What is the recommended surgical approach for a patient presenting with appendicitis, considering factors such as prior abdominal surgeries and underlying health conditions?

Surgical Approaches in Appendicitis

Primary Recommendation

Laparoscopic appendectomy is the recommended surgical approach for both uncomplicated and complicated acute appendicitis in adults and children, offering superior outcomes including reduced postoperative pain, lower surgical site infection rates, shorter hospital stays, faster return to work, and improved quality of life compared to open appendectomy. 1, 2

Laparoscopic Approach: The Gold Standard

General Population

• Laparoscopic appendectomy should be performed as first-line treatment whenever laparoscopic equipment and expertise are available 1, 2
• This approach demonstrates significant advantages over open surgery across all patient populations 1
• The benefits are particularly pronounced in complicated appendicitis, where laparoscopic approach reduces hospital stay by 2 days compared to open surgery 3

Special Populations Where Laparoscopy is Particularly Beneficial

• Obese patients: Laparoscopic approach provides superior visualization and reduced wound complications 1
• Elderly patients: Despite higher baseline risk, laparoscopic approach reduces morbidity when surgery is performed promptly 1, 2
• Pregnant patients: Laparoscopic appendectomy is recommended over open approach when surgery is indicated 2
• Immunocompromised/transplant patients: Laparoscopic approach should be preferred when feasible, with surgery performed within 24 hours of diagnosis 2
• Patients with prior abdominal surgeries: Laparoscopy allows for diagnostic visualization and adhesiolysis when needed 4

Pediatric Patients

• Conventional three-port laparoscopic appendectomy is the recommended approach for all pediatric patients 5
• Port configuration: 10-12 mm umbilical port for camera, 5 mm suprapubic port for traction, 5 mm left iliac fossa port for dissection 5
• Single-incision techniques may be considered in favorable anatomy with appropriate expertise, but have longer operative times and higher wound infection rates 5

Timing of Surgery

Critical Time Windows

• Appendectomy must be performed within 24 hours of hospital admission for uncomplicated appendicitis 1, 2
• For complicated appendicitis in children, early appendectomy within 8 hours is recommended 2, 5
• Delaying surgery beyond 24 hours significantly increases complication rates and should be avoided 1, 2

Special Timing Considerations

• Transplant patients require appendectomy as soon as possible, typically within 24 hours, due to higher rates of complicated appendicitis in this population 2
• Elderly patients should undergo surgery as soon as the decision to operate is made, as this population has higher mortality with delayed surgery 2

Intraoperative Technical Recommendations

Mesoappendix Dissection

• Use monopolar electrocautery or bipolar energy for mesoappendix dissection as the most cost-effective approach 6, 1
• Other energy devices may be used based on surgeon judgment and available resources 6
• No clinical differences exist in outcomes between various dissection techniques 6

Appendiceal Stump Closure

• Use endoloops/suture ligation or polymeric clips for stump closure in both uncomplicated and complicated appendicitis 6, 1
• Polymeric clips are the cheapest and easiest method with shorter operative times for uncomplicated cases 6
• Endostaplers offer no clinical advantage over endoloops except possibly lower wound infection rates in children with uncomplicated appendicitis 6
• Simple ligation is strongly preferred over stump inversion, as it provides shorter operative times, less postoperative ileus, and quicker recovery 6

Management of Intra-abdominal Collections

• Perform suction alone without peritoneal irrigation for complicated appendicitis with intra-abdominal collections 6, 1
• Peritoneal irrigation provides no benefit in preventing intra-abdominal abscesses or wound infections 6

Drainage Considerations

• Do not place abdominal drains after appendectomy for complicated appendicitis in either adults or children 6, 1
• Drains do not prevent intra-abdominal abscesses and lead to longer hospitalization, increased antibiotic requirements, and potentially increased 30-day morbidity and mortality 6

Open Appendectomy: When and How

Indications for Open Approach

• Open appendectomy should be reserved only for situations where laparoscopic equipment or expertise is unavailable 5
• Conversion from laparoscopic to open may be necessary based on intraoperative findings 4

Open Technique Recommendations

• Use McBurney or Rocky-Davis incision in the right lower quadrant 5
• Employ wound ring protectors to decrease surgical site infection risk, especially in complicated appendicitis with contaminated/dirty wounds 6
• Perform primary skin closure with single absorbable intradermal (subcuticular) suture 6, 5
• Avoid delayed primary closure, as it increases hospital stay and costs without reducing infection risk 6

Complicated Appendicitis with Abscess

Management Algorithm

• Patients with periappendiceal abscess can be managed with percutaneous image-guided drainage in surgical departments with ready access to interventional radiology 6
• When percutaneous drainage is not available, surgery is recommended 6
• In centers with advanced laparoscopic expertise, early laparoscopic appendectomy demonstrates superior outcomes with 90% uneventful recovery versus 50% with conservative management 2
• Early appendectomy shows lower incidence of bowel resection compared to initial non-operative management that subsequently fails 2

Outpatient Laparoscopic Appendectomy

Patient Selection

• Outpatient laparoscopic appendectomy may be considered for uncomplicated appendicitis in selected patients 1, 2
• This approach requires well-defined Enhanced Recovery After Surgery (ERAS) protocols and appropriate patient information/consent 1, 2
• Studies demonstrate safety with complication rates of 2.4% in outpatients versus 11.7% in inpatients 7

Critical Pitfalls to Avoid

Diagnostic Pitfalls

• Always remove the appendix even if it appears normal during surgery when no other pathology is found in symptomatic patients 1, 2
• Surgeon's macroscopic assessment of early appendicitis is highly inaccurate and variable 2
• Routine histopathological examination must always be performed to identify unexpected findings 1, 2

Management Pitfalls

• Never delay surgery beyond 24 hours from admission without compelling reason 1, 2
• Do not attempt conservative management in immunocompromised or transplanted patients—operative management is safer 2
• Avoid stump inversion, as it increases operative time and postoperative ileus without benefit 6
• Do not place drains routinely in complicated appendicitis 6

Follow-up Considerations

Interval Appendectomy

• Interval appendectomy is not routinely recommended after non-operative management for complicated appendicitis in young adults (<40 years) and children 2
• Interval appendectomy should always be performed for patients with recurrent symptoms 6, 2

Oncologic Surveillance

• For patients ≥40 years with complicated appendicitis, perform colonoscopy and contrast-enhanced CT scan follow-up due to higher incidence (3-17%) of appendiceal neoplasms 1