Treatment of Appendicitis
Laparoscopic appendectomy is the standard treatment for appendicitis, with early surgical intervention (within 24 hours of diagnosis) recommended to prevent complications. 1
Surgical Management
Surgical treatment remains the cornerstone of appendicitis management, with specific approaches based on disease severity:
Uncomplicated Appendicitis
- Laparoscopic appendectomy is 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 1
- Simple ligation of the appendiceal stump is recommended over stump inversion 1
- No postoperative antibiotics are needed for uncomplicated cases 2
Complicated Appendicitis (Perforated/Gangrenous)
- Early appendectomy (within 8 hours) is recommended 1
- Laparoscopic approach is still preferred when expertise is available 2
- Postoperative antibiotics are required:
Antibiotic Regimens
For Complicated Appendicitis
- Piperacillin-tazobactam is FDA-approved for appendicitis complicated by rupture or abscess 3
- Usual dosage: 3.375 grams every six hours for 7-10 days 3
- Alternative regimens include:
- Ceftriaxone plus metronidazole
- Cefotaxime plus metronidazole
- Amoxicillin/clavulanate 1
For Uncomplicated Appendicitis
- In selected patients with CT-confirmed uncomplicated appendicitis without appendicolith, non-operative management with antibiotics may be considered 1, 4
- However, this approach has a significant recurrence rate (approximately 27% at 1 year) 1
Management of Appendiceal Abscess or Phlegmon
- Small abscesses (<4-5cm) may be treated with antibiotics alone 1
- Larger abscesses require percutaneous image-guided drainage combined with antibiotics 1
- Appendectomy is generally deferred in these cases 1
- Early appendectomy has shown superior outcomes compared with initial non-operative management in some studies 2
Special Considerations
Drains
- Drains are not recommended following appendectomy for complicated appendicitis in adults 1
- Evidence suggests abdominal drainage may increase hospital stay and does not prevent intraperitoneal abscess or wound infection 5
- Abdominal drainage may actually increase the risk of mortality in patients undergoing open appendectomy for complicated appendicitis 5
Outpatient Management
- Outpatient laparoscopic appendectomy is feasible for uncomplicated appendicitis when ambulatory setting is available 1
- Criteria for safe same-day discharge include:
- Uncomplicated appendicitis
- Adequate pain control
- Ability to tolerate oral intake
- Availability of transportation and support at home
- No significant comorbidities requiring monitoring 1
Treatment Algorithm
- Diagnosis confirmed → Determine if complicated or uncomplicated
- Uncomplicated appendicitis:
- Standard: Laparoscopic appendectomy
- Alternative (selected patients): Antibiotics-first approach
- Complicated appendicitis:
- Without abscess/phlegmon: Early laparoscopic appendectomy + antibiotics
- With abscess/phlegmon: Percutaneous drainage + antibiotics; consider interval appendectomy
- Postoperative care:
- Uncomplicated: No antibiotics needed
- Complicated: Antibiotics for <7 days (IV → oral switch after 48h)
Common Pitfalls and Caveats
- Delaying appendectomy beyond 24 hours from admission increases risk of adverse outcomes 1
- CT findings of appendicolith, mass effect, and a dilated appendix >13 mm are associated with higher risk of failure (≈40%) with an antibiotics-first approach 4
- Pseudomonas aeruginosa is sometimes isolated in acute appendicitis and may not be covered by standard prophylactic antibiotics, potentially leading to surgical site infections 6
- Routine histopathology examination of the appendix is recommended after appendectomy to rule out any underlying conditions 1