ISSN: 2595-7651

Acta Sci Anat. 2019;1(2):144-147.

Topographic presentation of the

Appendix in 100 cases
Raquel Libanesa Rosario Beltré1,2, Reginaldo Franklin1,3

ABSTRACT
Introduction: The term vermiform appendix comes from the Latin vermis which means worm-shaped. The
appendix is a muscular cylindrical canal of reduced lumen with the presence of lymphoid tissue, usually 3 to
20 cm in length. It projects itself from the posteromedial face of the cecum, 2.5 cm inferior to the ileocecal
junction, although this is prone to vary. We aim to identify the anatomical presentations of the vermiform
appendix in cases of necropsies according to gender. Material and Methods: One-hundred random cases of
necropsies were included in this work. The appendix was identified in situ and classified according to the
implantation of its base at the cecum and the position of its tip. The findings were classified according to
official nomenclature, with 50 female cadavers and 50 male cadavers. Results: The most frequent anatomic
position was retrocecal for both genders, representing 49%, followed by pelvic position with 27% and subcecal
with 21%. Post-ileal and paracecal positions were not found. For the female sample the appendix was
retrocecal in 24%, pelvic in 16% and subcecal in 8% of cases. For the female sample the appendix was
retrocecal in 25%, subcecal in 13% and pelvic in 11% of cases. Conclusions: As such, the anatomic-
topographic presentation with the most frequency was retrocecal for both genders. Comparatively, the male
sample had a higher prevalence of the subcecal presentation of the appendix.

Keywords: topographic anatomy, vermiform appendix, retrocecal, pelvic, subcecal

INTRODUCTION The most common position of the appendix

The vermiform appendix (Latin: vermis,
worm-shaped). It is an anatomical projection that
usually originates from the base of the cecum. It is a
"diverticulum" or, specifically, a cylindrical canal of
reduced light with the presence of lymphoid tissue,
projecting itself by invagination at the posteromedial
aspect of the cecum, distal and inferiorly 2.5 cm
from the ileocecal junction [1, 2].
The vermiform appendix presents a serous
peritoneal layer, which fixes it in the inferior portion
of the mesentery, named mesoappendix - giving
passage to the appendicular vessels and nerves.
This triangular peritoneal reflection is short, deriving
from the terminal mesentery of the ileum, posteriorly
[3, 4].
is retrocecal. However, the free tip of the appendix
can be positioned in several directions, either to the
right pelvic wall or to curl in the direction of the
retrocecal recess, anteriorly or posteriorly towards
the terminal ileum. The appendix lies,
topographically, 5 cm from the lateral end of an
imaginary line from the anterior superior iliac spine
to the umbilical scar (McBurney’s point) [3, 4].
Considering the cecum as a reference, we can have
the following types: internal lateral, external lateral,
descending and retrocecal.
According to Wakeley (1933) [5] the most
common appendicular positions are, respectively,
retrocecal (65.3%); pelvic (31.6%); subcecal (2.3%);
in the paracolic gutter (0.4%); in a postero-ileal

1Medicolegal Institute, Rio de Janeiro, Brazil.

2Anatomy Department, Rio de Janeiro State University, Rio de Janeiro, Brazil.
3Legal Medicine Department, Medical School, Grande Rio University (UNIGRANRIO), Rio de Janeiro, Brazil.

Corresponding author: Raquel Libanesa Rosário Beltré, MD, MsC - raquel_rosario7@hotmail.com


The appendix in Brazilians
position (0.4%), corroborating with O'Connor and
Reed (1994) [6].
The ileoceoapendicular area is supplied by:
the ileocolic artery, terminal branch of the superior
mesenteric artery and which irrigates the cecum.
The ileocolic vein, tributary of the superior
mesenteric vein, is responsible for draining the
blood from the cecum and the appendix. In addition
to the role of regional defense, the lymphatic vessels
from the cecum and the appendix follow the ileocolic
lymph nodes, distributed in the vicinity of the
ileocolic artery and from there to the superior
mesenteric lymph nodes [4].
Regarding the its innervation, we highlight
the sympathetic fibers originating from the
sympathetic nerves of the 10th thoracic segment
and the parasympathetic fibers of the vagus nerve,
which concentrate at the level of the superior
mesenteric plexus [3,4].
The importance of the vermiform appendix
lies in the peculiarity of being target for pathologies,
the most common being acute appendicitis, being
more common in males. This pathology is
considered a common surgical emergency and its
diagnosis and early treatment directly influence its
prognosis [1].
In 1889, Charles McBurney established
techniques and the clinical management of
appendicitis that are actively used in our times. Its
clinical manifestations are different according to the
location of the appendix [7], and the age group
between 5 and 45 years is more affected by
functional histological changes in the tissue [8]. An
appendicular inflammatory picture in the elderly
leads to the investigation of neoplasms in the
cecum, appendix or terminal ileum [9].
Since the pathology affecting this organ is
one of the most common surgical emergencies and
without rapid diagnosis and treatment it can lead to
the death, more information is needed regarding the
location of the vermiform appendix in the population
of Rio de Janeiro.
MATERIAL AND METHODS
The study was carried out at the Afrânio
Peixoto Medical Medical Institute (Rio de Janeiro,
Brazil), with ethical approval from the
aforementioned institution.
145
The sample consisted of 100 necropsies
performed in the rooms of the institute, randomly
selected. In total, there were 50 men and 50 women.
During the autopsy, the identification of the
vermiform appendix was performed in situ according
to the implantation of the organ base in the caecum
and the position of its tip.
Prior to the analysis, we excluded any
corpses with previous surgeries or lesions in the
abdominal region that altered the anatomy of the
site and patients without the vermiform appendix.
The findings were then classified according
to the types of anatomical location in retrocecal,
pelvic, pre-ileal, post-ileal, subcecal and paracecal.
RESULTS AND DISCUSSION
Regarding the anatomical position, the
results are presented in Table 1. Mainly, the sample
showed a frequency of 49% of the retrocecal
appendices (Figure 1). The others had the following
frequency: pelvic (27%), subcecal (21%) and pre-
ileal (3%) (Figures 2, 3 and 4, respectively), post-
ileal and paracecal topographies were not found in
the sample.
Table 1: Overall situation of the appendix.
Position n %
Retrocecal 49 49%
Subcecal 21 21%
Pelvic 27 27%
Post-ileal 0 0%
Pre-ileal 3 3%
Paracecal 0 0%
Total 100 100%
Regarding the gender, the data showed
greater frequency of retrocecal appendicitis in males
and pelvic females (Table 2), and were corroborated
by the study of Collins (1963) [10], which observed
respectively the frequency of 47% (retrocecal) and
33% (pelvic). In the series by Wekeley et al. (1933)
[5], 31% of appendix cases with pelvic topography
were observed.
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The appendix in Brazilians

Figure 1: Retrocecal appendix (white arrow) and the

caecum (black arrow).
Figure 3: Subcecal appendix (white arrow) and the caecum

Figure 2: Pelvic appendix (white arrow) and the caecum

(black arrow). Figure 4: Pre-ileal appendix (white arrow) and the caecum

The retrocecal data maintained the same

Table 2: Position of the appendix by gender. prevalence percentage for both genders 24% and
Position Male Female Total 25%, which is in agreement with the results of
% % % Verdugo and Olave (2010) [11]. The pelvic and
Retrocecal 25% 24% 49% subcecal presentations presented the same
Subcecal 13% 8% 21% prevalence for the masculine gender with a low
Pelvic 11% 16% 27% differentiation of 2% between them, results similar to
Post-ileal 0% 0% 0% those of Maisel (1960) [12].
Pre-ileal 1% 2% 3%
Paracecal 0% 0% 0%
Total 100%
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The appendix in Brazilians

CONCLUSIONS 4. Moore KL, Dalley II AF, Agur AMR. Clinically

It is of great importance to consider the
position of the appendix as an indicator of the type
of incision. Clinical manifestations are essential for
the orientation of the surgical approach, aided by
complementary exams such as ultrasonography.
New non-operative approaches have taken
the initiative with satisfactory results. In some cases
appendectomies are performed even without evident
pathology as strategy to avoid appendicitis.
CONFLICTS OF INTEREST
The authors declare no conflicts of interest.
ACKNOWLEDGMENTS
None.
REFERENCES
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5. Wakeley CPG. The Position of the
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RESUMO
Apresentação topográfica do apêndice vermiforme em 100 casos
Introdução: O termo apêndice vermiforme vem do latim “vermis”, que significa em forma de verme. O
apêndice é um canal cilíndrico muscular de luz reduzida com a presença de tecido linfóide, geralmente de 3 a
20 cm de comprimento. Ele se projeta a partir da face póstero-medial do ceco, 2,5 cm inferior à junção
ileocecal, embora isso seja propenso a variar. O objetivo deste trabalho é identificar as apresentações
anatômicas do apêndice vermiforme em casos de necropsias de acordo com o gênero. Material e Métodos:
Cem casos aleatórios de necropsias foram observadas (50 homens e 50 mulheres). O apêndice foi
identificado in situ e classificado de acordo com a literatura. Resultados: A posição anatômica mais frequente
foi retrocecal para ambos os sexos, representando 49%, seguida pela posição pélvica com 27% e subcecal
com 21%. Posições pós-ileais e paracecais não foram encontradas. Para a amostra feminina, o apêndice foi
retrocecal em 24%, pélvico em 16% e subcecal em 8% dos casos. Para a amostra feminina, o apêndice foi
retrocecal em 25%, subcecal em 13% e pélvico em 11% dos casos. Conclusões: Assim, a apresentação
topográfico-anatômica com maior frequência foi retrocecal para ambos os gêneros. Comparativamente, o
sexo masculino apresentou maior número da apresentação subcecal do apêndice.
Palavras-chave: anatomia topográfica, apêndice vermiforme, retrocecal, pélvico, subcecal