Sub-hepatic vermiform appendix and associated anomalies: a case report

The vermiform appendix is an out-pouching from the caecum in the shape of a blind ended tube. The position of its base is fixed in relation to the caecum, though the size, shape and direction of the appendix may vary. The commonest position found during surgeries is the retro caecal position. Nevertheless, recent radiological studies suggest a retroileal position as the commonest among all. The caecum is usually found in the right iliac fossa and hence the appendix too is found there. Since appendicitis is one of the commonest scenarios which require surgical intervention, it is important to understand its variations in relation to its position. During routine dissection of an adult male cadaver in Department of Anatomy, Faculty of Medicine, University of Peradeniya, the caecum was found to be in the right sub hepatic region and the right iliac fossa was empty. The appendix was behind the caecum (retrocaecal) and it was 5.1 cm in length in cephalic direction. The tip of the appendix was located 0.9 cm below the liver and was lying over the right kidney. This was about 2.5 cm away from the ileocecal junction. Further the ascending colon was found to be short, underdeveloped and 1 cm in length. An abnormal arterial supply too was observed. There was only one artery representing both ileo-colic and right colic arteries which supply the caecum including the appendix and the very short ascending colon. At the distal part of the ascending colon, this artery anastomosed with the middle colic artery that supplied the remaining part of the midgut derivatives During intrauterine life, failure in elongation of the colon that is returned into the abdominal cavity causes sub hepatic caecum, appendix and short ascending colon. Further this may be the reason for the arterial variation that was observed here. Awareness of such variations is important in the diagnosis and management of situations such as acute appendicitis where surgical intervention is necessary.