What is the recommended treatment regimen for a patient with appendicitis?

Treatment Regimen for Appendicitis

Laparoscopic appendectomy is the recommended first-line treatment for acute appendicitis, with surgery performed within 24 hours of admission, preceded by a single preoperative dose of broad-spectrum antibiotics administered 0-60 minutes before incision. 1, 2, 3

Uncomplicated Appendicitis

Surgical Approach

• Laparoscopic appendectomy is strongly preferred over open appendectomy due to less postoperative pain, lower surgical site infection rates, shorter hospital stays, and earlier return to work 1, 2, 3, 4
• Use conventional three-port laparoscopic technique rather than single-incision approaches, which are associated with longer operative times and higher wound infection rates 2, 3
• Perform surgery within 24 hours of admission—delays beyond this timeframe significantly increase complications 2, 5, 3

Antibiotic Management

• Administer a single preoperative dose of broad-spectrum antibiotics 0-60 minutes before surgical incision 1, 2, 5, 3
• Do not continue postoperative antibiotics for uncomplicated appendicitis with adequate source control 1, 2, 5

Surgical Technique Details

• Remove the appendix even if it appears macroscopically normal during surgery when no other pathology is found—27.8% of "normal-appearing" appendices are inflamed histologically 2, 3
• Use simple ligation of the appendiceal stump rather than stump inversion 2
• Do not place drains following appendectomy as they provide no benefit and prolong hospitalization 2, 3
• Send all specimens for routine histopathology to identify unexpected findings 2, 5, 3

Complicated Appendicitis (Perforation, Abscess, Phlegmon)

Treatment Strategy

• When advanced laparoscopic expertise is available, proceed with laparoscopic appendectomy—this approach is associated with fewer readmissions and additional interventions compared to conservative management 1, 2, 5, 3
• Maintain a low threshold for conversion to open surgery if technical difficulties arise, particularly in the setting of shock 2
• If laparoscopic expertise is unavailable, use non-operative management with antibiotics plus percutaneous drainage (if the abscess is accessible) 1, 5, 3

Antibiotic Management for Complicated Cases

• Administer a single preoperative dose of broad-spectrum antibiotics before surgery 1, 2
• Continue postoperative antibiotics for 3-5 days maximum when adequate source control has been achieved—do not prolong beyond this duration 1, 2, 5, 3
• Appropriate broad-spectrum regimens include piperacillin-tazobactam monotherapy or combination therapy with cephalosporins/fluoroquinolones plus metronidazole 6
• In children with complicated appendicitis, switch to oral antibiotics after 48 hours with total therapy duration less than 7 days 1

Antibiotic-Only Treatment Considerations

While antibiotics alone may be considered in highly selected cases of uncomplicated appendicitis, this approach has significant limitations:

• Approximately 30% of patients require subsequent appendectomy within one year 6, 7
• Only 63-73% of antibiotic-treated patients remain asymptomatic without complications or recurrences at one year 8, 7
• CT findings that predict antibiotic failure include: appendiceal diameter ≥13 mm, presence of appendicolith, or mass effect—these patients should undergo surgery if fit for operation 6
• Success rates are approximately 70% overall, but drop to 60% in patients with high-risk CT features 6

Given these failure rates, appendectomy remains the definitive first-line treatment, and antibiotics alone should only be considered in unfit surgical candidates or highly selected patients who are fully informed of recurrence risks. 6, 7

Special Populations and Follow-Up

Age-Related Considerations

• For patients ≥40 years old treated with any approach (operative or non-operative), perform both colonoscopy and interval contrast-enhanced CT scan due to 3-17% incidence of appendicular or colonic neoplasms 1, 3
• For patients <40 years old, do not perform routine interval appendectomy after successful non-operative management unless recurrent symptoms develop 1, 3

Elderly Patients

• Laparoscopic appendectomy is preferred due to reduced morbidity, length of stay, and costs 1
• For complicated appendicitis with abscess, use non-operative management with percutaneous drainage when accessible 1
• Do not use non-operative management in elderly patients with diffuse peritonitis or free perforation—these require urgent appendectomy 1
• Colonic screening is strongly recommended for all elderly patients with appendicitis regardless of treatment approach 1

Critical Pitfalls to Avoid

• Never delay appendectomy beyond 24 hours from admission—delays beyond 48 hours significantly increase surgical site infections and adverse events 2, 5, 3
• Do not rely on macroscopic appearance alone—always remove the appendix if no other pathology is found, as surgeon judgment is inaccurate 2, 3
• Do not use routine intraoperative irrigation as it does not prevent abscess formation 2
• Do not continue postoperative antibiotics beyond 3-5 days in complicated appendicitis with adequate source control 1, 2, 3
• Do not skip histopathology examination—unexpected findings occur and malignancy risk increases with age 2, 5, 3
• In young women, maintain high clinical suspicion as female sex is associated with higher perforation rates 2