When should we perform an emergency appendectomy (surgical removal of the appendix)?

Emergency Appendectomy Indications

Emergency appendectomy should be performed immediately in patients with complicated appendicitis presenting with diffuse peritonitis or suspected free-perforated appendicitis, as conservative management is contraindicated in these cases due to significantly higher mortality rates. 1, 2

Indications for Emergency Appendectomy

• Emergency appendectomy is mandatory for patients with complicated appendicitis with diffuse peritonitis or suspected free-perforated appendicitis at CT scan 1
• Once the decision for surgery is made in patients with acute appendicitis, appendectomy should be performed as soon as possible and within 24 hours of admission to minimize complications 1, 2
• For pediatric patients with complicated appendicitis, early appendectomy within 8 hours should be performed to reduce morbidity and mortality 1, 2
• In elderly patients with acute appendicitis requiring surgery, appendectomy should be performed as soon as possible to prevent adverse outcomes 1

Surgical Approach

• Laparoscopic appendectomy is the preferred surgical approach over open appendectomy for both uncomplicated and complicated acute appendicitis when expertise is available 1, 2
• In elderly patients, laparoscopic appendectomy is particularly beneficial due to reduced length of stay, morbidity, and costs 1, 3
• Pre-operative broad-spectrum antibiotics should be administered 0-60 minutes before surgical incision 1, 3
• Post-operative antibiotics are not recommended for uncomplicated appendicitis but should be given for 3-5 days in complicated cases 1

Non-Operative Management Considerations

• Non-operative management (NOM) with antibiotics may be considered for selected patients with uncomplicated appendicitis who wish to avoid surgery and accept the risk of recurrence 1, 4
• NOM with percutaneous drainage (if accessible) can be considered for patients with appendicular abscess 1
• However, NOM is absolutely contraindicated in cases with diffuse peritonitis or suspected free-perforated appendicitis due to high mortality risk 1
• About one-third of patients initially treated with antibiotics will require subsequent appendectomy within one year 4, 5

Special Population Considerations

• Elderly patients have significantly higher rates of complicated appendicitis (18-70%) compared to younger patients (3-29%) 6
• Mortality risk increases threefold with each decade of age beyond 65 years, reaching more than 16% in nonagenarians 6
• The perforation rate in appendicitis varies from 16% to 40%, with higher frequencies in younger age groups (40-57%) and in patients older than 50 years (55-70%) 6
• Mortality rates differ significantly by disease severity: less than 0.1% for non-gangrenous appendicitis versus approximately 5% for perforated appendicitis 6

Common Pitfalls to Avoid

• Delaying appendectomy beyond 24 hours from admission, which increases risk of adverse outcomes 1, 2
• Attempting non-operative management in patients with diffuse peritonitis or free perforation 1
• Inadequate preoperative antibiotic coverage, which should include coverage for enteric gram-negative organisms and anaerobes 3
• Failing to recognize complicated appendicitis requiring urgent intervention 2, 6
• Prolonging postoperative antibiotics beyond 3-5 days in complicated cases with adequate source control 2

Decision Algorithm

1. Immediate emergency appendectomy is indicated for:

   • Patients with diffuse peritonitis 1
   • Suspected free-perforated appendicitis on CT scan 1
   • Hemodynamic instability 2, 6

2. Urgent appendectomy within 24 hours is indicated for:

   • Uncomplicated acute appendicitis requiring surgery 1, 2
   • Elderly patients with acute appendicitis 1

3. Consider non-operative management only for:

   • Selected patients with uncomplicated appendicitis who wish to avoid surgery 1
   • Patients with appendicular abscess where percutaneous drainage is accessible 1