What are the indications for an emergency appendectomy in patients with suspected acute appendicitis?

Indications for Emergency Appendectomy in Suspected Acute Appendicitis

Emergency appendectomy is strongly indicated in patients with complicated appendicitis with diffuse peritonitis or with suspected free-perforated appendicitis at CT scan. 1

Primary Indications for Emergency Appendectomy

• Patients with complicated appendicitis with free perforation and diffuse peritonitis require urgent appendectomy due to significantly higher mortality (11.9-15% vs 1.5-2.3%) compared to non-perforated cases 1
• Early appendectomy within 8 hours should be performed for complicated appendicitis to minimize adverse outcomes 2
• Surgery should be performed within 24 hours of admission for uncomplicated acute appendicitis to minimize risk of adverse outcomes 2
• Delaying appendectomy beyond 24 hours from admission is associated with increased risk of complications 2

Specific Clinical Scenarios

Uncomplicated Appendicitis

• Laparoscopic appendectomy is recommended for uncomplicated acute appendicitis, with surgery performed within 24 hours of admission 1
• While non-operative management (NOM) with antibiotics can be considered for selected patients with uncomplicated appendicitis without appendicolith, surgery remains the definitive treatment 1

Complicated Appendicitis

• Different management approaches based on specific clinical entities:
  • Free perforated appendicitis with generalized peritonitis: Urgent surgical intervention required 1, 3
  • Appendicular abscess: Non-operative management with percutaneous drainage (if accessible) is suggested in elderly patients 1
  • In case of failure to improve or clinical deterioration with non-operative management, laparoscopic abscess drainage and appendectomy should be considered 1

Surgical Approach Considerations

• Laparoscopic appendectomy is strongly preferred over open appendectomy for both uncomplicated and complicated acute appendicitis due to:
  • Less pain and lower incidence of surgical site infection
  • Decreased length of hospital stay and earlier return to work
  • Better overall quality of life scores 1, 2
• The laparoscopic approach is particularly beneficial for:
  • Obese patients
  • Older patients
  • Patients with comorbidities
  • Pregnant patients 4

Special Populations

• Elderly patients: Laparoscopic appendectomy is suggested due to reduced length of stay, morbidity, and costs 1
• Transplanted patients: Appendectomy should be performed as soon as possible, usually within 24 hours from diagnosis 2
• Immunocompromised patients: Laparoscopic appendectomy should be preferred when feasible and not contraindicated 2
• Pregnant patients: Laparoscopic appendectomy is recommended when surgery is indicated 2

Common Pitfalls and Caveats

• Surgeon's macroscopic judgment of early grades of acute appendicitis is inaccurate and highly variable 2
• If the appendix appears "normal" during surgery and no other disease is found in symptomatic patients, appendix removal is still suggested 2
• Routine histopathology after appendectomy is recommended to identify unexpected findings, particularly in elderly patients who have higher incidence of caecal or appendiceal cancer (1.6-24%) 1, 2
• Non-operative management alone is not appropriate for perforated appendicitis without abscess formation 3
• Elective colonic screening is strongly recommended in all elderly patients with acute appendicitis (both treated non-operatively and operatively) due to increased risk of colon cancer 1