What is the treatment for appendicitis?

Treatment of Appendicitis

Laparoscopic appendectomy is the recommended first-line treatment for both uncomplicated and complicated acute appendicitis due to its significant advantages over open appendectomy in terms of less pain, lower incidence of surgical site infection, decreased length of hospital stay, earlier return to work, lower overall costs, and better quality of life. 1

Surgical Management

Preferred Surgical Approach

• Laparoscopic appendectomy should be performed over open appendectomy whenever laparoscopic equipment and expertise are available 1
• Conventional three-port laparoscopic appendectomy is recommended over single-incision laparoscopic appendectomy due to shorter operative times, less postoperative pain, and lower incidence of wound infections 1
• For pediatric patients, laparoscopic appendectomy is also preferred due to lower postoperative pain, lower incidence of surgical site infection, and higher quality of life 1

Special Patient Populations

• Laparoscopic appendectomy is particularly beneficial for:
  • Obese patients 1
  • Older patients 1
  • Patients with comorbidities 1
  • Pregnant patients (when surgery is indicated) 1

Timing of Surgery

• For uncomplicated appendicitis in pediatric patients, appendectomy should not be delayed beyond 24 hours from admission 1
• For complicated appendicitis in pediatric patients, early appendectomy within 8 hours is recommended 1

Intraoperative Considerations

• During laparoscopic appendectomy for complicated appendicitis with intra-abdominal collections, suction alone is recommended without peritoneal irrigation 1
• If the appendix appears normal during surgery and no other disease is found in symptomatic patients, appendix removal is still suggested 1

Management of Complicated Appendicitis with Phlegmon or Abscess

Non-Operative Management

• Non-operative management with antibiotics and percutaneous drainage (if available) is suggested for complicated appendicitis with peri-appendicular abscess in settings where laparoscopic expertise is not available 1

Operative Management

• Laparoscopic approach is suggested as treatment of choice for patients with complicated appendicitis with phlegmon or abscess where advanced laparoscopic expertise is available 1
• Interval appendectomy (delayed surgery after initial non-operative management) is not routinely recommended after successful non-operative management for complicated appendicitis in young adults (<40 years old) and children 1
• Interval appendectomy is recommended only for patients with recurrent symptoms 1
• For patients ≥40 years old treated non-operatively, both colonic screening with colonoscopy and interval full-dose contrast-enhanced CT scan are suggested due to higher incidence of appendicular neoplasms (3-17%) 1

Antibiotic Therapy

Perioperative Antibiotics

• A single preoperative dose of broad-spectrum antibiotics is recommended for all patients with acute appendicitis undergoing appendectomy 1
• Postoperative antibiotics are not recommended for patients with uncomplicated appendicitis 1
• For complicated appendicitis with adequate source control, antibiotics should not be prolonged beyond 3-5 days postoperatively 1

Antibiotics-Only Approach

• While appendectomy remains the gold standard treatment for acute appendicitis worldwide, antibiotic therapy may be considered as an alternative in selected patients with uncomplicated appendicitis 1
• However, this approach has significant recurrence rates (approximately 27% at 1 year) and requires CT-proven diagnosis of uncomplicated appendicitis 1
• Antibiotic regimens typically include broad-spectrum coverage such as piperacillin-tazobactam monotherapy or combination therapy with either cephalosporins or fluoroquinolones with metronidazole 2

Outpatient Management

• Outpatient laparoscopic appendectomy for uncomplicated appendicitis is feasible and safe when an ambulatory setting with well-defined enhanced recovery after surgery (ERAS) protocols and proper patient information/consent are established 1

Common Pitfalls and Caveats

• CT findings of appendicolith, mass effect, and a dilated appendix greater than 13 mm are associated with higher risk of failure (approximately 40%) with an antibiotics-first approach 2
• Surgical management should be recommended in patients with these high-risk CT findings who are fit for surgery 2
• For patients without high-risk CT findings, either appendectomy or antibiotics can be considered as first-line therapy 2
• In unfit patients without high-risk CT findings, an antibiotics-first approach is recommended, with surgery considered if antibiotic treatment fails 2