What is the recommended treatment for appendicitis?

Treatment of Appendicitis

Laparoscopic appendectomy is the preferred treatment for acute appendicitis, offering superior outcomes including less postoperative pain, lower surgical site infection rates, shorter hospital stays, and better quality of life compared to both open surgery and antibiotic therapy. 1

Surgical Approach for Uncomplicated Appendicitis

Laparoscopic appendectomy should be performed as the first-line treatment when equipment and expertise are available. 1 This recommendation is based on high-quality evidence demonstrating:

• Reduced postoperative pain compared to open surgery 1
• Lower incidence of surgical site infections 1
• Decreased length of hospital stay 1
• Earlier return to work and physical activity 1
• Better quality of life scores 1

Technical Considerations

• Use conventional three-port laparoscopic technique rather than single-incision approaches, as single-incision methods are associated with longer operative times, higher analgesic requirements, and increased wound infection rates 1, 2
• Perform surgery within 24 hours of admission, as delays beyond this timeframe increase complications 2
• Administer a single preoperative dose of broad-spectrum antibiotics 0-60 minutes before surgical incision 2
• Postoperative antibiotics are not needed for uncomplicated appendicitis with adequate source control 2

Management of Complicated Appendicitis

Appendiceal Abscess or Phlegmon

For complicated appendicitis with appendiceal abscess, laparoscopic appendectomy remains preferred when expertise is available, as it results in fewer readmissions and additional interventions compared to conservative management. 2, 3

• If laparoscopic expertise is unavailable, use non-operative management with antibiotics plus percutaneous drainage (if technically accessible) 1, 2
• Perform suction alone rather than irrigation during laparoscopic appendectomy for intra-abdominal collections 1, 2

Diffuse Peritonitis or Free Perforation

Urgent appendectomy is mandatory for complicated appendicitis with diffuse peritonitis or free perforation. 1 These patients have significantly higher mortality (11.9-15% vs 1.5-2.3% for non-perforated cases) and require immediate surgical intervention 1

• Continue postoperative antibiotics for 3-5 days when adequate source control is achieved 2
• Maintain low threshold for conversion to open surgery if technical difficulties arise, particularly with shock 2

Special Populations

Elderly Patients

• Laparoscopic appendectomy is preferred due to reduced length of stay, morbidity, and costs 1
• For appendiceal abscess in elderly patients, use non-operative management with percutaneous drainage when accessible 1
• Strongly recommend elective colonic screening in all elderly patients (>55-65 years) with appendicitis, as cancer incidence ranges from 1.6-24% in this population 1

Pregnant Patients

• Laparoscopic appendectomy should be preferred over open surgery when expertise is available, as it is associated with shorter hospital stays and lower surgical site infection rates 1

Obese and High-Risk Patients

• Laparoscopic approach is particularly beneficial in obese patients, older patients, and those with comorbidities 1

Antibiotic Therapy as Alternative Treatment

While some evidence suggests antibiotics can treat uncomplicated appendicitis, this approach has significant limitations that make surgery the preferred option. 4, 5

• Antibiotic therapy fails in approximately 30% of patients within one year, requiring subsequent appendectomy 5
• Success rates are only 63-78% at one year compared to 97% with immediate appendectomy 6, 5
• CT findings of appendicolith, mass effect, or appendiceal diameter >13mm predict 40% failure rate with antibiotics 4
• Antibiotics may increase negative appendectomy rates when surgery is eventually needed (RR 3.16) 5

The antibiotics-first approach should only be considered in highly selected patients who are unfit for surgery and lack high-risk CT findings. 4

Critical Pitfalls to Avoid

• Do not delay surgery beyond 24 hours from admission for uncomplicated appendicitis, as this increases complications 2
• Do not use single-incision laparoscopic techniques as routine practice due to inferior outcomes 1, 2
• Do not perform routine irrigation during laparoscopic appendectomy, as it provides no benefit in preventing intra-abdominal abscess 1, 2
• Always remove the appendix even if it appears normal during exploration, as 27.8% of "normal-appearing" appendices are inflamed histologically 2
• Always send the appendix for routine histopathology to identify unexpected findings including malignancy 2, 3