Is surgery necessary for a ruptured appendix?

Management of Ruptured Appendicitis

Surgery is necessary for a ruptured appendix, as it requires urgent intervention to provide adequate source control and prevent life-threatening complications. 1

Surgical Management for Ruptured Appendicitis

Immediate Surgical Intervention

• Patients with perforated appendicitis should undergo urgent surgical intervention to provide adequate source control of the infection 1
• Surgery should not be delayed while waiting for swab results, especially in emergency situations 1
• The decision to proceed with surgery should be shared and discussed with the anesthesia team, particularly when ICU resources may be limited 1

Surgical Approach

• Both open and laparoscopic appendectomy are viable approaches for the surgical treatment of acute appendicitis 1
• For perforated appendicitis in COVID-19 positive patients, an open approach is preferable, though laparoscopy can be considered if adequate devices are available 1
• The choice of surgical approach should be dictated by the surgeon's expertise in performing that particular procedure 1
• Laparoscopic appendectomy offers significant advantages over open appendectomy in terms of less pain, lower incidence of surgical site infection, decreased length of hospital stay, and earlier return to work 1

Post-Surgical Management

• Appropriate antimicrobial therapy should include agents effective against facultative and aerobic gram-negative organisms and anaerobic organisms 1
• Drains are not recommended following appendectomy for complicated appendicitis in adult patients, as they provide no benefit in preventing intra-abdominal abscess and may lead to longer hospitalization 1
• Primary skin closure with a unique absorbable intradermal suture is recommended for open appendectomy wounds 1

Special Circumstances: Appendiceal Abscess

Management of Appendiceal Abscess

• Patients with a well-circumscribed periappendiceal abscess can be managed with percutaneous drainage or operative drainage when necessary 1
• In surgical departments with ready access to diagnostic and interventional radiology, periappendiceal abscesses can be managed with percutaneous image-guided drainage 1
• When percutaneous drainage is not available, surgery is suggested 1
• Appendectomy is generally deferred in patients with well-circumscribed periappendiceal abscesses 1

Interval Appendectomy

• In patients treated conservatively for complicated appendicitis, interval appendectomy may not be necessary following initial non-operative treatment 1
• However, interval appendectomies should always be performed for patients with recurrent symptoms 1

Pitfalls and Caveats

• Delaying appendectomy beyond 24 hours from admission is associated with an increased risk of adverse outcomes 1
• Non-operative management alone is not appropriate for perforated appendicitis without abscess formation, as it requires urgent surgical intervention 1
• Initial assessment of a potentially surgical candidate should be conducted by a senior clinician with the expertise to promptly recognize whether surgery is required 1
• Colorectal anastomosis should be avoided in patients with suspected or confirmed COVID-19, due to high risk of complications 1
• Routine histopathology is recommended after appendectomy to identify any unexpected findings 1

Algorithm for Management of Ruptured Appendicitis

1. Confirm diagnosis of ruptured appendicitis through clinical evaluation and imaging 1
2. Assess for periappendiceal abscess:
   • If present and accessible: Consider percutaneous drainage plus antibiotics 1
   • If abscess is not amenable to drainage or no abscess is present: Proceed to urgent surgery 1
3. Surgical intervention:
   • Choose appropriate surgical approach (open vs. laparoscopic) based on surgeon expertise and patient factors 1
   • Perform appendectomy with adequate source control 1
4. Postoperative care:
   • Continue appropriate antibiotic therapy 1
   • Monitor for complications such as intra-abdominal abscess or wound infection 1
5. For patients initially managed with drainage:
   • Consider interval appendectomy if symptoms recur 1
   • Otherwise, continued observation may be appropriate 1

In conclusion, ruptured appendicitis is a surgical emergency that requires prompt intervention to prevent serious complications including peritonitis, sepsis, and death. While certain cases with well-circumscribed abscesses may be initially managed with drainage and antibiotics, definitive surgical management remains necessary for most patients with perforated appendicitis.