What is the management and treatment of acute appendicitis?

Management and Treatment of Acute Appendicitis

Laparoscopic appendectomy is the preferred treatment for acute appendicitis, offering superior outcomes in terms of pain, infection rates, hospital stay, and quality of life compared to open surgery. 1

Initial Management Approach

Uncomplicated Acute Appendicitis

Surgical Management (First-Line)

• Perform laparoscopic appendectomy within 24 hours of admission to minimize complications—delays beyond this timeframe significantly increase adverse outcomes 1, 2
• Use conventional three-port laparoscopic technique rather than single-incision approach, as single-incision is associated with longer operative times, higher analgesic requirements, and increased wound infections 1
• Administer a single preoperative dose of broad-spectrum antibiotics 0-60 minutes before surgical incision 1, 2
• Do not continue postoperative antibiotics for uncomplicated appendicitis with adequate source control 2
• Simple ligation of the appendiceal stump is preferred over stump inversion 2
• Perform suction alone without peritoneal irrigation, as irrigation provides no benefit in preventing intra-abdominal abscess 1

Non-Operative Management (Alternative in Selected Patients)

• Antibiotics-first strategy can be discussed as a safe alternative in selected patients with uncomplicated appendicitis without appendicolith 1
• Success rate is approximately 70% at one year, with 63-78% remaining asymptomatic without recurrence 3, 4
• This approach should NOT be used if CT shows appendicolith, mass effect, or appendiceal diameter >13 mm, as these findings predict 40% treatment failure 3
• Initial intravenous antibiotics (piperacillin-tazobactam, or cephalosporin/fluoroquinolone plus metronidazole) with subsequent switch to oral based on clinical response 1, 3
• Patients must be counseled about possibility of failure and risk of misdiagnosing complicated appendicitis 1

Complicated Appendicitis (Perforation, Abscess, Phlegmon)

When Laparoscopic Expertise Available:

• Laparoscopic approach is the treatment of choice for complicated appendicitis with phlegmon or abscess where advanced expertise exists, with low threshold for conversion 1
• This approach results in fewer readmissions and fewer additional interventions than conservative management 1, 2
• Maintain low threshold for conversion to open surgery if technical difficulties arise, particularly with shock 2

When Laparoscopic Expertise NOT Available:

• Non-operative management with antibiotics and percutaneous drainage (if accessible) is recommended 1, 2
• Continue postoperative antibiotics for 3-5 days when adequate source control is achieved 2

Interval Appendectomy Decisions:

• Do NOT perform routine interval appendectomy after non-operative management in patients <40 years old—only perform for recurrent symptoms 1
• Recurrence rates after non-operative treatment range 12-24%, but routine interval appendectomy is not cost-effective (prevents recurrence in only 1 of 8 patients) 1

Special Populations

Pregnant Patients

• Laparoscopic appendectomy is preferred over open surgery when expertise is available, offering shorter hospital stay and lower surgical site infection rates 1
• Laparoscopy is safe regarding fetal loss and preterm delivery risk 1
• Pregnant patients should undergo timely surgical intervention rather than prolonged conservative management 5

Pediatric Patients

• Laparoscopic appendectomy is strongly recommended where expertise available, associated with lower postoperative pain, lower surgical site infections, and higher quality of life 1
• Non-operative management with antibiotics is feasible and safe in children with uncomplicated appendicitis without appendicolith 1
• Do not delay appendectomy beyond 24 hours from admission; perform within 8 hours for complicated appendicitis 1

High-Risk Patients

• Laparoscopic approach is suggested for obese patients, elderly patients, and those with comorbidities 1
• Immunosuppressed patients should undergo timely surgical intervention to decrease complication risk 5

Patients ≥40 Years Old

• Both colonoscopy and interval full-dose contrast-enhanced CT scan are recommended for follow-up after non-operative management due to 3-17% incidence of appendicular neoplasms 1, 6

Critical Pitfalls to Avoid

• Never delay appendectomy beyond 24 hours from admission when surgery is indicated—delays beyond 48 hours significantly increase surgical site infections and adverse events 1, 2
• Do not use single-incision laparoscopic technique routinely—it offers no advantage and increases complications 1
• Do not place drains following appendectomy for complicated appendicitis in adults—they provide no benefit and prolong hospitalization 2
• Do not perform peritoneal irrigation during laparoscopic appendectomy—suction alone is sufficient 1
• Remove the appendix even if it appears normal during surgery, as surgeon's macroscopic judgment is inaccurate (27.8% of "normal" appendices are inflamed histologically) 2
• Always obtain routine histopathology after appendectomy to identify unexpected findings including neoplasms 1, 2
• Use an intraoperative grading system (WSES or AAST) to guide postoperative management decisions 1, 2