Vol 44 # 4 December 2012 - Kma.org.kw

331
Double Appendix: Report of a Case
December 2012
Wallbridge [6] modified Cave’s [5] original
classification of duplicated vermiform appendix into
three types as follows:
A: Partial duplication of the appendix on a single
cecum
B: Single cecum 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-cecal valve
B2: One appendix arises from the usual site on the
cecum, with another rudimentary appendix arising
from the cecum along the line of the tenia at varying
distance from the first
C: Two ceca, each bearing its own appendix
Though majority of the cases are diagnosed at
surgery or on postmortem examination, some of the
cases can be picked up preoperatively on barium enema.
Peddu et al reported an incidental finding of Type B1
double appendix by barium enema in a 73-year-old
man who was investigated for the rectal bleeding [7] .
In such cases the patient may be informed about the
abnormality; however the role of conventional /
laparoscopic appendectomy for the removal of the
asymptomatic double appendix has not been welldefined.
Although preoperative diagnosis could be
made with the aid of radiological studies such as a
barium enema, in cases associated with duplication
of colon, the majority of cases have been diagnosed at
surgery or upon pathological examination [8] .
The present case represents type B2 of appendicular
duplication, thought to represent the persistence of the
“transient appendix”. Duplication of the vermiform
appendix must be distinguished from a solitary
diverticulum of the cecum [5,6] . True double appendices
have lymphoid tissue and muscular walls, but a cecal
diverticulum does not contain lymphoid tissue and is
merely an out-pouching of mucosa and submucosa
through a muscular defect [5,6] . In the current case, there
were two separate appendices which were proved
microscopically.
Some cases of double appendix are associated with
intestinal, genitor-urinary or vertebral malformation [8,9] .
We should be aware of these possible malformations
and the patient should be explored for the same at
time of operation. The risk of associated malformation
seems to be greater in young children, especially those
with type B1 and C malformations [9] . In our present
case, double appendix was incidentally found while
performing laparoscopic appendectomy and we did
not find any other gastrointestinal congenital anomalies
like intestinal duplications that were commonly
associated with double appendix. But she had other
anomalies like scoliosis and skin lesions which were
recorded for further notification with double appendix
in the future. Kothari et al [3] reported duplex appendix
in association with imperforate anus [3] .
In patients with double appendix, when only a
single appendix is found to be inflamed on exploration
or laparoscopy, both the appendices should be
removed so as to avoid diagnostic confusion that may
arise on removal of a single appendix [10] . To the best of
our knowledge, surgical management for the double
appendix is same as the conventional / laproscopic
appendectomy. No literature describes any unique
technique for double appendix differently. However,
one should explore for the possible associated
malformation. In the current case, only the bigger and
longer appendix was inflamed, however we removed
both the appendices including the smaller noninflamed
one.
CONCLUSION
Double appendix is extremely rare. Surgical
residents should be aware of the possibility of
duplication of appendix to avoid missing double
appendix and its medico-legal consequences.
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