What is the recommended treatment for acute appendicitis, including the approach for appendectomy?

Recommended Treatment for Acute Appendicitis

Laparoscopic appendectomy is the strongly recommended first-line treatment for acute appendicitis in both adults and children, and should be performed within 24 hours of admission to minimize complications. 1, 2

Surgical Approach Selection

Primary Recommendation: Laparoscopic Appendectomy

• Laparoscopic appendectomy should be preferred over open appendectomy for both uncomplicated and complicated acute appendicitis when equipment and expertise are available 1, 3
• This approach provides superior outcomes including:
  • Lower postoperative pain 1, 4
  • Reduced surgical site infection rates 1, 5
  • Shorter hospital stays 1, 5
  • Earlier return to work 1
  • Better quality of life scores 1, 3

Specific Laparoscopic Technique

• Conventional three-port laparoscopic appendectomy is strongly recommended over single-incision techniques 1, 2
• Three-port technique demonstrates:
  • Shorter operative times 1, 2
  • Less postoperative pain 1, 2
  • Lower wound infection rates 1, 2

Special Populations Where Laparoscopy is Particularly Beneficial

• Obese patients 1, 3, 6
• Elderly patients 1, 3, 6
• Patients with comorbidities 1, 3, 6
• Pregnant patients (safe and feasible when expertise available) 1, 3, 6

Timing of Surgery

Critical Time Windows

• Appendectomy must be performed within 24 hours of admission for uncomplicated appendicitis 2, 3, 6
• For complicated appendicitis, early appendectomy within 8 hours is recommended 2, 3, 6
• Delaying surgery beyond 24 hours significantly increases complication risk 2, 3, 6

Intraoperative Technical Recommendations

Mesoappendix Dissection

• Monopolar electrocoagulation or bipolar energy are recommended as cost-effective techniques 2, 3
• No significant clinical differences exist between various dissection methods 3

Appendiceal Stump Closure

• Use endoloops/suture ligation or polymeric clips for stump closure in both uncomplicated and complicated appendicitis 1, 2, 3
• Polymeric clips are the most cost-effective option with shortest operative times for uncomplicated cases 1, 3
• Endostaplers may be reserved for complicated cases based on surgeon judgment 1
• Simple ligation is strongly preferred over stump inversion (shorter operative times, less postoperative ileus, quicker recovery) 1, 2

Management of Intra-abdominal Collections

• Perform suction alone without peritoneal irrigation in complicated appendicitis with collections 1, 2, 3
• Irrigation provides no benefit in preventing intra-abdominal abscesses or wound infections 1, 3

Wound Protection (Open Appendectomy)

• Use wound ring protectors in open appendectomy to decrease surgical site infection risk 1
• Perform primary skin closure with single absorbable intradermal suture 1

Postoperative Management

Drain Usage

• Abdominal drains are strongly discouraged following appendectomy for complicated appendicitis in adults 1, 2, 3
• Drains do not prevent intra-abdominal abscesses and lead to longer hospitalization 1
• Prophylactic drainage is not recommended in children after laparoscopic appendectomy for complicated appendicitis 1, 2

Antibiotic Management

• Single preoperative dose of broad-spectrum antibiotics should be given 0-60 minutes before incision 6
• Postoperative antibiotics are not needed for uncomplicated appendicitis 6
• For complicated cases with adequate source control, do not extend antibiotics beyond 3-5 days 6

Outpatient Management

• Outpatient laparoscopic appendectomy is feasible for uncomplicated appendicitis when well-defined ERAS protocols are established 1, 2, 3, 6

Alternative Treatment Consideration

Antibiotic Therapy Alone

While appendectomy remains the gold standard, antibiotics may be considered in highly selected cases of uncomplicated appendicitis, but this approach has significant limitations:

• Approximately 30% of patients require subsequent appendectomy within one year 2
• Only 63-73% of patients remain asymptomatic at one year follow-up 4, 7
• Success rates are lower with certain CT findings (appendicolith, mass effect, appendix >13mm) 4
• Surgical management should be recommended for patients fit for surgery, particularly those with high-risk CT findings 4

Critical Pitfalls to Avoid

Intraoperative Decisions

• Always remove the appendix even if it appears normal during surgery in symptomatic patients when no other pathology is found 2, 3, 6
• Surgeon's macroscopic judgment of early appendicitis is highly inaccurate and variable 1, 6

Postoperative Follow-up

• Routine histopathological examination is mandatory after all appendectomies to identify unexpected findings 1, 2, 3, 6
• For patients ≥40 years with complicated appendicitis, perform colonoscopy and contrast-enhanced CT follow-up due to 3-17% incidence of appendiceal neoplasms 3

Timing Errors

• Never delay appendectomy beyond 24 hours from admission without compelling reason 2, 3, 6
• For complicated cases, aim for surgery within 8 hours 2, 3, 6

Grading System Adoption

• Routine use of an intraoperative grading system (e.g., WSES 2015 or AAST EGS grading score) is suggested to standardize postoperative management and resource utilization 1