What is the recommended treatment for appendicitis?

Treatment of Appendicitis

Laparoscopic appendectomy is the recommended first-line treatment for acute appendicitis, with specific management approaches varying based on disease severity and patient factors. 1

Uncomplicated Appendicitis

Surgical Management

• 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, and better quality of life 1
• Surgery should be performed within 24 hours of admission, as delays beyond this timeframe are associated with increased risk of complications 1
• A single preoperative dose of broad-spectrum antibiotics should be administered 0-60 minutes before surgical incision 1
• Postoperative antibiotics are not recommended for uncomplicated appendicitis with adequate source control 1

Antibiotic Alternative

• Antibiotic therapy alone may be considered as an alternative in selected patients with uncomplicated appendicitis without appendicolith 1, 2
• However, antibiotic-only treatment is less effective long-term due to significant recurrence rates (approximately 30% within one year) 1, 3
• CT findings of appendicolith, mass effect, or appendix diameter >13mm are associated with higher antibiotic treatment failure rates (~40%) and should prompt surgical management 2

Complicated Appendicitis (Perforation, Abscess, Phlegmon)

Appendiceal Abscess or Phlegmon

• For patients with periappendiceal abscess where laparoscopic expertise is not available: non-operative management with antibiotics and percutaneous drainage (if available) is recommended 1
• Where advanced laparoscopic expertise is available: laparoscopic approach is suggested as treatment of choice, with a low threshold for conversion 1
• Laparoscopic management is associated with fewer readmissions and fewer additional interventions than conservative treatment 1

Antibiotic Therapy for Complicated Appendicitis

• Broad-spectrum antibiotics covering gastrointestinal bacteria are indicated 4
• Piperacillin-tazobactam is FDA-approved for complicated appendicitis (ruptured or with abscess) 4
• Postoperative antibiotics should not be continued beyond 3-5 days when adequate source control has been achieved 1
• In children with complicated appendicitis, early switch (after 48 hours) to oral antibiotics is recommended, with total therapy duration less than 7 days 1

Interval Appendectomy

• Routine interval appendectomy after successful non-operative management is not recommended for young adults (<40 years) and children 1
• Interval appendectomy should be performed only for patients with recurrent symptoms 1
• For patients ≥40 years treated non-operatively, both colonoscopy and interval full-dose contrast-enhanced CT scan are suggested due to higher incidence (3-17%) of appendiceal neoplasms 1

Special Considerations

Surgical Technique

• Simple ligation of the appendiceal stump is recommended over stump inversion in both open and laparoscopic appendectomy 1
• Drains are not recommended following appendectomy for complicated appendicitis in adults as they provide no benefit in preventing intra-abdominal abscess and lead to longer hospitalization 1
• 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

Normal-Appearing Appendix

• If the appendix appears normal during surgery and no other pathology is found in symptomatic patients, appendix removal is still suggested 1
• Routine histopathology after appendectomy is recommended to identify unexpected findings 1

Pitfalls and Caveats

• Delaying appendectomy beyond 24 hours from admission increases risk of adverse outcomes 1
• Surgeon's macroscopic judgment of early grades of acute appendicitis is inaccurate and highly variable, affecting decisions about postoperative antibiotics 1
• Single-incision laparoscopic appendectomy is associated with longer operative times, higher analgesic requirements, and higher wound infection rates compared to conventional three-port laparoscopic appendectomy 1
• Routine use of intraoperative irrigation for appendectomies does not prevent intra-abdominal abscess formation and may be avoided 1

The evidence strongly supports laparoscopic appendectomy as the gold standard treatment for acute appendicitis, with specific management approaches tailored to disease severity, patient factors, and available expertise.