When is an appendicectomy (appendectomy) recommended for a patient with acute appendicitis?

When to Perform Appendectomy for Acute Appendicitis

Appendectomy should be performed within 24 hours of admission for patients with acute appendicitis requiring surgery, with laparoscopic approach being preferred over open surgery when expertise is available. 1

General Recommendations for Appendectomy

• Laparoscopic appendectomy is the preferred surgical approach for both uncomplicated and complicated acute appendicitis due to significant advantages including less pain, lower incidence of surgical site infection, decreased hospital stay, earlier return to work, and better quality of life 1, 2
• Surgery should be performed within 24 hours of admission for uncomplicated acute appendicitis to minimize risk of adverse outcomes 1
• Delaying appendectomy beyond 24 hours from admission is associated with increased risk of complications 1, 3
• For complicated appendicitis, early appendectomy within 8 hours should be performed 1, 2

Specific Clinical Scenarios

Uncomplicated Appendicitis

• Surgical management remains the standard treatment, though antibiotic therapy may be considered as an alternative in selected patients 2, 4
• When surgery is indicated, appendectomy should be performed within 24 hours of admission 1
• A single preoperative dose of broad-spectrum antibiotics should be administered 0-60 minutes before surgical incision 1, 2
• Postoperative antibiotics are not recommended for uncomplicated appendicitis 1

Complicated Appendicitis (Perforation, Abscess, Phlegmon)

• For perforated appendicitis without abscess formation, urgent surgical intervention is required 3
• For appendicitis with phlegmon or abscess, two approaches are possible:
  • Non-operative management with antibiotics and percutaneous drainage (if available) in settings where laparoscopic expertise is not available 1
  • Laparoscopic approach in centers with advanced laparoscopic expertise, which may be associated with fewer readmissions and additional interventions 1, 3
• Postoperative antibiotics should not be prolonged beyond 3-5 days with adequate source control 1

Special Populations

Immunocompromised Patients

• Transplanted patients with acute appendicitis should undergo appendectomy as soon as possible and usually within 24 hours from diagnosis 1
• There is insufficient data to recommend conservative treatment of acute appendicitis in transplanted patients 1
• Laparoscopic appendectomy should be preferred when feasible and not contraindicated in immunocompromised patients 1

Pregnant Patients

• Laparoscopic appendectomy is recommended over open appendectomy in pregnant patients when surgery is indicated 1
• Short, in-hospital delay with observation and repeated trans-abdominal ultrasound in pregnant patients with equivocal appendicitis is acceptable 1

Elderly and High-Risk Patients

• Laparoscopic appendectomy is suggested for obese patients, older patients, and patients with high perioperative risk factors 1

Outpatient vs. Inpatient Management

• Outpatient laparoscopic appendectomy may be considered for uncomplicated appendicitis in selected patients 1, 5
• This approach requires well-defined ERAS (Enhanced Recovery After Surgery) protocols and appropriate patient information/consent 1

Common Pitfalls and Caveats

• Surgeon's macroscopic judgment of early grades of acute appendicitis is inaccurate and highly variable 1
• If the appendix appears "normal" during surgery and no other disease is found in symptomatic patients, appendix removal is still suggested 1
• Routine histopathology after appendectomy is recommended to identify unexpected findings 2, 3
• Non-operative management alone is not appropriate for perforated appendicitis without abscess formation 3
• Interval appendectomy is not routinely recommended after non-operative management for complicated appendicitis in young adults (<40 years) and children, but is recommended for patients with recurrent symptoms 1