What is the treatment for appendicitis?

Treatment of Appendicitis

Laparoscopic appendectomy is the recommended first-line treatment for acute appendicitis, offering advantages of less pain, lower surgical site infection rates, shorter hospital stays, and earlier return to work compared to open appendectomy. 1

Surgical Management Options

Uncomplicated Appendicitis

• Laparoscopic appendectomy is strongly preferred over open appendectomy when equipment and expertise are available 1
• Surgery should be performed within 24 hours of admission to minimize complications 1
• Conventional three-port laparoscopic technique is preferred over single-incision approaches due to shorter operative times and less postoperative pain 1, 2
• For mesoappendix dissection, monopolar or bipolar energy are recommended as cost-effective techniques 1
• For stump closure, endoloops/suture ligation or polymeric clips are recommended 1

Complicated Appendicitis (with phlegmon or abscess)

• Early appendectomy has shown superior outcomes compared to initial non-operative management in complicated appendicitis 1, 3
• Laparoscopic approach is recommended where advanced expertise is available, with a low threshold for conversion to open procedure 3
• In settings without laparoscopic expertise, non-operative management with antibiotics and percutaneous drainage (if available) is suggested 3
• Early appendectomy demonstrates a lower incidence of bowel resection (3.3% vs 17.1%) compared to non-operative management 3

Antibiotic Management

• A single preoperative dose of broad-spectrum antibiotics is recommended for all patients undergoing appendectomy 3
• For uncomplicated appendicitis, postoperative antibiotics are not recommended 3
• In complicated appendicitis with adequate source control, antibiotics should not be continued beyond 3-5 days postoperatively 3
• Antibiotic therapy alone may be considered in selected cases of uncomplicated appendicitis, but has limitations including approximately 30% of patients requiring subsequent appendectomy within one year 1, 4
• Broad-spectrum antibiotics (such as piperacillin-tazobactam or cephalosporins/fluoroquinolones with metronidazole) can successfully treat uncomplicated appendicitis in approximately 70% of patients 5

Special Considerations

• The normal-appearing appendix should be removed during surgery when no other pathology is found in symptomatic patients 3, 1
• Outpatient laparoscopic appendectomy can be considered for uncomplicated appendicitis when an ambulatory setting with well-defined protocols is available 1
• Abdominal drains are not recommended following appendectomy for complicated appendicitis in adults or children 1
• 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 (3-17%) 3, 6
• Interval appendectomy is not routinely recommended after non-operative management for complicated appendicitis in young adults (<40 years) and children, but should be performed for those with recurrent symptoms 3, 6

Predictors of Antibiotic Treatment Failure

• CT findings of appendicolith, mass effect, or a dilated appendix greater than 13 mm are associated with higher risk (≈40%) of antibiotic treatment failure 5
• Surgical management should be recommended in patients with these high-risk CT findings who are fit for surgery 5

Common Pitfalls to Avoid

• Delaying appendectomy beyond 24 hours from admission increases risk of adverse outcomes 1
• Failure to perform routine histopathological examination of the appendix may miss unexpected findings 1
• Macroscopic judgment of early appendicitis is often inaccurate, so the appendix should be removed even if it appears normal during surgery in symptomatic patients 1
• Failure to follow up patients ≥40 years old who have higher risk of underlying malignancy 6