What is the treatment for a perforated appendix?

Treatment of Perforated Appendicitis

Laparoscopic appendectomy is the preferred treatment for perforated appendicitis when laparoscopic expertise is available, as it is associated with fewer readmissions, fewer additional interventions, and comparable hospital stays compared to conservative management. 1

Surgical Management Options

Primary Surgical Approach

• Laparoscopic appendectomy: First-line treatment when expertise is available

  • Benefits: Lower wound infection rates, shorter hospital stay, less pain, earlier return to work 1, 2
  • Technique considerations: Use suction alone for intra-abdominal collections 1
  • Stump closure: Endoloops/suture ligation or polymeric clips are recommended 1

• Open appendectomy: Alternative when laparoscopic expertise is unavailable

  • Indicated particularly during COVID-19 pandemic for confirmed positive patients 1
  • Wound protection: Use wound ring protectors to decrease surgical site infection risk 1
  • Closure: Primary skin closure with absorbable intradermal suture 1, 2

Conservative Management Approach

Conservative management with antibiotics and percutaneous drainage can be considered in specific situations:

• Indications for non-operative management:

  • Appendiceal phlegmon or abscess 1
  • Settings where laparoscopic expertise is not available 1
  • Percutaneous drainage should be used as an adjunct when accessible 1

• Failure predictors for non-operative management:

  • Appendicolith presence 3
  • Leukocytosis >15,000 WBC/μL 3
  • Increased bands 3
  • CT evidence of disease beyond right lower quadrant 3

Antibiotic Therapy

• For all perforated appendicitis cases:

  • Broad-spectrum antibiotics effective against facultative and aerobic gram-negative organisms and anaerobes 2, 4
  • Piperacillin/tazobactam is FDA-approved for appendicitis complicated by rupture or abscess 4

• Duration of antibiotic therapy:

  • Continue antibiotics postoperatively for 3-5 days 2
  • Early switch (after 48 hours) to oral antibiotics is recommended 2
  • Discontinue based on clinical improvement (resolution of fever, normalization of leukocytosis) 2

Special Considerations

Timing of Surgery

• Surgery should be performed within 24 hours of admission 2
• For children with complicated appendicitis, surgery within 8 hours is recommended 2
• Delaying surgery to accommodate surgeon preference or hospital efficiency does not significantly increase patient risk, provided appropriate antibiotics and hydration are initiated 5

Age-Specific Recommendations

• Patients ≥40 years old:
  • Higher incidence of appendicular neoplasms (3-17%) 1, 2
  • Recommend colonoscopy and interval full-dose contrast-enhanced CT scan 1, 2

Postoperative Care

• Early mobilization to stimulate bowel function 2
• Minimize opioid analgesics to reduce constipation risk 2
• Early oral intake (within hours after surgery) 2
• Avoid routine use of abdominal drains 1, 2

Outcomes and Complications

Perforated appendicitis carries significant morbidity:

• Surgical site infection (most common complication, up to 42%) 6
• Wound dehiscence (16.6%) 6
• Intestinal obstruction (1.6-2.4%) 6
• Intra-abdominal abscess formation 6
• Mortality rate of approximately 4.8% 6

Laparoscopic approach shows better outcomes compared to open appendectomy:

• Significantly lower wound-related complications (23.5% vs 40.5%) 7
• Shorter hospital stay 7
• Reduced analgesic requirements 7

Common Pitfalls to Avoid

1. Delaying diagnosis and treatment (increases risk of complications)
2. Underestimating the severity of peritoneal contamination
3. Routine use of drains (not recommended and may increase complications)
4. Overlooking potential neoplasms in older patients (≥40 years)
5. Inadequate antibiotic coverage or premature discontinuation

The evidence strongly supports laparoscopic appendectomy as the treatment of choice for perforated appendicitis when expertise is available, with conservative management reserved for specific situations where surgical expertise is limited or in cases of appendiceal phlegmon or abscess.