What is the recommended treatment for acute appendicitis?

Appendectomy for Acute Appendicitis: Current Management

Laparoscopic appendectomy is the preferred treatment for acute appendicitis due to its significant advantages over open appendectomy, including less pain, lower surgical site infection rates, decreased hospital stay, earlier return to work, and better quality of life. 1, 2

Surgical Management of Acute Appendicitis

Timing of Surgery

• Appendectomy should be performed within 24 hours of admission to minimize complications and adverse outcomes 3, 1
• Delaying surgery beyond 24 hours increases risk of complications 3, 2
• For complicated appendicitis in pediatric patients, early appendectomy within 8 hours should be performed 3

Surgical Approach

• Laparoscopic appendectomy is strongly recommended over open appendectomy for both uncomplicated and complicated appendicitis (Quality of Evidence: High; Strength of recommendation: Strong) 3
• Conventional three-port laparoscopic appendectomy is preferred over single-incision laparoscopic appendectomy due to shorter operative times, less postoperative pain, and lower wound infection rates 3, 2
• In pediatric patients, laparoscopic appendectomy is associated with lower postoperative pain, lower surgical site infection rates, and higher quality of life 3

Special Populations

• Laparoscopic appendectomy is recommended for:
  • Obese patients 3
  • Older patients 3
  • Patients with comorbidities 3
  • Pregnant patients (safe in terms of fetal loss and preterm delivery) 3

Technical Considerations

• Peritoneal irrigation provides no advantage over suction alone in complicated appendicitis; suction alone is recommended 3, 2
• Simple ligation of the appendiceal stump is recommended over stump inversion 2
• Routine histopathology after appendectomy is recommended to identify unexpected findings 2

Non-Operative Management (NOM)

Patient Selection for NOM

• Non-operative management with antibiotics can be considered as an alternative to surgery in selected patients with uncomplicated acute appendicitis 3, 4
• NOM should be avoided in patients with appendicolith, as this is associated with higher treatment failure rates (approximately 40%) 5
• CT findings of mass effect or appendiceal dilation >13mm are also associated with higher risk of antibiotic treatment failure 5

Antibiotic Therapy

• Initial intravenous antibiotics with subsequent switch to oral antibiotics is recommended for NOM 3
• Broad-spectrum antibiotics (piperacillin-tazobactam monotherapy or combination therapy with cephalosporins/fluoroquinolones with metronidazole) successfully treat uncomplicated appendicitis in approximately 70% of patients 5
• For complicated appendicitis with periappendiceal abscess, non-operative management with antibiotics and percutaneous drainage (if available) can be considered 2, 6

Outcomes of NOM

• Approximately 63-73% of patients treated with antibiotics alone remain asymptomatic without complications or recurrences after one year 4
• NOM has fewer immediate complications than surgery but more subsequent failures 4, 7

Outpatient Management

• Outpatient laparoscopic appendectomy for uncomplicated appendicitis is feasible and safe when ambulatory settings with well-defined ERAS protocols are available 3
• This approach offers potential benefits of earlier recovery and lower hospital and social costs 3

Pitfalls and Caveats

• Patients ≥40 years treated non-operatively should undergo colonoscopy and CT scan due to risk of underlying neoplasm 1
• Drains provide no benefit following appendectomy for complicated appendicitis and may lead to longer hospitalization 1, 2
• Single-incision laparoscopic appendectomy requires higher doses of analgesia and is associated with higher wound infection rates 3, 2
• Routine intraoperative irrigation does not prevent intra-abdominal abscess formation and can be avoided 2