What is the recommended treatment for a patient with appendicitis?

Treatment of Appendicitis

Laparoscopic appendectomy is the recommended first-line treatment for acute appendicitis, with surgery performed within 24 hours of admission to minimize complications. 1, 2

Uncomplicated Appendicitis

Surgical Management (Preferred)

• Laparoscopic appendectomy is superior to open appendectomy, offering less postoperative pain, lower surgical site infection rates, shorter hospital stays, earlier return to work, and better quality of life 1, 2
• Perform surgery within 24 hours of admission—delays beyond this timeframe significantly increase complication rates including surgical site infections and adverse events 1, 2
• Administer a single preoperative dose of broad-spectrum antibiotics 0-60 minutes before surgical incision to reduce wound infections and intra-abdominal abscesses 3, 1
• Do not continue postoperative antibiotics for uncomplicated appendicitis with adequate source control 3, 1

Antibiotic-Only Management (Selected Cases)

While surgery remains standard, antibiotics may be considered in highly selected patients:

• Approximately 70% of patients with uncomplicated appendicitis respond to antibiotics alone, avoiding surgery in the short term 4
• However, only 63-73% remain asymptomatic at one year without recurrence or need for surgery 5, 6
• Antibiotics are associated with 76 more treatment failures per 1000 patients compared to surgery 6
• One-third of antibiotic-treated patients require appendectomy within one year 6

Antibiotics should NOT be used if:

• Appendicolith is present on CT (≈40% failure rate) 4
• Appendiceal diameter ≥13 mm 4
• Mass effect is present 4
• Patient is fit for surgery 4

Recommended antibiotic regimens (when antibiotics are chosen): piperacillin-tazobactam monotherapy, or combination therapy with cephalosporins/fluoroquinolones plus metronidazole for 8-15 days 7, 5, 4

Complicated Appendicitis (Perforation, Abscess, Peritonitis)

Surgical Approach

• Laparoscopic appendectomy is preferred even for complicated cases when advanced laparoscopic expertise is available, with low threshold for conversion to open surgery 3
• Laparoscopic management reduces readmissions and additional interventions compared to conservative treatment 3, 1
• Maintain low threshold for conversion to open surgery if technical difficulties arise, particularly with shock 1
• Remove the appendix even if it appears normal during exploration—27.8% of "normal-appearing" appendices are inflamed histologically 1

Antibiotic Management

• Administer preoperative broad-spectrum antibiotics as a single dose 0-60 minutes before incision 3
• Continue postoperative antibiotics for 3-5 days maximum when adequate source control is achieved 3, 1
• Do not prolong antibiotics beyond 3-5 days postoperatively—fixed-duration therapy has similar outcomes to longer courses 3
• Piperacillin-tazobactam is FDA-approved for complicated appendicitis (ruptured or with abscess) caused by beta-lactamase producing organisms 7

Abscess/Phlegmon Management

• For large appendiceal abscess or phlegmon: percutaneous drainage plus antibiotics is a safe alternative when advanced laparoscopic expertise is unavailable 3, 8
• Do NOT perform routine interval appendectomy after successful non-operative management in patients <40 years old 3
• Interval appendectomy is only indicated for recurrent symptoms (recurrence rate 12-24%) 3

Special Populations

Patients ≥40 Years Old

• Perform colonoscopy and interval contrast-enhanced CT after non-operative treatment due to 3-17% incidence of appendiceal neoplasms 3

Pediatric Patients

• Early switch to oral antibiotics after 48 hours for complicated appendicitis, with total therapy <7 days 3
• No postoperative antibiotics for uncomplicated appendicitis in children 3

Pregnant and Immunosuppressed Patients

• Proceed with timely surgical intervention to decrease complication risk 8

Key Technical Points

• Simple ligation of the appendiceal stump is recommended over stump inversion in both open and laparoscopic procedures 1, 2
• Do not routinely place drains after appendectomy for complicated appendicitis—they provide no benefit and prolong hospitalization 1
• Avoid routine intraoperative irrigation—it does not prevent intra-abdominal abscess formation 1
• Perform routine histopathology after all appendectomies to identify unexpected findings 1, 2

Critical Pitfalls to Avoid

• Do not delay surgery beyond 24 hours from admission—delays beyond 48 hours significantly increase surgical site infections 1, 2
• Avoid single-incision laparoscopic appendectomy—it has longer operative times, higher analgesic requirements, and higher wound infection rates than conventional three-port technique 1
• Do not use antibiotics as first-line in patients with appendicolith, mass effect, or appendix >13 mm—these have ≈40% failure rates 4
• In young women, maintain high clinical suspicion—female sex is associated with higher perforation rates 1