When is surgical intervention indicated for acute appendicitis?

From the Guidelines

Surgical intervention is indicated for acute appendicitis in most cases, and appendectomy should be performed promptly once the diagnosis is confirmed, typically within 24-48 hours of symptom onset. The procedure may be performed using either an open technique or laparoscopically, with laparoscopic appendectomy generally preferred due to faster recovery, less pain, and lower wound infection rates 1.

Indications for Surgical Intervention

• Uncomplicated appendicitis: surgery is the standard of care, but non-operative approach with antibiotics may be considered in specific situations, such as significant surgical risks or resource-limited settings 1
• Complicated appendicitis (with perforation, abscess, or peritonitis): surgery is necessary, and prompt intervention is crucial to prevent increased morbidity and mortality rates due to widespread infection in the abdominal cavity 1
• Patients who fail antibiotic therapy or have uncertain diagnosis: surgery is necessary to prevent complications and ensure proper diagnosis and treatment 1

Preoperative Antibiotic Therapy

• A single dose of broad-spectrum antibiotics given preoperatively (from 0 to 60 min before the surgical skin incision) is recommended to decrease wound infection and postoperative intra-abdominal abscess 1
• Postoperative antibiotics are not recommended for patients with uncomplicated appendicitis, but may be necessary for patients with complicated appendicitis or those who have not achieved complete source control 1

Non-Operative Management

• May be considered for uncomplicated appendicitis in patients with significant surgical risks or in resource-limited settings, using antibiotics such as piperacillin-tazobactam or ceftriaxone plus metronidazole 1
• May be considered for patients with periappendiceal abscess, using percutaneous drainage and antibiotic therapy 1

From the Research

Indications for Surgical Intervention

Surgical intervention is indicated for acute appendicitis in the following situations:

• Patients with high-risk CT findings, such as appendicolith, mass effect, or a dilated appendix greater than 13 mm, who are fit for surgery 2
• Patients with perforated or gangrenous appendicitis, as antimicrobial prophylaxis has been shown to reduce postoperative infectious complications in these cases 3
• Patients who have failed antibiotic treatment, as surgery may be necessary to resolve the condition 4
• Patients with moderate- to high-risk appendicitis, as prompt surgical consultation can reduce morbidity and mortality resulting from perforation 5

Contrasting Views on Surgical Intervention

Some studies suggest that antibiotics can be used as first-line therapy for acute appendicitis, with surgery reserved for cases where antibiotic treatment fails 4

• A population-based study found that 77% of patients treated with antibiotics as first-line therapy recovered without the need for surgery, while 23% required subsequent appendectomy due to failed initial treatment 4
• However, other studies recommend appendectomy via open laparotomy or laparoscopy as the standard treatment for acute appendicitis, with intravenous antibiotics considered first-line therapy only in selected patients 5

Diagnostic Considerations

Imaging plays a crucial role in diagnosing acute appendicitis and its complications, as well as suggesting alternate diagnoses 6

• Ultrasonography (USG) is recommended as the first-line imaging modality for all ages, particularly for children and non-obese young adults, including women of reproductive age group 6
• Computed tomography (CT) scan or magnetic resonance imaging (MRI) may be used as follow-up or further imaging in cases of equivocal USG findings or clinico-radiological dissociation 6