What are the recommended methods for appendectomy?

Recommended Methods for Appendectomy

Laparoscopic appendectomy using the conventional three-port technique is the preferred surgical method for both uncomplicated and complicated acute appendicitis in adults and children, offering superior outcomes in pain reduction, surgical site infection rates, hospital stay duration, and quality of life compared to open appendectomy. 1

Primary Surgical Approach

Laparoscopic vs. Open Appendectomy

• Laparoscopic appendectomy should be performed as the first-line approach when equipment and expertise are available, with strong evidence (QoE: High, Strength 1A) supporting its use for both uncomplicated and complicated appendicitis 1

• The laparoscopic approach provides measurable advantages including:

  • Lower postoperative pain levels 1, 2
  • Reduced surgical site infection rates (1.4% vs 10.6% in open) 2
  • Shorter hospital stays (1.4 days vs 2.7 days for open) 2
  • Earlier return to work (11.5 days vs 16.1 days) 2
  • Better overall quality of life scores 1, 3

• These benefits apply equally to pediatric patients, where laparoscopic appendectomy demonstrates lower postoperative pain, lower SSI incidence, and higher quality of life (QoE: Moderate, Strength 1B) 1, 4

Three-Port vs. Single-Incision Technique

• Conventional three-port laparoscopic appendectomy is strongly recommended over single-incision laparoscopic appendectomy (QoE: High, Strength 1A) 1

• Single-incision approaches have significant disadvantages:

  • Longer operative times 1
  • Higher postoperative analgesia requirements 1
  • Increased wound infection rates 1

• Exception for pediatric patients: In children with favorable anatomy, single-incision/transumbilical extracorporeal laparoscopic-assisted technique may be performed based on local expertise (QoE: Low, Strength 2C) 1

Special Population Considerations

High-Risk Patients

• Laparoscopic appendectomy is specifically recommended for:
  • Obese patients (QoE: Moderate, Strength 2B) 1
  • Older patients (QoE: Moderate, Strength 2B) 1
  • Patients with significant comorbidities (QoE: Moderate, Strength 2B) 1
  • Pregnant patients, where it is safe regarding fetal loss and preterm delivery risk (QoE: Moderate, Strength 2B) 1

Pediatric Patients

• Perform laparoscopic appendectomy within 24 hours for uncomplicated appendicitis 4
• Perform early appendectomy within 8 hours for complicated appendicitis to reduce adverse outcomes 4

Intraoperative Technical Recommendations

Mesoappendix Dissection

• Use monopolar electrocoagulation or bipolar energy as the most cost-effective techniques (QoE: Moderate, Strength 2B) 1, 3, 5
• Other energy devices may be used based on intraoperative judgment and available resources 1

Stump Closure

• Use endoloops/suture ligation or polymeric clips for both uncomplicated and complicated appendicitis 3, 5
• Simple ligation is preferred over stump inversion in both open and laparoscopic approaches 3
• No clinical advantage exists for endostaplers over endoloops in adults 1

Management of Intra-abdominal Collections

• Perform suction alone without irrigation in complicated appendicitis with intra-abdominal collections (QoE: Moderate, Strength 1B) 1, 3
• Peritoneal irrigation does not prevent intra-abdominal abscess or wound infections and offers no advantage over suction alone 1

Drainage

• Do not place abdominal drains following appendectomy for complicated appendicitis in adults or children 3, 5

Timing of Surgery

• Perform appendectomy within 24 hours of admission for uncomplicated appendicitis to minimize complications (QoE: Moderate, Strength 1B) 1, 3, 5
• Do not delay beyond 24 hours, as this increases risk of adverse outcomes 1, 3, 5
• For complicated appendicitis in children, perform surgery within 8 hours (QoE: Low, Strength 2C) 1, 4

Outpatient Management

• Outpatient laparoscopic appendectomy can be performed safely for uncomplicated appendicitis when:

  • An appropriate ambulatory setting is available 1, 3
  • Well-defined ERAS protocols are established 1
  • Proper patient information and consent processes are in place 1

• This approach offers earlier recovery and lower hospital/social costs without increased readmission rates (QoE: Moderate, Strength 2B) 1

Critical Pitfalls to Avoid

• Never delay surgery beyond 24 hours from admission for uncomplicated appendicitis, as this significantly increases adverse outcomes 1, 3, 5

• Always remove the appendix even if it appears macroscopically normal during surgery in symptomatic patients, as macroscopic judgment of early appendicitis is often inaccurate 3, 5

• Avoid single-incision laparoscopic approaches unless specific expertise exists and patient anatomy is favorable, due to longer operative times, increased pain, and higher infection rates 1

• Do not perform peritoneal irrigation in complicated appendicitis, as it provides no benefit and wastes operative time 1, 3

• Maintain a low threshold for conversion to open procedure when laparoscopic visualization is inadequate or complications arise 5