Standard Treatment for Appendicitis
Laparoscopic appendectomy is the gold standard treatment for acute appendicitis, offering advantages of less postoperative pain, lower surgical site infection rates, shorter hospital stays, and earlier return to work compared to open appendectomy. 1, 2
Uncomplicated Appendicitis
- Surgery should be performed within 24 hours of admission to minimize complications 1, 2
- Laparoscopic approach is preferred over open appendectomy when equipment and expertise are available 1, 2
- Conventional three-port laparoscopic technique is superior to single-incision approaches due to shorter operative times and lower wound infection rates 2
- A single preoperative dose of broad-spectrum antibiotics should be administered 0-60 minutes before surgical incision 1
- Postoperative antibiotics are not recommended for uncomplicated appendicitis with adequate source control 1
Complicated Appendicitis (with Phlegmon or Abscess)
- In settings with advanced laparoscopic expertise, laparoscopic appendectomy is recommended as first-line treatment 3, 2
- When laparoscopic expertise is not available, non-operative management with antibiotics and percutaneous drainage (if available) is suggested 3, 1
- Early appendectomy has shown superior outcomes compared to initial non-operative management in complicated appendicitis 2
- Postoperative antibiotics should not be continued beyond 3-5 days when adequate source control has been achieved 1
Intraoperative Considerations
- Simple ligation of the appendiceal stump is recommended over stump inversion in both open and laparoscopic appendectomy 1, 2
- For stump closure, endoloops/suture ligation or polymeric clips are effective techniques 2
- In complicated appendicitis with intra-abdominal collections, suction alone is recommended over irrigation 2
- The appendix should be removed even if it appears "normal" during surgery when no other pathology is found in symptomatic patients, as macroscopic judgment of early appendicitis is often inaccurate 3, 2
Postoperative Management
- Abdominal drains are not recommended following appendectomy for complicated appendicitis in adults 1, 2
- Routine histopathological examination of the appendix is necessary to identify unexpected findings 3, 2
- Outpatient laparoscopic appendectomy can be considered for uncomplicated appendicitis when an ambulatory setting with well-defined protocols is available 2
Alternative Treatment Options
- While appendectomy remains the gold standard, antibiotic therapy may be considered in selected cases of uncomplicated appendicitis 3, 4
- However, antibiotic therapy has significant limitations, including approximately 30% of patients requiring subsequent appendectomy within one year 4, 5
- Specific CT findings such as appendiceal dilatation ≥7 mm or presence of appendicoliths identify patients for whom an antibiotics-first strategy is more likely to fail 6
Special Considerations
- For patients ≥40 years old with complicated appendicitis, both colonoscopy and interval full-dose contrast-enhanced CT scan are recommended for follow-up due to higher incidence of appendicular neoplasms in this age group 3, 7
- Interval appendectomy is not routinely recommended after non-operative management for complicated appendicitis in young adults (<40 years old) and children, but should be performed for those with recurrent symptoms 3
Common Pitfalls to Avoid
- Delaying appendectomy beyond 24 hours from admission increases risk of adverse outcomes 1, 2
- Failure to follow up patients ≥40 years old who have higher risk of underlying malignancy 7
- Overlooking the need to remove a normal-appearing appendix during surgery in symptomatic patients when no other pathology is found 3, 2