What is the recommended treatment for acute appendicitis?

Treatment of Acute Appendicitis

Laparoscopic appendectomy is the recommended first-line treatment for acute appendicitis, offering superior outcomes compared to open surgery in terms of less pain, lower surgical site infection rates, shorter hospital stays, and better quality of life. 1

Surgical Management

Primary Approach

• Laparoscopic appendectomy should be performed as the preferred surgical technique over open appendectomy for both uncomplicated and complicated acute appendicitis where laparoscopic equipment and expertise are available, based on high-quality evidence from the World Journal of Emergency Surgery 1
• Conventional three-port laparoscopic appendectomy is strongly recommended over single-incision techniques due to shorter operative times, less postoperative pain, and lower wound infection rates 1
• Surgery should be performed within 24 hours of admission to minimize complications; delays beyond this timeframe increase the risk of adverse outcomes 1, 2, 3
• For complicated appendicitis, early appendectomy within 8 hours should be performed to reduce adverse outcomes 4

Special Populations

• In pregnant patients, laparoscopic appendectomy is preferred over open surgery when surgical intervention is indicated, as it is associated with shorter hospital stays and lower surgical site infection rates 1
• In obese patients, older patients, and those with comorbidities, laparoscopic appendectomy offers relevant advantages and should be the preferred approach 1
• In pediatric patients, laparoscopic appendectomy is strongly recommended over open surgery, offering lower postoperative pain, lower surgical site infections, and higher quality of life 1, 4

Antibiotic Management

Perioperative Antibiotics

• A single preoperative dose of broad-spectrum antibiotics should be administered 0-60 minutes before surgical incision to decrease wound infection and postoperative intra-abdominal abscess rates 4, 2, 3
• Piperacillin-tazobactam is FDA-approved for treatment of appendicitis complicated by rupture or abscess 5
• For uncomplicated appendicitis with adequate source control, postoperative antibiotics are not recommended 4, 2, 3

Complicated Appendicitis

• Postoperative broad-spectrum antibiotics are indicated for complicated appendicitis 4, 2
• Early switch to oral antibiotics after 48 hours is safe in pediatric patients, with total antibiotic duration less than 7 days 4
• Antibiotic therapy should not exceed 3-5 days when adequate source control has been achieved 2, 3

Non-Operative Management

Uncomplicated Appendicitis

• Non-operative management with antibiotics can be discussed as a safe alternative to surgery in selected patients with uncomplicated acute appendicitis and absence of appendicolith, though patients must be advised of the possibility of treatment failure and risk of misdiagnosing complicated appendicitis 1
• Approximately 70% of patients with uncomplicated appendicitis can be successfully treated with broad-spectrum antibiotics such as piperacillin-tazobactam monotherapy or combination therapy with cephalosporins or fluoroquinolones with metronidazole 6
• Initial intravenous antibiotics with subsequent switch to oral antibiotics based on clinical conditions is recommended when pursuing non-operative management 1
• After one year, approximately 63-73% of patients treated with antibiotics alone remain asymptomatic without complications or recurrences, compared to 97% with immediate appendectomy 7

Contraindications to Non-Operative Management

• Patients with CT findings of appendicolith, mass effect, or dilated appendix greater than 13 mm should undergo surgical management as these features are associated with approximately 40% treatment failure rates with antibiotics-first approach 6
• Patients ≥40 years treated non-operatively should undergo colonoscopy and CT scan due to risk of underlying neoplasm 3

Management of Complicated Appendicitis with Abscess

• Where advanced laparoscopic expertise is available, laparoscopic approach is the suggested treatment of choice for appendiceal abscess or phlegmon 4
• In settings without laparoscopic expertise, non-operative management with antibiotics and percutaneous drainage (if available) is suggested 4, 2
• Laparoscopic management is associated with fewer readmissions and fewer additional interventions than conservative treatment 2
• Routine interval appendectomy after successful non-operative management is not recommended in children and should only be performed for recurrent symptoms 4

Technical Considerations

• Simple ligation of the appendiceal stump is recommended over stump inversion in both open and laparoscopic appendectomy 2
• Suction alone should be performed in complicated appendicitis patients with intra-abdominal collections; peritoneal irrigation does not prevent intra-abdominal abscess or wound infections 1
• Drains are not recommended following appendectomy for complicated appendicitis as they provide no benefit and lead to longer hospitalization 2, 3
• Routine histopathology after appendectomy is recommended to identify unexpected findings 2

Outpatient Management

• Outpatient laparoscopic appendectomy for uncomplicated appendicitis is feasible and safe when an appropriate ambulatory setting with well-defined enhanced recovery after surgery (ERAS) protocols and proper patient information/consent are established 1, 4

Common Pitfalls and Caveats

• Delaying appendectomy beyond 24 hours from admission significantly increases the risk of adverse outcomes and should be avoided 1, 2, 3
• In pediatric patients, particularly those under 5 years of age, atypical presentations are common and can lead to delayed diagnosis with higher perforation rates 4
• Single-incision laparoscopic appendectomy should be avoided as it is associated with longer operative times, higher analgesic requirements, and higher wound infection rates compared to conventional three-port technique 1
• Pregnant patients with equivocal appendicitis may benefit from short in-hospital observation with repeated ultrasound, but surgery should not be delayed if diagnosis is confirmed 1