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 when equipment and expertise are available 1, 2
• The benefits include less postoperative pain, lower incidence of surgical site infections, decreased length of hospital stay, earlier return to work, lower overall costs, and better quality of life scores 1, 2, 3
• Conventional three-port laparoscopic appendectomy is superior to single-incision techniques, as single-incision approaches require longer operative times, higher analgesic doses, and have higher wound infection rates 1

Timing of Surgery

• Surgery must be performed within 24 hours of admission to minimize complications 1, 4, 2, 3
• Delaying appendectomy beyond 24 hours significantly increases the risk of adverse outcomes including perforation and postoperative morbidity 1, 2, 3
• For complicated appendicitis in pediatric patients, early appendectomy within 8 hours should be performed 4

Special Populations

• Pregnant patients: Laparoscopic appendectomy is preferred over open surgery when indicated, as it is safe and associated with shorter hospital stays and lower surgical site infection rates 1
• Obese patients, elderly patients, and those with comorbidities: Laparoscopic approach is recommended due to relevant advantages over open surgery 1
• Pediatric patients: Laparoscopic appendectomy is strongly recommended over open appendectomy, 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 must be administered 0-60 minutes before surgical incision to decrease wound infection and postoperative intra-abdominal abscess rates 4, 2, 3
• Appropriate antibiotic choices include piperacillin-tazobactam 5, 6 or combination therapy with cephalosporins or fluoroquinolones plus metronidazole 6

Postoperative Antibiotics

• For uncomplicated appendicitis with adequate source control: NO postoperative antibiotics are recommended 4, 2, 3
• For complicated appendicitis: Postoperative broad-spectrum antibiotics are indicated, with early switch to oral antibiotics after 48 hours and total duration less than 7 days 4, 2
• Antibiotic therapy should not exceed 3-5 days when adequate source control has been achieved 2, 3

Non-Operative Management (Selected Cases Only)

When to Consider Antibiotics-First Strategy

• Non-operative management with antibiotics can be discussed as an alternative to surgery in selected patients with uncomplicated acute appendicitis who have no appendicolith on imaging 1, 6
• This approach is supported by high-quality evidence showing approximately 70% success rates 6
• Patients must be counseled about the possibility of treatment failure and risk of misdiagnosing complicated appendicitis 1

Contraindications to Antibiotics-First Approach

• Presence of appendicolith on CT imaging is associated with approximately 40% treatment failure rate and warrants surgical management 6
• CT findings of mass effect or dilated appendix >13 mm indicate higher risk of treatment failure and surgery should be recommended 6
• Patients who are fit for surgery with these high-risk CT findings should undergo appendectomy 6

Antibiotic Regimen for Non-Operative Management

• Initial intravenous antibiotics with subsequent switch to oral antibiotics based on clinical conditions 1
• Total duration typically 8-15 days 7
• Approximately 63% of patients remain asymptomatic at one year without surgery 7

Management of Complicated Appendicitis

Appendiceal Abscess or Phlegmon

• Where advanced laparoscopic expertise is available: Laparoscopic approach is the treatment of choice 4, 2
• In settings without laparoscopic expertise: Non-operative management with antibiotics and percutaneous drainage (if available) is recommended 4, 2
• Laparoscopic management is associated with fewer readmissions and fewer additional interventions than conservative treatment 2

Interval Appendectomy

• Routine interval appendectomy after successful non-operative management is NOT recommended in children 4
• Should only be performed for children with recurrent symptoms 4
• Patients ≥40 years treated non-operatively should undergo colonoscopy and CT scan due to risk of underlying neoplasm 3

Intraoperative Considerations

Technical Details

• 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 provides no advantage and 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

Postoperative Care

• Routine histopathology after appendectomy is recommended to identify unexpected findings 2
• Outpatient laparoscopic appendectomy may be considered for uncomplicated appendicitis when appropriate ambulatory settings with well-defined ERAS protocols are available 1, 4

Common Pitfalls and Caveats

• Avoid delaying surgery beyond 24 hours from admission, as this significantly increases complication rates 1, 2, 3
• Do not use single-incision laparoscopic techniques routinely, as they are associated with worse outcomes compared to conventional three-port approach 1, 2
• Atypical presentations are common in preschool children under 5 years, leading to delayed diagnosis and higher perforation rates 4
• Avoid routine intraoperative irrigation, as it does not prevent intra-abdominal abscess formation 2
• In pregnant patients with equivocal appendicitis, short in-hospital observation with repeated ultrasound is acceptable and does not increase maternal or fetal adverse outcomes 1