What is the treatment for appendicitis?

Treatment of Appendicitis

Laparoscopic appendectomy is the first-line treatment for acute appendicitis, with surgery recommended within 24 hours of admission to minimize complications and optimize outcomes. 1

Surgical Management: The Gold Standard

Primary Surgical Approach

• Laparoscopic appendectomy is the preferred technique for acute appendicitis, offering significant advantages including less postoperative pain, lower surgical site infection rates, shorter hospital stays, and earlier return to work compared to open appendectomy. 1
• The conventional three-port laparoscopic technique is superior to single-incision approaches due to shorter operative times and less postoperative pain. 1
• Surgery should be performed within 24 hours of admission—delaying beyond this timeframe increases the risk of adverse outcomes. 1

Technical Considerations

• For mesoappendix dissection, monopolar or bipolar energy are recommended as cost-effective techniques. 1
• For appendiceal stump closure, endoloops/suture ligation or polymeric clips are recommended. 1
• Abdominal drains are not recommended following appendectomy for complicated appendicitis in adults or children. 1

Intraoperative Decision-Making

• If the appendix appears normal during surgery and no other pathology is found in symptomatic patients, the appendix should still be removed. 2, 1 This recommendation exists because surgeon's macroscopic judgment of early appendicitis is inaccurate and highly variable, with 19-40% of normal-appearing appendices showing pathological abnormalities on histology. 2
• Routine histopathological examination of all appendectomy specimens is mandatory, as intraoperative diagnosis alone is insufficient for identifying unexpected disease, including malignancy. 2

Management of Complicated Appendicitis

Appendicitis with Phlegmon or Abscess

The approach depends on available surgical expertise:

• Where advanced laparoscopic expertise is available: Laparoscopic appendectomy is the treatment of choice for complicated appendicitis with phlegmon or abscess, with a low threshold for conversion to open procedure. 2, 1 This approach is associated with fewer readmissions, fewer additional interventions, and shorter length of stay compared to non-operative management. 2

• Where laparoscopic expertise is not available: Non-operative management with antibiotics and percutaneous drainage (if accessible) is suggested. 2, 1

• Early appendectomy demonstrates superior outcomes in complicated appendicitis, with a significantly lower incidence of bowel resection (3.3% vs 17.1%) compared to initial non-operative management. 1

Interval Appendectomy Considerations

• Routine interval appendectomy is NOT recommended after non-operative management for complicated appendicitis in young adults (<40 years old) and children. 2, 1
• Interval appendectomy should only be performed for patients with recurrent symptoms, as the recurrence rate after non-surgical treatment ranges from 12-24%. 2, 1
• The cost of elective interval appendectomy to prevent recurrence in only one of eight patients does not justify routine performance. 2

Antibiotic Management

Perioperative Antibiotics

• A single preoperative dose of broad-spectrum antibiotics (administered 0-60 minutes before surgical incision) is mandatory for all patients undergoing appendectomy, regardless of the degree of inflammation. 2, 1
• For uncomplicated appendicitis, postoperative antibiotics are NOT recommended. 2, 1
• In complicated appendicitis with adequate source control, antibiotics should not be continued beyond 3-5 days postoperatively. 1

Antibiotics as Primary Treatment

While laparoscopic appendectomy remains the gold standard, antibiotic therapy alone may be considered in highly selected cases:

• Broad-spectrum antibiotics (piperacillin-tazobactam monotherapy, or combination therapy with cephalosporins or fluoroquinolones plus metronidazole) successfully treat uncomplicated acute appendicitis in approximately 70% of patients. 3
• However, approximately 30% of patients treated with antibiotics alone require subsequent appendectomy within one year. 1, 4
• After one year, only 63-73% of patients treated with antibiotics remain asymptomatic without complications or recurrences, compared to 97% with immediate appendectomy. 4

High-Risk Features Predicting Antibiotic Failure

Specific CT findings identify patients for whom antibiotics-first strategy is more likely to fail (≈40% failure rate):

• Appendicolith (conglomeration of feces in appendiceal lumen) 3
• Mass effect 3
• Dilated appendix >13 mm 3

Surgical management should be recommended in patients with these high-risk CT findings who are fit for surgery. 3 In patients without high-risk CT findings, either appendectomy or antibiotics can be considered as first-line therapy. 3

Special Population Considerations

Age-Related Recommendations

• For patients ≥40 years old with complicated appendicitis treated non-operatively, both colonoscopy and interval full-dose contrast-enhanced CT scan are recommended for follow-up. 2, 1 This is critical because the incidence of appendicular neoplasms is high (3-17%) in this age group. 2, 1

Outpatient Management

• Outpatient laparoscopic appendectomy can be considered for uncomplicated appendicitis when an ambulatory setting with well-defined protocols is available. 1

Critical Pitfalls to Avoid

• Delaying appendectomy beyond 24 hours from admission increases risk of adverse outcomes. 1
• Failing to remove a normal-appearing appendix during surgery in symptomatic patients when no other pathology is found—macroscopic judgment is unreliable. 2, 1
• Omitting routine histopathological examination may miss unexpected findings including malignancy. 1
• Failing to follow up patients ≥40 years old who have higher risk of underlying malignancy after non-operative management. 1
• Routinely performing interval appendectomy in young patients after successful non-operative management—this is not cost-effective and exposes patients to unnecessary surgical risk. 2