What is the acute treatment for appendicitis?

Acute Treatment of Appendicitis

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

Surgical Management

Timing and Approach

• Surgery must be performed within 24 hours of admission to minimize complications—delays beyond 48 hours significantly increase surgical site infections and adverse events 2
• Laparoscopic appendectomy is strongly preferred over open appendectomy due to less postoperative pain, lower surgical site infection rates (reduced by 75%), shorter hospital stays, and earlier return to work 1, 2
• The conventional three-port laparoscopic technique is preferred over single-incision approaches due to shorter operative times and less postoperative pain 1
• In settings without laparoscopic expertise, open appendectomy remains appropriate, though a low threshold for conversion from laparoscopic to open should be maintained 1

Technical Considerations

• For mesoappendix dissection, monopolar or bipolar electrocoagulation are recommended as the most cost-effective techniques 3, 1
• For appendiceal stump closure, endoloops/suture ligation or polymeric clips are recommended over endostaplers in uncomplicated cases 3, 1
• Simple ligation should be used over stump inversion as it results in shorter operative times, less postoperative ileus, and quicker recovery 3
• Always remove the appendix even if it appears normal during surgery when no other pathology is found—macroscopic judgment of early appendicitis is highly inaccurate 1, 2
• Wound ring protectors should be used in open appendectomy to decrease surgical site infection risk 3
• Primary skin closure with absorbable intradermal suture is recommended over delayed closure 3

Antibiotic Management

Uncomplicated Appendicitis

• Administer a single preoperative dose of broad-spectrum antibiotics 0-60 minutes before surgical incision 1, 2
• Appropriate regimens include piperacillin-tazobactam monotherapy, or combination therapy with cephalosporins or fluoroquinolones plus metronidazole 4
• Do not continue postoperative antibiotics for uncomplicated appendicitis with adequate source control 1, 2

Complicated Appendicitis (Perforation, Abscess, Peritonitis)

• Administer preoperative broad-spectrum antibiotics as above 2
• Continue postoperative antibiotics for a maximum of 3-5 days when adequate source control has been achieved—do not extend beyond this duration 1, 2
• For periappendiceal abscess/phlegmon when advanced laparoscopic expertise is available, proceed with laparoscopic appendectomy as this approach is associated with fewer readmissions and additional interventions 1, 2
• If laparoscopic expertise is unavailable, non-operative management with antibiotics plus percutaneous drainage (if accessible) is recommended 1, 2

Antibiotic-Only Treatment: A Limited Alternative

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 1, 4, 5
• Success rates at one year are only 73% with antibiotics versus 97% with immediate appendectomy 6
• CT findings of appendicolith, mass effect, or appendiceal diameter >13 mm are associated with 40% treatment failure rates and should prompt surgical management 4
• This approach requires CT-proven uncomplicated appendicitis without appendicolith, which adds diagnostic burden and radiation exposure 3
• Given concerns about antimicrobial resistance, antibiotic overuse should be limited 3

Therefore, appendectomy remains the gold-standard treatment and antibiotics-only should be reserved for patients unfit for surgery or those who strongly prefer this approach after informed discussion of recurrence risks. 3, 4

Special Populations and Considerations

Elderly Patients

• Laparoscopic appendectomy is preferred due to reduced morbidity, length of stay, and costs 2
• Never use non-operative management in elderly patients with diffuse peritonitis or free perforation—these require urgent appendectomy 2

Patients ≥40 Years Old

• Both colonoscopy and interval full-dose contrast-enhanced CT scan are mandatory for follow-up due to 3-17% incidence of appendicular or colonic neoplasms 1, 2, 7
• Failure to follow up these patients is a critical pitfall that may miss underlying malignancy 7

Pregnant and Immunosuppressed Patients

• These populations should undergo timely surgical intervention to decrease risk of complications 8

Pediatric Patients

• Laparoscopic appendectomy is appropriate, though not first-choice due to increased joint-related adverse events 9
• Prophylactic abdominal drainage after laparoscopic appendectomy for complicated appendicitis is not recommended 3

Drainage Considerations

• Do not use abdominal drains following appendectomy for complicated appendicitis in adults—drains provide no benefit in preventing intra-abdominal abscess and lead to longer hospitalization with increased 30-day morbidity and mortality 3, 1
• In children, prophylactic drainage after laparoscopic appendectomy for complicated appendicitis is also not recommended 3, 1

Follow-Up and Interval Appendectomy

• Routine histopathology of the appendix specimen is mandatory as intra-operative diagnosis alone is insufficient for identifying unexpected disease 3
• Interval appendectomy is not routinely recommended after non-operative management for complicated appendicitis in young adults (<40 years) and children, but should be performed for those with recurrent symptoms 1, 7
• Outpatient laparoscopic appendectomy can be considered for uncomplicated appendicitis when well-defined protocols are available 1