Treatment of Appendicitis
Laparoscopic appendectomy is the preferred first-line treatment for acute appendicitis, with non-operative antibiotic management being a reasonable alternative for selected patients with uncomplicated appendicitis. 1
Surgical Management
Laparoscopic Appendectomy
- Strongly preferred over open appendectomy due to:
- Less postoperative pain
- Lower incidence of surgical site infections
- Decreased length of hospital stay
- Earlier return to work
- Better quality of life scores
- Lower overall costs 1
Timing of Surgery
- Should be performed within 24 hours of hospital admission for uncomplicated cases
- Within 8 hours for complicated appendicitis to minimize adverse outcomes 1
Surgical Technique
- Simple ligation of the appendiceal stump is recommended over stump inversion in both open and laparoscopic approaches 2
- Routine histopathology examination of the appendix is recommended after appendectomy 2
- Drains are not recommended following appendectomy for complicated appendicitis in adults 2
- Primary skin closure with a unique absorbable intradermal suture is recommended for open appendectomy wounds 2
Antibiotic Management
Uncomplicated Appendicitis
- A single preoperative dose of broad-spectrum antibiotics is recommended for all patients undergoing appendectomy 2, 1
- Postoperative antibiotics are not recommended for uncomplicated appendicitis 2
- Antibiotic-only treatment may be considered for selected patients with uncomplicated appendicitis:
Complicated Appendicitis
- Postoperative broad-spectrum antibiotics are recommended, especially if complete source control has not been achieved 2, 1
- Antibiotics should not be prolonged beyond 3-5 days with adequate source control 2
- Recommended regimens include:
- Amoxicillin/clavulanate
- Ceftriaxone + metronidazole
- Cefotaxime + metronidazole 1
Management of Perforated Appendicitis/Abscess
Non-Operative Management
- Non-operative management with antibiotics and percutaneous drainage (if available) is suggested for complicated appendicitis with peri-appendicular abscess, particularly in settings where laparoscopic expertise is not available 2, 1
Operative Management
- Laparoscopic approach is the treatment of choice for patients with complicated appendicitis with phlegmon or abscess where advanced laparoscopic expertise is available 2
- May be associated with shorter hospital stay, reduced readmissions, and fewer additional interventions than conservative treatment 2
Follow-up After Non-Operative Management
- Routine interval appendectomy after successful non-operative management is not recommended for young adults (<40 years) and children 2
- Interval appendectomy is recommended only for patients with recurrent symptoms 2
- For patients ≥40 years old treated non-operatively, both colonoscopy and interval full-dose contrast-enhanced CT scan are suggested due to higher incidence (3-17%) of appendicular neoplasms 2, 1
Special Considerations
Patient Selection for Outpatient Management
- Outpatient management may be considered for uncomplicated appendicitis cases 1, 5
- Criteria for safe same-day discharge:
- Uncomplicated appendicitis
- Adequate pain control
- Ability to tolerate oral intake
- Availability of transportation and support at home
- No significant comorbidities requiring monitoring 1
Risk Factors for Antibiotic Failure
- CT findings that predict higher failure rates (≈40%) with antibiotic-only approach:
- Appendicolith
- Mass effect
- Dilated appendix greater than 13 mm 3
- Surgical management should be recommended for patients with these findings who are fit for surgery 3
Complications to Monitor
- Surgical site infections
- Intra-abdominal abscess formation
- Urinary retention
- Ileus
- Bleeding 1
By following this evidence-based approach to appendicitis management, clinicians can optimize outcomes while minimizing morbidity and mortality for patients with this common surgical condition.