation make the clinical
presentation of the appendicitis, notoriously
inconsistent.5
Das NK et al. / Transworld Medical Journal. 2(1):69. Before 1933, the commonest position of the
appendix was considered to be postileal (splenic).6
However in 1933, a study analyzing 10,000 cases
showed that retrocecal position is the commonest
in 65.2% followed by pelvic position in 31.01%,
subcaecal in 2.26%, anterior or preileal in 1.0%,
posterior or postileal or splenic position in 0.4%,
and the ectopic position in 0.05%.7
(2)
However in Indian population, the position of the
vermiform appendix is at variation when
compared to the available mentioned literature as
noticed by this study.
(3)
The aim of this study was to analyse the various
positions of vermiform appendix among the
Indian population, and its relationship with
gender, dietary habits of the individuals and also
with appendicular pathology.
(4)
Materials and Methods
(5)
Study design: Retrospective hospital based. Study
period: 1979-2010. Study population: 16,128
patients. During the initial years of the study, the
position of the vermiform appendix was recorded
in all laparotomy cases, whenever the appendix
was accessible. In the last decade, with the
increasing use of the appendix, the same was
noted laparoscopically. The sex and the food habits
of all individuals are recorded. Presence or absence
of the appendicular pathology was also recorded.
(6)
Results
Ethical approval was obtained from the local and
regional ethical committees. For the purpose of the
present study, following definitions are used.
The positions of vermiform appendix recorded in
16128 patients. The various positions of vermiform
appendix are shown in Table–1.
(1) Retrocaecal Appendix: There are various
positions in which a retro–caecal or retro–colic
appendix may be found.
a. The appendix may be free, lying in a retro–
caecal or retro–colic pouch of peritoneum
with a short mesoappendix.
b. There may be shorter mesentery which
holds the appendix in contact with the
posterior surface of the cecum and
ascending colon.
c. It may be so adherent to the posterior
surface of the cecum and ascending colon,
that together with these two structures it
forms the anterior wall of the retrocolic
pouch of peritoneum.
Table – 1 : Incidence of position of vermiform appendix
Position
Incidence
(%)
1
Retrocaecal
8248
51.14
2
Pelvic
6820
42.29
3
Subcaecal
843
5.23
4
Anterior (preileal)
83
0.51
5
Posterior (Postileal)
129
0.80
6
Ectopic
5
0.03
Out of the total number of 16128 individuals
observed, 9878 were males and 6250 were females,
and the corresponding positions are depicted in
Table–2.
7 d. It may be extra peritoneal owing to the fact
that retro–colic pouch has been obliterated.
e. It may be quite free from the posterior
surface of the caecum and colon but
adherent to the posterior abdominal wall.
Pelvic appendix: Here the tip of the appendix
is directed downwards on the psoas major
muscle and according to its length it may hang
over the brim of the pelvis.
Subcaecal Appendix: It lies on the iliac fossa
and the peritoneal covering of the fossa alone;
separate the organ from the iliacus muscle. The
appendix with its mesentery is twisted in a
clock wise direction from left to right, and
frequently its tip is directed upwards.
Anterior or preileal appendix: The tip is
directed upwards and forwards over the
terminal part of ileum. There is long mesoappendix frequently extending up to the tip of
the organ and there is often an ileocaecal fold.
Posterior or postileal or splenic appendix: The
tip is directed leftwards, posteriorly over the
terminal part of the ileum. An ileocaecal fold
(the blood less fold of Treves) may be present.
Ectopic positions of appendix: It may be in the
left iliac fossa as in situs inversus totalis, may
be subhepatic in position or it may be in the
umbilical region below the stomach and
transverse colon as in incomplete/ malrotation
of the gut.
Das NK et al. / Transworld Medical Journal. 2(1):69. notoriously inconsistent5, hence the importance of
the position of vermiform appendix for a surgeon.
Till 1933, it was believed that post ileal/splenic
was the commonest position of vermiform
appendix as per the teaching of Sir Frederick
Treves.6 However in 1933, Cecil PG Wakely
analyzed 10,000 case and reported that retro-cecal
position as the commonest position at 65.28%,
followed by pelvic position at 31.01%, subcaecal
2.26%, preileal 1%, and post ileal/splenic 0.4%.7
Table 2: Position of appendix in relation to sex
Males
Females
Position
Incidence (%)
Incidence (%)
Retrocaecal
5532(56.00)
2716(43.46)
Pelvic
3822(38.69)
2998(47.97)
Sub-caecal
433(4.38)
410(6.56)
Anterior
49(0.50)
34(0.54)
(pre-ileal)
Posterior
39(0.39)
90(1.44)
(Post-ileal)
Ectopic
3(0.03)
2(0.03)
Out of 16,128 individuals, 1,428 were vegetarian
and rests 14,700 were non-vegetarians. The various
positions of vermiform appendix in relation to diet
is depicted in Table–3.
Since then all the standard text books in medical
literature categorically says that the retrocecal
position of vermiform appendix is the commonest
at 61% to 65%, followed by pelvic position at 25 to
30%.
Table– 3 : Position of appendix in relation to diet
Position
Retrocaecal
Pelvic
Sub-caecal
Anterior (preileal)
Posterior
(Post-ileal)
Ectopic
Vegetarians
Incidence (%)
659(46.15)
713(49.93)
30(2.10)
9(0.63)
17(1.19)
0
Non-vegetarians
Incidence (%)
7589(51.63)
6107(41.54)
813(5.53)
74(0.50)
Thereafter there have been various studies from
various geographical regions regarding the
position of appendix. However most of these
studies were based on less number of
observations. As per a study in the USA, the
incidence of retrocecal position of appendix was
the highest.8 A study from Dhaka region of
Bangladesh retrocecal position was the highest.9
However, a similar study from the same country
but from a different region of Mymensing,
revealed pelvic appendix as the highest in
incidence.10 A laparoscopic study by Irfan et al,
revealed pelvic appendix at 51.2%, post ileal at
22.1% and retrocecal position at 20.1%.11 As per the
study in South East Caspian sea region (Gorgian
Iran) pelvic position was the predominant position
at (33.3%) followed by retrocaecal (32.4%), reileal
(18.8%), Subcaecal(12.8%) and postileal (2.6%).12
112(0.76)
5(0.04)
Out of 16,128 individuals observed, 10,030 were
suffering from appendicular pathology either in
form of acute appendicitis mostly, or in the form of
recurrent appendicitis. The various positions of
vermiform appendix in relation to appendicular
pathology is shown in Table–6.
Table 4: Relationship of appendicular position with
pathology
In nonIn appendicular
appendicular
Position
pathology
pathology
Incidence (%)
Incidence (%)
Retrocaecal
5798(57.81)
2450(40.18)
Pelvic
3656(36.45)
3164(51.89)
Sub-caecal
436(4.35)
407(6.67)
Anterior
51(0.51)
32(0.52)
(pre-ileal)
Posterior
89(0.89)
40(0.66)
(Post-ileal)
Ectopic
0
5(0.08)
The present study was conducted over many
geographical region of India, on a study
population of 16,128 individuals. When compared
to the other regions of the world, the food habit of
Indians is vastly different. A sect of strict
vegetarians exists in India over different regions.
In this study the rectocaecal position of appendix
is still the highest at 51.14%, but it is much less
than quoted figures of the standard text books of
Anatomy and surgery. At the same time the pelvic
appendix is observed at a higher rate 42.29%.
Discussion
Variation in position of vermiform appendix
makes the clinical presentation of appendicitis
Regarding the relationship of the appendix
position and the sex of the individual there are not
8 Das NK et al. / Transworld Medical Journal. 2(1):69. many studies available in the medical literature. In
the present study the pelvic position is found to be
the highest at 47.97% in female patients. However
in the study in Bangladesh the pelvic position was
seen mostly in male.9
O’ Connel P. The vermiform appendix. In: Baily and
Loves Short practice of Surgery, 23rd Ed, London,
UK. Arnold publication 2000;11:1076-92.
4. Kozar RMA, Roshyn J. The Appendix, Principle of
surgery. 7th international Edition. McGraw–Hill
Health Profession Division 1992: 1389–94.
5. Ohmann C, Young Q, Frank C. Diagnostic score for
Acute Appendicitis. Eu J Surg. 2002;16:273-81.
6. Treves F. British Med J. 1885:1.
7. Walkey CPG. The position of the vermiform
appendix as ascertained by an Analysis of 10,000
cases. J Aanal. 1933;67(2):277-83.
8. Oto A, Ernst Rd, Mileski WJ et al. Localisation of
appendix with MDCT and influence of finding on
choice of appendectomy incision. AJR. 2006;187:98790.
9. Paul UK, Naushaba H, Begum T et al. Position of
vermiform appendix: A postmortem study.
Bangladesh Journal of Anatomy. 2009;7(1):34-6.
10. Rahman MM, Khalil M, Rahman H, et al.
Anatomical positions of vermiform appendix in
Bangladeshi people. J Bangladesh Soc Physiol.
2006;1:5-9.
11. Ahmed I, Kristfan S, Asgehrrsiow, et al. The
position of the vermiform appendix at laparoscopy.
Surgical and Radiological Anatomy.2007;29(2):1658.
12. Golalipour MJ, Arya B, Azarhoosh R, et al.
Anatomical variations of vermiform appendix in
South-East Caspian Sea (Gorgan-IRAN). J Anat Soc
India. 2003;52(2):141-3.
3.
Regarding the relationship of appendix position
and the food habits of the individuals, the present
study is the only study known so far. In
vegetarians, the pelvic appendix is the highest at
49.93% the non-vegetarians the retrocaecal is the
highest at 51.63%.
Regarding the relationship of position of appendix
and its pathology in the form of appendicitis, there
is a higher incidence of retrocecal position of
position of appendix at 57.81% in individuals
suffering from appendicitis. However in
individuals who are not suffering from
appendicular pathology, pelvic position is seen at
51.89%. It is suggested that the vermiform
appendix may be more liable to inflammation
when fixed retrocecally, because the blood vessels
could be compressed or kinked by caecum.
Conclusion
In Indian population, the position of vermiform
appendix is at variance when compared to the
others.
Cite this article: Das NK, Kumar KLS, Mohanty
P. Position of Vermiform Appendix in Indian
population- a case report. Transworld Medical
Journal. 2014;2(1):6-9.
References
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2.
Hardin DM. Acute Appendicitis: Review and
Update. Am Fam Physician. 1999;60:2027–34.
Harrington JL Jr. The vermiform appendix: its
surgical history. Contemp Surg.1991;39:36-43.
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