What is the management of acute appendicitis?

Management of Acute Appendicitis

Laparoscopic appendectomy performed within 24 hours of admission is the recommended first-line treatment for acute appendicitis, offering superior outcomes including less pain, lower infection rates, shorter hospital stays, and faster return to work compared to both open surgery and non-operative management. 1, 2

Surgical Management: The Gold Standard

Timing and Approach

• Surgery must be performed within 24 hours of admission to minimize complications and adverse outcomes 1, 2
• Delays beyond 24 hours significantly increase surgical site infections and adverse events, with delays beyond 48 hours showing even worse outcomes 2
• Laparoscopic appendectomy is superior to open appendectomy for both uncomplicated and complicated appendicitis 1, 2
• Use conventional three-port laparoscopic technique rather than single-incision approaches, which have longer operative times, higher analgesic requirements, and higher wound infection rates 2

Technical Considerations

• For mesoappendix dissection: use monopolar or bipolar energy as cost-effective techniques 1
• For stump closure: use endoloops/suture ligation or polymeric clips; simple ligation is preferred over stump inversion 1, 2
• Remove the appendix even if it appears normal during surgery when no other pathology is found in symptomatic patients—macroscopic judgment is inaccurate, with 27.8% of "normal-appearing" appendices showing inflammation on histopathology 1, 2
• Maintain a low threshold for conversion to open surgery if technical difficulties arise, particularly in complicated appendicitis with shock 2

Antibiotic Management

Perioperative Antibiotics

• Administer a single preoperative dose of broad-spectrum antibiotics 0-60 minutes before surgical incision 1, 2
• For uncomplicated appendicitis with adequate source control: do NOT continue postoperative antibiotics 1, 2
• For complicated appendicitis with adequate source control: limit postoperative antibiotics to 3-5 days maximum 1, 2

Non-Operative Management with Antibiotics

• Non-operative management (antibiotics alone) may be considered for uncomplicated appendicitis in selected patients, but has significant limitations 1, 3
• Approximately 30% of patients treated with antibiotics alone require appendectomy within one year 1
• At one year, only 63-73% of antibiotic-treated patients remain asymptomatic without complications or recurrence, compared to 97% with immediate appendectomy 4
• Antibiotic therapy is NOT recommended as first-line for patients who are fit for surgery 3

Management of Complicated Appendicitis

Periappendiceal Abscess/Phlegmon

• Where advanced laparoscopic expertise is available: laparoscopic appendectomy is the treatment of choice, associated with fewer readmissions (3% vs 27%) and fewer additional interventions (7% vs 30%) compared to conservative management 5, 1, 2
• Where laparoscopic expertise is NOT available: use non-operative management with antibiotics plus percutaneous drainage (if accessible) 5, 1, 2
• Early appendectomy demonstrates lower incidence of bowel resection (3.3% vs 17.1%) compared to non-operative management 1

Perforated Appendicitis

• Patients with perforated appendicitis require urgent intervention for adequate source control 5
• Well-circumscribed periappendiceal abscess can be managed with percutaneous drainage when necessary, with appendectomy generally deferred 5

Special Populations and Considerations

Outpatient Management

• Outpatient laparoscopic appendectomy can be considered for uncomplicated appendicitis when an ambulatory setting with well-defined protocols is available 1, 6
• Selected patients can be safely dismissed on the day of surgery with complication rates of 2.4% 6

Follow-up Requirements

• For patients ≥40 years old with complicated appendicitis: perform both colonoscopy and interval full-dose contrast-enhanced CT scan due to higher incidence of appendicular neoplasms (3-17%) 1
• Patients <40 years old do NOT require routine interval colonoscopy or CT follow-up 2
• Routine histopathological examination of the appendix is mandatory to identify unexpected findings 1, 2

Interval Appendectomy

• Interval appendectomy is NOT routinely recommended after successful non-operative management for complicated appendicitis in young adults (<40 years) and children 1
• Perform interval appendectomy only for those with recurrent symptoms 1
• The recurrence rate after non-surgical treatment is up to 20.5% in children 5

Technical Details to Avoid Complications

What NOT to Do

• Do NOT use abdominal drains following appendectomy for complicated appendicitis in adults or children—they provide no benefit in preventing intra-abdominal abscess and lead to longer hospitalization 1, 2
• Do NOT perform routine intraoperative irrigation—it does not prevent intra-abdominal abscess formation 2
• Do NOT delay surgery beyond 24 hours to accommodate surgeon preference or hospital efficiency 1, 2, 7

Intraoperative Grading

• Use an intraoperative grading system (WSES or AAST) to guide postoperative management 2

Common Pitfalls

• Failing to operate within 24 hours increases complications 1, 2
• Assuming a normal-appearing appendix should be left in place—27.8% are inflamed histologically 1, 2
• Continuing antibiotics beyond 3-5 days postoperatively in complicated appendicitis with adequate source control 1, 2
• Not following up patients ≥40 years old who have higher risk of underlying malignancy 1
• Choosing single-incision laparoscopy when conventional three-port technique is superior 2