What is the treatment plan for a patient with acute appendicitis in the surgical ward?

Indoor Treatment Plan for Acute Appendicitis in Surgical Ward

Laparoscopic appendectomy is the treatment of choice for acute appendicitis, offering significant advantages over open appendectomy including less pain, lower surgical site infection rates, decreased hospital stay, and earlier return to work. 1

Initial Management

• Obtain baseline vital signs and laboratory tests including complete blood count, C-reactive protein, and basic metabolic panel 2
• Administer a single preoperative dose of broad-spectrum antibiotics 0-60 minutes before surgical incision 2
• Ensure adequate intravenous hydration and pain control while awaiting surgery 3
• Document the severity of appendicitis using a standardized grading system (e.g., WSES 2015 grading score or AAST EGS grading score) based on clinical, imaging, and operative findings 1

Surgical Approach

• Perform laparoscopic appendectomy as the preferred approach over open appendectomy for both uncomplicated and complicated acute appendicitis 1
• Schedule surgery within 24 hours of admission for uncomplicated appendicitis 2
• For complicated appendicitis (perforation, abscess), perform surgery within 8 hours if possible 2
• Use conventional three-port laparoscopic technique rather than single-incision approach, as it is associated with shorter operative times and lower incidence of wound infection 1

Management of Complicated Appendicitis

• For patients with appendiceal phlegmon or abscess:
  • If laparoscopic expertise is available, proceed with laparoscopic appendectomy as it is associated with fewer readmissions and additional interventions 1
  • If laparoscopic expertise is not available, consider non-operative management with antibiotics and percutaneous drainage (if available) 1
• Perform suction alone (rather than irrigation) in complicated appendicitis patients with intra-abdominal collections during laparoscopic appendectomy 1

Postoperative Care

• Remove the appendix even if it appears "normal" during surgery when no other disease is found in symptomatic patients 1
• Send the appendix specimen for routine histopathology examination 1
• For open appendectomy wounds, use primary skin closure with a unique absorbable intradermal suture 1
• Monitor for postoperative complications including surgical site infection, intra-abdominal abscess, and ileus 4

Antibiotic Therapy

• For uncomplicated appendicitis:
  • Single preoperative dose of antibiotics is sufficient 2
• For complicated appendicitis:
  • Continue antibiotics postoperatively: Metronidazole 500 mg every 6 hours + Vancomycin 25-30 mg/kg loading dose, then 15-20 mg/kg every 8 hours 2
  • Duration of antibiotic therapy should be guided by clinical improvement (resolution of fever, normalization of white blood cell count, return of bowel function) 4

Discharge Planning

• Consider outpatient laparoscopic appendectomy for uncomplicated appendicitis if an ambulatory setting with established ERAS protocols is available 1
• For standard inpatient care, discharge criteria include:
  • Tolerating oral intake
  • Adequate pain control with oral analgesics
  • No signs of complications
  • Afebrile for at least 24 hours 4
• Avoid routine interval appendectomy after non-operative management for complicated appendicitis in young adults (<40 years old) and children 1

Special Considerations

• For pregnant patients, laparoscopic appendectomy is preferred over open surgery when expertise is available 1
• For obese patients and older patients with comorbidities, laparoscopic approach is particularly beneficial 1
• During COVID-19 pandemic, consider non-operative management with antibiotics for uncomplicated appendicitis to avoid unnecessary surgery 1