Appendiceal
Duplication - A Rrare Condition with Serious Clinical
and Medico Legal Implications - Case report
.........................................................................................................................
Dr. Mohammed Nayef Al-Bdour, MD, JBS
Dr. Mohammed Ahmed Rashaideh, MD, JBS
Dr. Malek Abdelkareem Alkasasbeh, MD, JBS
Dr.Jameel Sa'ud Shawaqfeh, MD, JBR
Correspondence to:
Dr. Mohammed Al-Bdour, MD, JBS
Department of Surgery, KHH, Royal medical services,
Amman, Jordan
Po. Box 825, Jubiha 11941, Amman, Jordan
Mbdooor@yahoo.com
|
ABSTRACT
Appendicectomy
is usually left for junior surgical resident
to perform. Though rare, a greater awareness
of this entity among junior surgical residents
is essential.
A review of the
literature, with discussion about the
different forms of appendiceal duplication,
with concentration on clinical and medico
legal significance of this finding.
We present a case
of appendiceal duplication, discovered
incidentally intraoperatively.
A 20-year old male patient was admitted
to the surgical ward in our military field
hospital in Iraq, with symptoms and signs
of acute appendicitis. Intraoperatively
the patient was found to have appendiceal
duplication, appendectomy performed successfully,
with smooth post operative course.
Key
words: appendiceal duplication, vermiform
appendix, appendectomy.
|
A twenty -year-old male presented
to the emergency room with 48-hour history of
per umbilical and right lower quadrant (RLQ)
abdominal pain, vomiting, and anorexia.
The physical exam was significant
for low grade fever, localized RLQ tenderness
and guarding. Both rebound and cough signs were
positive.
The patient's white blood
cell count (WBC) was 15,000, his blood chemistry
and urine analysis were within normal. Abdominal
ultrasound was reported free.
The patient was admitted
and taken to the theatre for appendectomy, intra
operative findings were two appendices with
two separate bases (figure 1,2,3,4), one of
them showed gross signs of inflammation with
no evidence of perforation. Appendectomies were
performed successfully through grid-iron incision.
The patient had a smooth
postoperative course and was discharged home
on the third day of admission.
The anomalies of the vermiform appendix are
rare; appendiceal duplication is reported with
an incidence of 0.004%1
Appendiceal anomalies include anomalous location
of a single appendix, horseshoe anomaly of the
appendix, agenesis, duplication, and triplication2.
Double appendix is usually asymptomatic, the
majority of them are diagnosed at surgery or
on postmortem examination, and some of them
can be discovered accidentally or preoperatively
on barium enema3.
Cave and Wall Bridge have classified the duplication
of appendix into three types. A: Partial duplication
of the appendix on a single caecum; B: Single
caecum with two completely separate appendices;
B1: "Bird-like appendix" called so
because of its resemblance to the normal arrangement
in birds, where there are two appendices symmetrically
placed on either side of the ileo-caecal valve;
B2: One appendix arises from the usual site
on the caecum, with another rudimentary appendix
arising from the caecum along the line of one
the taenia coli; and C: Two caeca, each bear
an appendix. The present case represents Type
B1 of appendicular duplication4.
When only one of the double appendixes is inflamed
on exploration or laparoscopy appendectomy should
be done for both of them so as to avoid diagnostic
confusion that may arise on removal of a single
appendix5.
Appendectomy is usually left for junior surgery
residents to perform, although congenital anomalies
of the vermiform appendix are rare; awareness
of them during performance of an operation carries
important clinical and medico-legal implications.
- Kjossev KT, Losanoff JE. Duplicated vermiform
appendix. British Journal of Surgery 1996;
83:1259.
- Mesko T. Horseshoe anomaly of the appendix:
A previously undescribed entity. Surgery 1989:563-66.
- Mitchell IC, Nicholls JC. Duplication of
the vermiform appendix. Report of a case:
Review of the classification and medico legal
aspects. Medicine, Science, Law 1990; 30(2):124-26.
- Walbridge PH. Double appendix. Br J Surg
1962; 50:346-7.
- Lin BC, Chen RJ, Fang JF, Lo TH, Kuo TT.
Duplication of the vermiform appendix. Eur
J Surg 1996; 162:589-91.
|
