Treatment of Appendicitis at McBurney's Point

Appendectomy remains the treatment of choice for acute appendicitis, with laparoscopic approach preferred when expertise is available. 1

Diagnosis and Initial Management

A step-up approach for diagnosis should be used, starting with clinical and laboratory examination, followed by appropriate imaging tailored to hospital resources 1
Point-of-care ultrasound (POCUS) should be considered the most appropriate first-line diagnostic tool in both adults and children when imaging is indicated based on clinical assessment 1
If ultrasound is inconclusive, contrast-enhanced low-dose CT scan is recommended over standard-dose CT to reduce radiation exposure while maintaining diagnostic accuracy 1
For pregnant patients with suspected appendicitis, MRI is suggested after inconclusive ultrasound, if available 1

Both laparoscopic and open appendectomy are acceptable procedures, with the approach dictated by the surgeon's expertise 1
Operative intervention for acute, nonperforated appendicitis should be performed as soon as reasonably feasible, though surgery may be briefly deferred according to institutional circumstances 1
For patients with perforated appendicitis, urgent intervention is necessary to provide adequate source control 1
Routine use of intra-operative irrigation during appendectomies does not prevent intra-abdominal abscess formation and may be avoided 1

All patients diagnosed with appendicitis should receive antimicrobial therapy 1
A single preoperative dose of broad-spectrum antibiotics is recommended for patients undergoing appendectomy 1
Appropriate antimicrobial therapy includes agents effective against facultative and aerobic gram-negative organisms and anaerobic organisms 1
For uncomplicated appendicitis:
- Postoperative antibiotics are not recommended in adults or children 1
For complicated appendicitis:
- Postoperative broad-spectrum antibiotics are recommended, especially if complete source control has not been achieved 1
- Antibiotics should not be prolonged longer than 3-5 days postoperatively with adequate source control 1
- In children, early switch (after 48 hours) to oral antibiotics is recommended, with total therapy duration shorter than 7 days 1

Non-operative management (NOM) with antibiotics alone may be considered in selected patients with uncomplicated acute appendicitis, particularly those showing marked improvement prior to operation 1
NOM may be considered for male patients, provided they are hospitalized for 48 hours and show sustained improvement in clinical symptoms and signs within 24 hours while receiving antimicrobial therapy 1
For patients with periappendiceal abscess:
- Management with percutaneous drainage or operative drainage is recommended when necessary 1
- Appendectomy is generally deferred in such patients 1
- When percutaneous drainage is not available, surgery is suggested 1

For patients with equivocal diagnostic imaging for suspected appendicitis, antimicrobial therapy should be initiated along with appropriate pain medication and antipyretics 1
In adults, antimicrobial therapy should be provided for a minimum of 3 days until clinical symptoms and signs of infection resolve or a definitive diagnosis is made 1
Interval appendectomy is not routinely recommended after non-operative management for complicated appendicitis in young adults (<40 years) and children, but should be performed for patients with recurrent symptoms 1
Patients over 40 years old with complicated appendicitis treated non-operatively should undergo colonic screening with colonoscopy and interval full-dose contrast-enhanced CT scan due to higher incidence (3-17%) of appendicular neoplasms 1

McBurney's point (junction of lateral and middle thirds of a line joining the umbilicus with the right anterior superior iliac spine) is the traditional surface marking for the appendix, but studies show only 35% of appendix bases lie within 5 cm of this point 2
75% of appendix bases are actually below and medial to a line joining the umbilicus with the right anterior superior iliac spine 2
This anatomical variation is important to consider during diagnosis, as less than half of all patients with appendicitis have tenderness maximal over McBurney's point 2
Delayed diagnosis and treatment increase the risk of perforation, which occurs in 17-32% of patients with acute appendicitis 3
Perforation can lead to sepsis, increasing morbidity and mortality 3