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 laparoscopic equipment and expertise are available 1
• The benefits include significantly 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
• Conventional three-port laparoscopic appendectomy is recommended over 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 should be performed within 24 hours of admission to minimize complications 1, 3, 4
• Delaying appendectomy beyond 24 hours from admission is associated with increased risk of adverse outcomes, including higher rates of surgical site infections 1, 2
• For complicated appendicitis in pediatric patients, early appendectomy within 8 hours should be performed 3

Special Populations

• Pregnant patients: Laparoscopic appendectomy is preferred over open surgery when expertise is available, as it is associated with shorter hospital stays and lower surgical site infection rates without increased risk of fetal loss or preterm delivery 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, 3

Antibiotic Management

Preoperative 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 3, 2, 4

Postoperative Antibiotics

• For uncomplicated appendicitis: Postoperative antibiotics are NOT recommended when adequate source control has been achieved 3, 2, 4
• For complicated appendicitis: Postoperative broad-spectrum antibiotics are indicated, with duration not exceeding 3-5 days when adequate source control is achieved 2, 4
• Early switch to oral antibiotics after 48 hours is safe in pediatric patients, with total antibiotic duration less than 7 days 3, 4

Non-Operative Management (Selected Cases Only)

Uncomplicated Appendicitis

• Non-operative management with antibiotics can be discussed as a safe alternative to surgery in selected adult patients with uncomplicated acute appendicitis and absence of appendicolith 1
• Patients must be counseled about the possibility of treatment failure (approximately 30% recurrence rate at one year) and risk of misdiagnosing complicated appendicitis 1, 5
• Initial intravenous antibiotics with subsequent switch to oral antibiotics is recommended 1
• Broad-spectrum antibiotics such as piperacillin-tazobactam monotherapy or combination therapy with cephalosporins or fluoroquinolones plus metronidazole are appropriate 5

Contraindications to Non-Operative Management

• Presence of appendicolith on imaging is a contraindication to antibiotics-first approach, as it is associated with approximately 40% treatment failure rate 5
• CT findings of mass effect or dilated appendix greater than 13 mm indicate higher risk of treatment failure and warrant surgical management 5

Pediatric Non-Operative Management

• Non-operative management with antibiotics may be discussed in children with uncomplicated appendicitis without appendicolith, though patients must be counseled about failure risk 1, 3

Management of Complicated Appendicitis

Appendiceal Abscess or Phlegmon

• Where advanced laparoscopic expertise is available, laparoscopic approach is the treatment of choice for appendiceal abscess or phlegmon 3, 2
• In settings without laparoscopic expertise, non-operative management with antibiotics and percutaneous drainage (if available) is recommended 3, 2
• Routine interval appendectomy after successful non-operative management is NOT recommended; it should only be performed for patients with recurrent symptoms 3

Intraoperative Considerations

• Perform suction alone rather than peritoneal irrigation in complicated appendicitis with intra-abdominal collections, as irrigation does not prevent intra-abdominal abscess formation or wound infections 1
• Drains are NOT recommended following appendectomy for complicated appendicitis, as they provide no benefit and lead to longer hospitalization 2
• Simple ligation of the appendiceal stump is recommended over stump inversion 2

Outpatient Management

• Outpatient laparoscopic appendectomy may be considered for uncomplicated appendicitis when an appropriate ambulatory setting with well-defined enhanced recovery after surgery (ERAS) protocols is available 1, 3, 4

Common Pitfalls and Caveats

• Do not delay surgery beyond 24 hours from admission, as this significantly increases surgical site infections and adverse events 1, 2
• In young children under 5 years of age, maintain high suspicion for atypical presentations, as delayed diagnosis leads to higher perforation rates 3
• Always perform routine histopathology after appendectomy to identify unexpected findings, including occult malignancy 2
• Patients ≥40 years old treated non-operatively should undergo colonoscopy and CT scan due to risk of underlying neoplasm 2, 4
• Avoid single-incision laparoscopic techniques unless specific expertise exists, as they are associated with longer operative times, higher pain, and more wound infections 1