McBurney's point—Fact or fiction?

Abstract

Anthropometric measurements were performed on 51 normal, supine, barium enema examinations to determine the position of the lower pole of the caecum and the base of the appendix relative to palpable bony landmarks (the anterior superior iliac spine and the symphysis pubis). Four quadrants were defined (iliac, umbilical, inguinal and pelvic) by the intersection of the right lateral line and the interspinous line (the line joining the left and right anterior superior iliac spines). The position of the lower pole of the caecum was iliac in 12%, inguinal in 37%, and pelvic in 51%. The appendix or appendix stump was visualised on 53% of the barium examinations. The position of the appendix was iliac in 15%, umbilical in 15%, inguinal in 11%, and pelvic in 59%. The positions of the lower pole of the caecum and base of the appendix are lower and more medial than previously described. 70% of appendices were found to lie inferior to the interspinous line, contrary to established surgical teaching, which assumes McBurney's point to be the surface landmark for the appendix.

Full text

Annals
of
the
Royal
College
of
Surgeons
of
England
(1990)
vol.
72,
304-308
McBurney's
point
fact
or
fiction?
Omar
M
Karim
FRCS
Registrar,
Academic
Unit
of
Surgery
Anne
E
Boothroyd
FRCR
Senior
Registrar,
Department
of
Radiology
John
H
Wyllie
FRCS
Professor
of
Surgery
Whittington
Hospital,
London
Key
words:
Appendix;
Caecum;
Barium
enema
Anthropometric
measurements
were
performed
on
51
normal,
supine,
barium
enema
examinations
to
determine
the
position
of
the
lower
pole
of
the
caecum
and
the
base
of
the
appendix
relative
to
palpable
bony
landmarks
(the
anter-
ior
superior
iliac
spine
and
the
symphysis
pubis).
Four
quadrants
were
defined
(iliac,
umbilical,
inguinal
and
pelvic)
by
the
intersection
of
the
right
lateral
line
and
the
inter-
spinous
line
(the
line
joining
the
left
and
right
anterior
superior
iliac
spines).
The
position
of
the
lower
pole
of
the
caecum
was
iliac
in
12%,
inguinal
in
37%,
and
pelvic
in
51%.
The
appendix
or
appendix
stump
was
visualised
on
53%
of
the
barium
examinations.
The
position
of
the
appendix
was
iliac
in
15%,
umbilical
in
15%,
inguinal
in
11%,
and
pelvic
in
59%.
The
positions
of
the
lower
pole
of
the
caecum
and
base
of
the
appendix
are
lower
and
more
medial
than
previously
described.
70%
of
appendices
were
found
to
lie
inferior
to
the
interspinous
line,
contrary
to
established
surgical
teaching,
which
assumes
McBurney's
point
to
be
the
surface
landmark
for
the
appendix.
the
caecum
and
terminal
ileum
(10-13).
There
has,
however,
been
only
one
radiological
study
to
determine
the
position
of
the
caecum
with
respect
to
the
pelvis
(14).
The
aim
of
this
study
was,
firstly,
to
determine
the
position
of
the
lower
pole
of
the
caecum
and
the
base
of
the
appendix
in
the
supine
position
relative
to
palpable
bony
landmarks.
Secondly,
to
ascertain
on
radiological
grounds
why
the
appendix
is
readily
accessible
through
a
low
incision
for
appendicectomy.
Various
incisions
have
been
described
for
appendi-
cectomy
(1-7).
Ever
since
McBurney
first
described
the
point
of
maximal
tenderness
in
acute
appendicitis
(McBurney's
point)
(8)
and
the
grid-iron
incision
(McBurney's
incision),
his
name
has
become
synony-
mous
with
appendicitis.
McBurney's
point
is
the
surface
marking
most
commonly
used
for
the
base
of
the
appendix
(9).
Low
incisions
for
appendicectomy
are
viewed
with
some
scepticism,
mainly
on
the
grounds
that
they
deviate
from
McBurney's
point.
There
have
been
several
studies
on
the
position
of
the
normal,
diseased
and
post-mortem
appendix
relative
to
Figure
1.
Correspondence
to:
A
E
Boothroyd,
Department
of
Radiology,
The
Middlesex
Hospital,
Mortimer
Street,
London
WlN
8AA

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306
0
M
Karim
et
al.
Methods
The
position
of
the
caecum
and
appendix
was
studied
retrospectively
in
51
normal,
supine,
barium
enema
examinations.
The
age
range
for
these
patients
was
16
to
85
years
(mean
53.0
years).
There
were
35
females
(68.6%)
and
16
males
(31.4%).
There
was
no
significant
difference
between
the
age
range
for
the
males
and
females.
The
following
anthropometric
measurements
were
made
(Fig.
1
and
Table
I):
1
The
interspinous
distance
(SS')
between
the
anterior
superior
iliac
spines,
points
S
to
S'.
2
The
distance
(SP)
from
the
right
anterior
superior
iliac
spine,
point
S,
to
the
superior
aspect
of
the
symphysis
pubis,
point
P.
3
The
distance
(SC)
from
the
right
anterior
superior
iliac
spine
to
the
lower
pole
of
the
caecum,
point
C.
4
The
distance
(SA)
from
the
right
anterior
iliac
spine
to
the
base
of
the
appendix
is
visualised,
point
A.
In
addition,
three
angles
were
measured
(Fig.
2):
1
Angle
Pa
between
the
interspinous
line
and
the
line
SP
from
the
right
anterior
superior
iliac
spine,
point
S,
to
the
symphysis
pubis,
point
P.
2
Angle
Ca
between
the
interspinous
line
and
the
line
SC
joining
the
right
anterior
superior
iliac
spine,
point
S,
to
the
lower
pole
of
the
caecum,
point
C.
3
Angle
Aa
between
the
interspinous
line
and
the
line
Sa
joining
the
right
anterior
superior
iliac
spine
to
the
base
of
the
appendix
if
visualised,
point
A.
SI|
Hc
Ha
Right
anterior
superior
IIIsca
spin.
RIGHT
LATERAL
LINE
I
Angles
Ca
or
Aa
were
designated
positive
if
the
lower
pole
of
the
caecum
or
the
base of
the
appendix
was
above
SS'
and
negative
if
below
SS'.
All
the
measurements
were
performed
by
a
single
radiologist
(AB).
Rotated
films
or
films
which
failed
to
show
adequate
filling
of
the
caecum
were
excluded
from
the
study.
We
chose
to
study
only
the
supine
radiograph
as
we
felt
it
bore
more
relevance
to
the
clinical
situation
of
a
patient
lying
supine
on
the
operating
table.
From
trigonometry,
for
a
right-angled
triangle,
HcC,
HaA
and
HpP
the
vertical
distances
of
the
lower
pole
of
the
caecum,
the
base
of
the
appendix
and
the
symphysis
pubis,
respectively,
below
the
horizontal
SS'
were
de-
rived,
were:
HcC=
sin
Ca
SC
HaA
=
sin
AaSa
HpP=sin
Pa-SP
By
Pythagoras,
SHc
and
SHa,
the
distance
of
the
lower
pole
of
the
caecum
or
base
of
the
appendix,
respectively,
medial
to
the
right
anterior
iliac
spine
were
derived:
SHc=
(SC2-
HcC2)
and
SHa=
V(SA
2-
HaA2)
HpP
is
the
mid
point
of
SS',
hence,
SS'
SHp
=
-
The
distances
SHc
and
SHa
were
divided
by
a
constant
for
each
individual,
SHp,
to
obtain
the
relative
distances,
Hp
St
Left
anterior
superior
Iliac
spine
MIDLINE
7/
p
Symphysis
pubis
Figure
2.

McBurney's
point
xc
and
xa,
of
the
points
C
and
A
respectively,
medial
to
point
S,
the
right
anterior
superior
iliac
spine.
SHc
XC
=
SHp
SHa
xa
=SH
SHp
Similarly
HcC
and
HaA
were
divided
by
the
constant
HpP
for
the
individual
to
obtain
the
relative
distances,
yc
and
ya,
of
points
C
and
A,
respectively,
above
or
below
the
horizontal
SS'.
HcC
Y
HpP
HaA
ya
=Hp
YHpP
yc
or
ya
was
designated
positive
if
the
angle
Ca
or
Aa
was
positive,
ie
point
C
or
point
A
was
above
the
horizontal
SS'
and
vice
versa.
The
use
of
ratios
enabled
meaningful
comparative
data
to
be
obtained
on
points
C
and
A
in
individuals
with
differing
physical
characteristics.
These
ratios
or
coordi-
nates
were
used
to
plot
the
position
of
the
lower
pole
of
the
caecum
and
the
base
of
the
appendix
relative
to
the
right
anterior
superior
iliac
spine
and
the
superior
aspect
of
the
symphysis
pubis.
For
descriptive
purposes,
four
quadrants
(iliac,
umbilical,
inguinal
and
pelvic)
were
identified
on
the
scatter
plot
by
the
intersection
of
the
right
lateral
line
and
the
interspinous
line.
The
right
lateral
line
is
the
vertical
line
drawn
through
the
mid-
inguinal
point,
and
therefore
bisects
SHp
at
point
I
(Fig.
2).
The
iliac
quadrant
is
above
and
lateral
to
point
I,
the
umbilical
quadrant
above
and
medial
to
point
I,
the
inguinal
quadrant
is
below
and
lateral
to
point
I,
and
the
fourth
pelvic
quadrant
below
and
medial
to
point
I.
Results
In
the
supine
patient,
the
position
of
the
lower
pole
of
the
caecum
was
iliac
in
six
patients
(12%),
inguinal
in
19
patients
(37%)
and
pelvic
in
26
patients
(51%).
In
45
patients
(88%)
the
lower
pole
of
the
caecum
was
below
the
interspinous
line,
ie
in
inguinal
or
pelvic
quadrants
(Fig.
3).
The
appendix
was
visualised
in
27
(53%)
of
the
barium
enemas.
In
the
supine
patient
the
base
of
the
appendix
was
iliac
in
four
patients
(15%),
umbilical
in
four
patients
(15%),
inguinal
in
three
patients
(11%)
and
pelvic
in
16
patients
(59%).
In
19
patients
(70%)
the
base
of
the
appendix
was
below
the
interspinous
line
(Fig.
4).
Discussion
This
study
refutes
the
popular
misconception
that
the
base
of
the
appendix
lies
near
McBurney's
point.
In
a
study
on
healthy
young
British
and
American
students,
Moody,
in
1927
(14),
found
that
in
the
anatomical
position
(erect)
the
caecum
was
most
frequently
found
to
lie
in
the
true
pelvis
and
not
the
right
iliac
fossa.
However,
he
commented
that
in
the
supine
position
the
caecum
migrated
cranially
and
was
then
more
often
found
in
the
iliac
fossa.
Our
study
contradicts
Moody's
findings
in
that
we
have
shown
that
even
in
the
supine
position
the
lower
pole
of
the
caecum
and
the
base
of
the
appendix
lie
both
lower
and
more
medial
than
previously
thought.
We
do,
however,
confirm
Moody's
observations
that,
in
some
individuals,
the
caecum
can
move
markedly
with
posture.
Accurate
knowledge
of
the
position
of
the
lower
pole
of
the
caecum
and
the
base
of
the
appendix
might
influence
the
level
of
incision
for
appendicectomy.
McBurney's
clinical
observations
on
the
point
of
maximal
tenderness
in
only
eight
cases
of
acute
appendicitis
(McBurney's
point)
has
been
assumed
to
be
the
point
at
which
the
base
of
the
diseased
appendix
lies.
There
have,
however,
been
1.0
.
0.9-
RIGHT
LATERAL
LINE
0.8
ILIAC:
120o%
0.7
0.6
E
°
MIDIY
0.5I
0.4
0.3
AnteriorSupenor
Iliac
Spiite
(A.S.IS.)
0..
d
0.0~
-0.1
-0.2
-0.3
-0.4
-0.5
-0.6
-0.7
-0.8
-0.9
:0
0
INGUINAL:
37%
%a
PELVIC:
51%
ml
o
I
INE
Symphyis
Pubis
0.1
0.2
0.3
0.4
0.5
0.6 0.7
0.8 0.9
1.0
1.1
1.2
Xc
Figure
3.
Position
of
lower
pole
of
caecum
relative
to
ASIS
and
symphysis
pubis.
1.0
0.9
-
RIGHT
LATERAL
LINE
0.8-
(
0.7
ILIAC:
15%
UMBILICAL:
15%
0.6
MIDL
0.5
o
0.4
Anterior
Superior
Iliac
A.SIS.
0.3
/
o
0.2
-0.3
Q
°P
03
,
*k.c:
-0.4
o
-0.5
o
-0.6
INGUINAL:
11%
PELVIC:
59%
Syrnp
-0.7
-0.8
-0.9
-1.0
.
JNE
)hysis
Pubis
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
1.1
1.2
xa
Figure
4.
Position
of
base
of
appendix
relative
to
ASIS
and
symphysis
pubis.
a.
*1-
307

308
0
M
Karim
et
al.
no
previous
studies
to
accurately
determine
the
position
of
the
lower
pole
of
the
caecum
and
the
base
of
the
normal
appendix
relative
to
palpable
bony
landmarks.
Our
observations
above
explain
why
the
appendix
is
readily
accessible
through
a
low
incision
for
appendi-
cectomy.
Errors
in
measurement
due
to
parallax
and
magnifica-
tion
are
nullified
by
the
use
of
ratios.
Overdistension
of
the
caecum
was
considered
as
a
possible
cause
for
its
low
position,
but
most
of
the
supine
films
examined
were
taken
after
evacuation.
Some
patients
had
preliminary
films
and
in
these
there
was
no
difference
in
the
position
of
the
caecum
before
and
after
the
examination.
We
conclude
that
McBurney's
point
is
founded
on
anecdotal
evidence.
The
base
of
the
normal
appendix
is
considerably
lower
than
McBurney's
point.
Incisions
for
appendicectomy
should
be
lower,
in
the
inguinal
and
pelvic
quadrants
which
we
have
described
above.
We
would
like
to
thank
Dr
B
Timmis,
Consultant
Radiologist,
The
Whittington
Hospital,
for
his
encouragement
and
advice
in
preparing
this
paper.
References
I
McBurney
C.
The
incision
made
in
the
abdominal
wall
in
cases
of
appendicitis
with
a
description
of
a
new
method
of
operation.
Ann
Surg
1894;20:38-43.
2
Lanz
0.
Der
McBurneyschen
Punkt.
Zentralbl
Chir
1908;35:
185-90.
3
Jelenko
C,
Davis
LP.
A
transverse
lower
abdominal
appen-
dicectomy
incision
with
minimal
muscle
derangement.
Surg
Gynecol
Obstet
1973;136:451-2.
4
Askew
AR.
The
Fowler-Weir
approach
to
appendi-
cectomy.
Br
J
Surg
1975;62:303-4.
5
Amir-Jahed
AK.
The
cul-de-sac
approach
for
appendi-
cectomy.
Am
J
Surg
1977;134:656-8.
6
El-Boghdadly
SA,
Abel
K.
Pfannensteil
incision
for
appen-
dicectomy
in
females.
BrJ
Clin
Pract
1984;38:17-19.
7
Delany
HM,
Carnevale
NJ.
A
'bikini'
incision
for
appendi-
cectomy.
Am
j
Surg
1976;132:16-17.
8
McBurney
CH.
Experience
with
early
operative
interfer-
ence
in
cases
of
disease
of
the
vermiform
appendix.
N
Y
Med7
1889;21:676-84.
9
Williams
PL,
Warwick
R
eds.
Gray's
Anatomy
36th
Edition.
London
and
Edinburgh:
Churchill-Livingstone,
1980:
1353.
10
Collins
DC.
The
length
and
position
of
the
vermiform
appendix.
Am
Surg
1932;96:
1044-8.
11
Wakeley
CPG.
The
position
of
the
vermiform
appendix
as
ascertained
by
an
analysis
of
10
000
cases.
J
Anat
1933;67:77-83.
12
Maisel
H.
The
position
of
the
human
vermiform
appendix
in
fetal
and
adult
age
groups.
Anat
Rec
1960;136:385-9.
13
Buschard
K,
Kjaeldgaard
A.
Investigation
and
analysis
of
the
position,
fixation,
length
and
embryology
of
the
vermi-
form
appendix.
Acta
Chir
Scand
1973;139:293-8.
14
Moody
RO.
The
position
of
abdominal
viscera
in
healthy,
young
British
and
American
adults.
7
Anat
1927;61:223-
31.
Received
18
January
1990
Notes
on
books
Practical
Color
Atlas
of
Sectional
Anatomy:
Chest,
Abdomen
and
Pelvis
by
E
A
Lyons.
308
pages,
illus-
trated,
paperback.
Raven
Press,
New
York.
1990.
$70.00.
ISBN
0
88167
550
4
138
colour
photographs
of
thin,
frozen
cadaver
sections
in
transverse,
parasagittal
and
coronal
planes
are
accompanied
by
clear
explanatory
diagrams.
Useful
for
learning
sectional
ana-
tomy
so
as to
better
interpret
CT
and
MR
scans.
Recent
Advances
in
Anaesthesia
and
Analgesia-16
edited
by
R
S
Atkinson
and
A
P
Adams.
215
pages,
illustrated,
paperback.
Churchill
Livingstone,
Edin-
burgh.
1989.
£16.50.
ISBN
0
443
04041
9
The
latest
volume
in
a
well-known
series
which
will
be
'required
reading'
for
examination
candidates
and
'highly
desirable'
reading
for
established
anaesthetists.
The
editors
have
chosen
eleven
subjects
covering
a
wide
range
of
anaesthe-
tic
practice.
Some
of
the
chapters
review
recent
advances
in
clinical
methods
and
others
take
a
new
look
at
established
problems
and
seek
to
throw
new
light
on
matters
still
under
debate.
Cancer
of
the
Stomach
edited
by
John
W
L
Fielding.
246
pages,
illustrated.
Macmillan
Press,
Basingstoke.
1989.
£40.00.
ISBN
0
333
47264
0
Volume
3
in
the
series
Clinical
Cancer
Monographs
gives
data
on
cancer
of
the
stomach
derived
from
the
West
Midland
Region
Cancer
Registry
over
the
twenty-five
years
1957-1981.
31
716
patients
were
registered
during
this
period
and
only
39
(0.12%)
were
lost
to
follow-up;
a
truly
remarkable
statistic.
A
wealth
of
detailed
information
is
contained
within
the
pages,
principally
in
table,
histogram
and
graph
form.
A
contribution
to
the
literature
that
will
need
close
study
by
all
those
interested
in
this
most
common
of
cancers.
Advances
in
Cardiac
Surgery,
Volume
1
edited
by
R
B
Karp.
258
pages,
illustrated.
Yearbook
Medical
Publishers,
Chicago.
1990.
£49.00.
ISBN
0
8151
5031
8
Ten
reviews
on
different
aspects
of
cardiac
surgery
comprise
the
first
volume
in
this
new
series.
The
field
ranges
from
congenital
heart
disease
to
electrophysiology
and
from
bio-
chemistry
and
physiology
to
coronary
artery
disease
and
valvu-
lar
heart
disease.