What is the recommended treatment for acute appendicitis?

Recommended Treatment for Acute Appendicitis

Laparoscopic appendectomy is the preferred treatment for acute appendicitis, both uncomplicated and complicated, and should be performed within 24 hours of hospital admission. 1, 2

Surgical Approach

Laparoscopic appendectomy should be chosen over open appendectomy for the following reasons 1, 2:

• Lower postoperative pain 1
• Reduced surgical site infection rates 1, 3
• Shorter hospital stays 1, 3
• Faster return to work 1
• Better quality of life scores 1
• Lower major morbidity (22.6% vs 52.0% in complicated cases) 3

This recommendation applies to both adults and children when laparoscopic equipment and expertise are available 1, 2.

Specific Patient Populations Where Laparoscopy is Particularly Beneficial

• Obese patients 1, 2
• Elderly patients 1, 2
• Patients with comorbidities 1, 2
• Pregnant patients (safer with lower surgical site infection rates and shorter hospital stays) 1, 2
• Pediatric patients (lower postoperative pain and higher quality of life) 1

Surgical Timing

Surgery must be performed within 24 hours of hospital admission 2, 4, 5:

• Delays beyond 24 hours significantly increase the risk of complications, perforation, and adverse outcomes 2, 4, 5
• For pediatric patients with complicated appendicitis, perform surgery within 8 hours 2, 4
• Delays beyond 48 hours significantly increase surgical site infections 5

Preoperative Management

Administer a single dose of broad-spectrum antibiotics 0-60 minutes before surgical incision 2, 4, 5:

• For uncomplicated cases: second or third-generation cephalosporins (cefoxitin, cefotetan) 4
• For complicated cases: piperacillin-tazobactam, ampicillin-sulbactam, or combination therapy with cephalosporins or fluoroquinolones plus metronidazole 4, 6

Postoperative Antibiotic Management

• For uncomplicated appendicitis with adequate source control: no postoperative antibiotics are needed 5
• For complicated appendicitis: continue antibiotics for 3-5 days postoperatively when adequate source control is achieved 5

Laparoscopic Technique Specifications

Use conventional three-port laparoscopic appendectomy rather than single-incision technique 1:

• Single-incision approach has longer operative times 1
• Requires higher doses of analgesia 1
• Associated with higher wound infection rates 1

Intraoperative Considerations

• Use suction alone without peritoneal irrigation for complicated appendicitis with intra-abdominal collections 1, 2
• Irrigation does not prevent intra-abdominal abscesses or wound infections 1, 2
• Remove the appendix even if it appears normal during surgery, as macroscopic assessment is often inaccurate (27.8% of "normal" appendices are inflamed histologically) 2, 5
• Do not place drains after appendectomy for complicated appendicitis, as they provide no benefit and prolong hospitalization 2, 5

Non-Operative Management Considerations

While antibiotics alone can successfully treat uncomplicated appendicitis in approximately 70% of patients initially 6, surgery remains the first-line treatment because:

• Only 63-73% of antibiotic-treated patients remain asymptomatic at one year 6, 7
• 97% of surgically treated patients have optimal outcomes at one year 7
• CT findings of appendicolith, mass effect, or appendiceal diameter >13mm are associated with 40% antibiotic treatment failure 6

Antibiotic therapy may be considered only in highly selected patients who are unfit for surgery and lack high-risk CT findings 6, but this requires thorough patient counseling about failure risk and potential for misdiagnosis 4.

Special Situation: Periappendiceal Abscess

For patients with periappendiceal abscess where laparoscopic expertise is unavailable, consider non-operative management with antibiotics and percutaneous drainage 5. However, laparoscopic management is associated with fewer readmissions and fewer additional interventions 5.

Mandatory Follow-Up

• Routine histopathological examination of all removed appendices to identify unexpected findings 2, 5
• For patients ≥40 years with complicated appendicitis: perform colonoscopy and contrast-enhanced CT follow-up due to 3-17% incidence of appendiceal neoplasms 2

Critical Pitfalls to Avoid

• Never delay surgery beyond 24 hours from admission 2, 4, 5
• Never delay antibiotic administration until after surgery 4
• Never fail to perform histopathology on the removed appendix 2, 5
• Never use single-incision laparoscopy as routine approach due to inferior outcomes 1
• Never perform peritoneal irrigation in complicated cases 1, 2