What is the recommended treatment for a patient with appendicitis?

Treatment of Appendicitis

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

Surgical Management for Uncomplicated Appendicitis

Laparoscopic appendectomy is strongly preferred over open appendectomy due to superior outcomes including less postoperative pain, lower surgical site infection rates (reduced by approximately 50%), shorter hospital stays, and earlier return to work. 1, 2, 3

Critical Timing Considerations

• Surgery must be performed within 24 hours of admission—delays beyond this timeframe significantly increase complications, and delays beyond 48 hours dramatically increase surgical site infections and adverse events. 1, 2, 3
• This timing recommendation applies regardless of whether the appendicitis is complicated or uncomplicated. 1, 3

Technical Surgical Recommendations

• Use conventional three-port laparoscopic technique rather than single-incision approaches, which are associated with longer operative times and higher postoperative pain. 1, 2
• For mesoappendix dissection, use monopolar or bipolar electrocoagulation as the most cost-effective techniques. 1
• For appendiceal stump closure, use endoloops/suture ligation or polymeric clips rather than endostaplers in uncomplicated cases. 1
• Simple ligation is preferred over stump inversion as it results in shorter operative times, less postoperative ileus, and quicker recovery. 1, 2
• Always remove the appendix even if it appears grossly normal during surgery—surgeon's macroscopic judgment is highly inaccurate, with 27.8% of "normal-appearing" appendices showing inflammation on histopathology. 4, 1, 2

Antibiotic Protocol for Uncomplicated Appendicitis

• Administer a single preoperative dose of broad-spectrum antibiotics 0-60 minutes before surgical incision. 4, 1, 2, 3
• Acceptable regimens include piperacillin-tazobactam monotherapy, or combination therapy with cephalosporins or fluoroquinolones plus metronidazole. 5
• Do not continue postoperative antibiotics for uncomplicated appendicitis with adequate source control. 4, 1, 2, 3

Management of Complicated Appendicitis (Perforation, Abscess, Phlegmon)

The approach depends on available surgical expertise and patient presentation:

When Advanced Laparoscopic Expertise is Available

Laparoscopic appendectomy is the treatment of choice for complicated appendicitis with periappendiceal abscess or phlegmon, as it is associated with fewer readmissions, fewer additional interventions, and comparable hospital stays compared to non-operative management. 4, 1, 3

• Maintain a low threshold for conversion to open surgery if technical difficulties arise, particularly in patients with shock or diffuse peritonitis. 2
• Early appendectomy demonstrates superior outcomes with lower incidence of bowel resection (3.3% vs 17.1%) compared to initial non-operative management. 1

When Laparoscopic Expertise is Not Available

Non-operative management with broad-spectrum antibiotics plus percutaneous drainage (if accessible) is recommended for complicated appendicitis with periappendiceal abscess. 4, 1, 3

Antibiotic Protocol for Complicated Appendicitis

• Administer preoperative broad-spectrum antibiotics as described above. 4, 3
• Continue postoperative antibiotics for a maximum of 3-5 days when adequate source control has been achieved. 4, 1, 2, 3
• Do not extend antibiotic therapy beyond 5 days in patients with adequate source control. 1, 3

Drainage Considerations

Do not routinely place abdominal drains following appendectomy for complicated appendicitis—drains provide no benefit in preventing intra-abdominal abscess and lead to longer hospitalization in both adults and children. 1, 2

• This recommendation contradicts one older single-center study 6 but is based on higher-quality systematic evidence showing no benefit and potential harm. 1, 2

Antibiotic-Only Treatment (Selected Cases)

While laparoscopic appendectomy remains first-line, antibiotic therapy alone may be considered in highly selected patients with uncomplicated appendicitis who are unfit for surgery or strongly prefer non-operative management. 5

Patient Selection Criteria

Avoid antibiotic-only treatment in patients with high-risk CT findings:

• Appendicolith present
• Mass effect
• Appendiceal diameter >13 mm

These findings are associated with approximately 40% treatment failure rates and should prompt surgical management. 1, 5

Expected Outcomes with Antibiotic-Only Treatment

• Approximately 30% of patients will require appendectomy within one year. 1
• At one-year follow-up, only 63-73% of patients remain asymptomatic without complications or recurrence, compared to 97% with immediate appendectomy. 7, 5
• Treatment success is approximately 70% in appropriately selected patients without high-risk features. 5

Special Population Considerations

Patients ≥40 Years Old

All patients ≥40 years old with appendicitis (regardless of treatment approach) require:

• Colonoscopy for colonic screening
• Interval full-dose contrast-enhanced CT scan

This is mandatory due to 3-17% incidence of appendicular or colonic neoplasms in this age group. 4, 1, 3

Interval Appendectomy After Non-Operative Management

Routine interval appendectomy is NOT recommended after successful non-operative management for complicated appendicitis in young adults (<40 years) and children, as recurrence rates are only 12-24% and the cost-benefit ratio does not justify routine surgery. 4, 1

• Perform interval appendectomy only in patients who develop recurrent symptoms. 4, 1

Outpatient Laparoscopic Appendectomy

Outpatient same-day discharge can be considered for uncomplicated appendicitis when an ambulatory setting with well-defined protocols is available and patients are appropriately selected based on their clinical course in the operating and recovery rooms. 1, 8

Mandatory Follow-Up

Routine histopathological examination of all appendix specimens is mandatory, as intra-operative diagnosis alone is insufficient for identifying unexpected disease including neoplasms. 1, 2

Critical Pitfalls to Avoid

• Never delay appendectomy beyond 24 hours from admission unless pursuing deliberate non-operative management for abscess—delays increase complications exponentially. 1, 2, 3
• Never rely on macroscopic appearance alone—always remove the appendix if no other pathology is found, as visual assessment is unreliable. 1, 2
• Never continue postoperative antibiotics beyond 3-5 days in complicated appendicitis with adequate source control—this promotes antimicrobial resistance without benefit. 1, 3
• Never skip colonoscopy and CT follow-up in patients ≥40 years old—the malignancy risk is substantial. 4, 1, 3
• Never use routine intraoperative irrigation—it does not prevent abscess formation and may be avoided. 2