What is the complete treatment for appendicitis?

Complete Treatment for Appendicitis

Laparoscopic appendectomy is the recommended treatment for both uncomplicated and complicated acute appendicitis due to its advantages in terms of less pain, lower surgical site infection rates, shorter hospital stays, earlier return to work, and better quality of life. 1

Diagnosis and Initial Management

• Acute appendicitis is diagnosed based on clinical presentation, laboratory findings, and imaging studies 1, 2
• Appendectomy should be performed within 24 hours of admission to minimize complications 1
• In complicated appendicitis, early appendectomy within 8 hours is recommended 1

Surgical Approach

Preferred Surgical Technique

• Laparoscopic appendectomy is strongly recommended over open appendectomy for both adults and children when equipment and expertise are available 1
• Conventional three-port laparoscopic technique is preferred over single-incision laparoscopic appendectomy due to:
  • Shorter operative times
  • Less postoperative pain
  • Lower incidence of wound infection 1

Special Populations

• In pediatric patients with favorable anatomy, either single incision/transumbilical extracorporeal laparoscopic-assisted appendectomy or traditional three-port laparoscopic appendectomy can be performed based on local expertise 1
• Laparoscopic approach is particularly beneficial for:
  • Obese patients
  • Older patients
  • Patients with comorbidities
  • Pregnant patients 1

Intraoperative Management

Surgical Techniques

• For mesoappendix dissection, monopolar electrocoagulation and bipolar energy are recommended as cost-effective techniques 1
• For stump closure, endoloops/suture ligation or polymeric clips are recommended for both uncomplicated and complicated appendicitis 1
• Simple ligation is preferred over stump inversion in both open and laparoscopic appendectomy 1
• In complicated appendicitis with intra-abdominal collections, suction alone is recommended over irrigation 1

Wound Management

• Wound ring protectors are recommended in open appendectomy to decrease surgical site infection risk 1
• Primary skin closure with a unique absorbable intradermal suture is recommended for open appendectomy wounds 1

Postoperative Care

Drainage

• Abdominal drains are not recommended following appendectomy for complicated appendicitis in adults 1
• Prophylactic abdominal drainage is not recommended after laparoscopic appendectomy for complicated appendicitis in children 1

Outpatient Management

• Outpatient laparoscopic appendectomy can be considered for uncomplicated appendicitis when an ambulatory setting with well-defined ERAS (Enhanced Recovery After Surgery) protocols is available 1

Alternative Treatment Options

• While appendectomy remains the gold standard treatment, antibiotic therapy may be considered in selected cases of uncomplicated appendicitis 1
• However, antibiotic therapy has significant limitations:
  • Approximately 30% of patients initially treated with antibiotics require subsequent appendectomy within one year 3, 4
  • Additional diagnostic certainty with CT-proven diagnosis is often required 1
  • Concerns about antibiotic resistance with overuse 1

Management of Complicated Appendicitis

• In cases of periappendiceal abscess, percutaneous image-guided drainage is recommended when available 1
• When percutaneous drainage is not available, surgical intervention is suggested 1
• Early appendectomy has shown superior outcomes compared to initial non-operative management in complicated appendicitis 1

Common Pitfalls and Caveats

• Delaying appendectomy beyond 24 hours from admission increases the risk of adverse outcomes 1
• Routine histopathological examination of the appendix is necessary to identify unexpected findings 1
• The normal-appearing appendix should be removed during surgery in symptomatic patients when no other pathology is found 1
• Appendectomy should be performed even if the appendix appears normal during surgery, as macroscopic judgment of early appendicitis is often inaccurate 1