McBurney`s point Are we missing it?

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McBurney`s point Are we missing it?
Surg Radiol Anat (2002)24:363 365
DOI 10. 1007/s00276-002-0069-7
V. Naraynsingh'M.J. Ramdass'J. Singh
R. Singh-Rampaul'D. Maharaj
point Arewe missingit?
McBurney's
Received:4Ju1y2001/Accepted:12July2002/Publishedonline:18December2002
@ Springer-Ver|ag2002
Abstract A prospectivestudy of 100 post-evacuation
barium enemas was done. Films were centered at
McBurney'spoint, with an opaqueskin marker at that
point. Analyiis of theserevealedthat in only one case
McBurney'spoint'
itX; *ut the baseof the appendixat
was caudalto this
it
32oh
i" ely" it was cephalicand in
potnt as an anaMcBurney's
point. The limitationsof
This needsto be
recognized.
be
should
iomical landmark
to surgical
especially
anatomy,
in
teaching
highlighted
incisions
surgical
of
choice
and
Planning
triineis.
should be basedon an understandingof theseanatomical variationssinceMcBurney'soriginaldescriptionwas
clinicalratherthan anatomical.
The Frenchversionof this article is availablein the form
of electronicsupplementary
^Springer materialand can be obtained
Link server located at http ll
by using the
-7'
6-002-0069
1
007/s0027
1
0.
dx.doi.org/
limitesdu point de McBurneycommerepdreanatomique
doivent 0tre connues.Cela devrait 6tre soulignedans
de I'anatomie,notammentpour lesfuturs
l'enseignement
chirurliens. Pr6voir et choisir une voie d'abord chirdes varidevrait 6tre bas6esur la connaissance
urgical"le
de
originale
la
description
atilonsanatomiquespuisque
qu'anatomique'
plus
clinique
McBurney6tait beaucoup
KeywordsMcBurney'spoint' Vermiformappendix'
Anatomical variation
lntroduction
More than a century ago, McBurney describeda point
in acuteappendicitis,stating"the
of maximaltenderness
seatof greatestpain, determinedby the pressureof one
finger,lias beenvery exactlybetweenan inch and a half
uni tro inchesfrom the anterior spinousprocessof the
Le point de McBurney: va-t-il disparaitre?
ilium on a straight line drawn from that processto the
100
sur
umbilicus" [10]. The landmark for the base of the apR6sum6Une 6tude prospectivea 6t6 r6alis6e
Ces
clich6s
oendixas desciibedin textbooksas "the junction of the
clich6saprds6vacuationde lavementbaryt6'
par
un
marqu6
iateral and middle thirds of a line extendingfrom the
6taientcentr6ssur le point de McBurney,
a
radiographies
ces
de
right anterior superioriliac spine(ASIS)-to the umbilirepdrecutan6opaque.L'analyse
de
la
base
(l'h),
seulement
cas
.,ir" in fact inaccuratelymisquotes McBurney's demlntr6 que, dins un
a surface
I'appendiiecorrespondaitau point de McBurney' Dans scription [15]. Otto Lanz also described
the
as.one-third
cetteLase6taitplusc6phaliqueet, dans3270 -uiking of til. base of the appendix
ein aescas,
joining
two
the
line
a
point'
Les
distancJfrom the ASIS along
descas,elle6tait plus caudalepar rapport d ce
anterior superior iliac spines[B]. Naturally, the point
by Lanz lies inferior to McBurney's point'
The French version of this article is availablein the form of elec- described
using,th-e
by
by some studies[7, 13]' To further
obtained
be
supported
can
is
and
which
tronic supplementarymaterial
servei located at http://dx'doi'org/10' 1007/s00276- confusethJ picture, the World Organizationof GastS'pG"i'il"t
002-0069-7
roenterologyhas shownthat lessthan half of all patients
with appendicitis have maximal tenderness over
V . N a r a y n s i n g h ' M . J .R a m d a s s( X ) ' J ' S i n g h
McBurney'spoint [4]. Additionally' the variation in the
R. Singh-RamPaul' D. Maharaj
Hospital,
position of ttt. upp-.ttdixdependson the.rotationof the
Department of Surgery,General
Poit-of-Spain, Trinidad, West Indies
mesentericloop ind the McBurney'spoint is the point
E-mail: [email protected]
wheresomaticpains project in the parietalperitoneum'
Fax: * 1-868-6639064
The aim of this prospectivestudy was to determine
M.J. Ramdass
site of the baie of the appendix using doublethe
100 East Drive, Champs Fleurs, St. Joseph,
contrastpost-evacuationbarium enemas'
Trinidad, West Indies
364
intra-abdominalsurgeryor non-visualizationof the appendixwere
excluded from the study. The first 100 patients without these
exclusioncriteria were studied.
Materialsand methods
A study consistingof 100 consecutivepatients attending the General Hospital, Port-of-Spain, Trinidad was done. Each patient
underwent double-contrast barium enemas for suspectedlarge
bowel disease.There were 45 malesand 55 females(maie to female
ratio 1:1.2) rangingin agefrom 5 to 82 years(mean27 years).Prior
to the film, a radiopaque marker was placed on the skin at the
junction of the lateral and middle thirds of a line joining the right
ASIS to the umbilicus (McBurney's point). The post-evacuation
view was centered at McBurney's point to minimize off-center
geometric magnification. All examinationswere performed on a
remote-controlledfluoroscopicunit. Films were done in the supine
oosition to mimic the situation in which clinical examination
and surgicalproceduresare carried out (Fig. 1). Al1 patients with
right colon disease,any form of intestinal obstruction, previous
Results
In 67o/oof the patients the base of the appendix was seen
to lie cephalic to McBurney's point with a mean of
4.2 cm and a range of l-10 cm. In 32oh of the patients
the base of the appendix was seencaudal to McBurney's
point with a mean of 4.9 cm and a range of 1-10 cm
(Table 1). In one patient the base of the appendix did
correspond to McBurney's point (1%).
Discussion
Fig, I Supine radiograph of a double-contrast barium enema
showing the relationship between McBurney's point and the
appendix base. Three radiographic markers (one at the anteriorsuperior iliac spine, one at the umbilicus and one at McBurney's
rroint) were used to illustrate the surfaceanatomy
Table I The relationshipof the
appendix base in cephalic and
caudal directions to McBurney's point (cm)
Numerousstudieshave demonstratedthe variability of
the appendixin relation to the cecum[3, 9]. However,
its preciseanatomvery few publicationshave assessed
ical relationto McBurney'spoint. Ramsdenet al. !3]
a more caudalpositionin most subjects.
demonstrated
Our study,however,showedthat the appendixliesmore
cephalic.This may representa racial variation. our patients being primarily of African and East Indian descent.The variancecannot be due to a distendedcecum
as all films were performed post-evacuation,and secondly, a view centeredat McBurney'spoint to minimize
off-centergeometricmagnificationthat may occur with
the typical cecalview was employed.
Regardlessof the position of the baseof the appendix, thesefindings have clinical significancesincesome
surgeonsstill employ the classicMcBurney'sincision
[11].The obliquityof the skin incisionmay compensate
for the variation in position by allowing accessto the
cecumand appendixbasethat may lie superioror inferior to this point. Occasionally,it is still difficult to gain
accessthrough this incisionand the Kocher'smodification (musclecutting) or the Fowler-Weir incision (extending into the rectus sheath) may be necessaryto
perform the appendicectomy[2]. However, many surgeonsare now using the more cosmeticallyacceptable
transverseskin incision where upward and downward
Distanceof appendix base
from McBurney's point (cm)
No. of patientswith appendix
basecephalicto McBurney's
polnt
I
2
3
4
5
6
7
8
9
10
6
t8
9
6
8
o
1
I
2
4
Total
6'.7
Mean4.2cm
No. of patientswith appendix
basecaudal to McBurney's point
6
2
2
A
'/
A
A
0
1
2
JL
Mean 4.9 cm
:
K, KjaelgaardA (1973)lnvestigationand analysisof
may be more dimcult[1, 5, 6, 8, 15]'A min- 3. Buschard
extensions
position, fiiation, length and embryologyof the vermilorm
the
imally invasivetechniqueemploying a transverse1'5appendix. Acta Chir Scand 139: 293-298
in our setting[12]'
+. Oe Dombal FT (1988) The OMGE Acute Abdominal Pain
2.0 cm incisionhas beendescribed
Survey.ProgressReport. ScandJ Gastrol 23 3542
The marked variation in the position of the baseof
5.
Delany HM, Carnevale NJ (1976) A "bikini" incision for
clinically
point
is
the appendixin relationto McBurney's
appendectomy.Am J Surg 132 12c_.12'7
wheneverthe base
signifiiant.In the authors'experience,
6. JelenkoC 3rd, Davis LP (1973)A transverselower abdominal
iies caudal to this point it is usually
oi th. appendix
appendectomy incision with minimal muscle derangement'
-to
apan
perform
and
appendix
Surg Gynecol Obstet 136: 451452
the
possible deliver
(1990) McBurney's
pendicectomywithout having to extendthe transverse 7. Karlm OM, Boothroyd AE, Wyllie JHEnel72:304-308
Surg
R
Coll
point.
Fact
or
fiction?-Ann
incision.However,when it lies cephalicto McBurney's 8. Lanz O (1908)Der McBurneyschenPunkt. Zentralbl Chir 35:
to the cecumand appendixis considerably
ooint. access
18 5 - i 8 6
more difficuit and muscle-cuttingextensionsare more 9. Maisel H (1960)The position of the vermiform appendixin
fetal and adult age groups. Anat Rec 136 204-205
often necessary.
10. McBurney C (l8iigtExperiencewith early operativeinterfertransverse
using
surgeons
for
It is thereforeimportant
of the verrniformappendixN Y Med J
encein casesof disease
skin incisionsto considerperformingthe rnuscle-split50: 6'76-617
ting techniquewhen tire appendix lies cephalicto ll. McBurneyC (1894)The incisionmade in the abdominalwall
in casesoi appendicitis.with a descriptionof a new rnethodof
MJBurney'spoint in order to gain easieraccessto the
n n e r a l i n s A n n S r r r g? 0 : 3 8 - 3 9
for
baseof the appendix[12].This minimizesthe need
12. Pouchet-B,RarnpaulR. Maharaj D. RamcharanK, Kuruvilla
of
mobiiization
and extensive
muscle-cutting-extensions
T. NaraynsinghV (1999)Mini accessopen appendicectomy
the cecum,and surgeonsin training may need to be
West Indian Med J 48: 27-28
made more aware of the limitations of the popular 13. RarnsdenWH, Mannion RA. SimpkinsKC, de Dombal FT
( 1993)Is the appendixwhereyou think it is?And if not, doesit
McBurney'sPoin1.
matter?Clin Radiol 47: 100-103
References
l. Amir-JahedAK (1977)The cul-de-sacapproach for appendectomy.Am .l Surg 134:656-658
2. Askew AR (1975)fhe Fowler-Weirapproachto appendicectomy. Br J Surg 62: 303-304
14. SabistonDC, Lyerly HK (1997)Sabistontextbookof surgery:
the biologicalbasisof modernsurgicalpractice,l9th edn' WB
p 965
Philadelphia.
Saunders,
15. TempleWJ (1990i Bikini appendectomyincisionas an alternative to the McBurney approachfor appendicitis Can J Surg
33 343-344