What is the recommended immediate management for a patient with a ruptured appendix?

Immediate Management of Ruptured Appendix

For a patient with ruptured appendix, proceed immediately with laparoscopic appendectomy if advanced laparoscopic expertise is available, as this approach results in fewer readmissions and additional interventions compared to conservative management. 1, 2

Initial Resuscitation and Assessment

• Begin immediate fluid resuscitation and hemodynamic stabilization while preparing for definitive treatment 3
• Administer a single preoperative dose of broad-spectrum antibiotics (such as piperacillin-tazobactam, or combination therapy with cephalosporins/fluoroquinolones plus metronidazole) 0-60 minutes before surgical incision 2, 4
• Do not delay surgery to determine COVID-19 status or await test results—proceed with appropriate PPE for all patients 1

Surgical Approach Decision Algorithm

If advanced laparoscopic expertise is available:

• Proceed with laparoscopic appendectomy as first-line treatment for ruptured appendix with periappendiceal abscess or phlegmon 1, 2
• Maintain a low threshold for conversion to open surgery if technical difficulties arise, particularly in patients with shock or diffuse peritonitis 3
• Open approach is preferable in confirmed COVID-19 patients with perforation unless adequate aerosol-reducing equipment and full PPE are properly installed 1

If laparoscopic expertise is NOT available:

• Use non-operative management with IV antibiotics plus percutaneous drainage (if abscess is accessible and >3cm) 1, 2
• Percutaneous drainage has 70-90% efficacy for mature abscesses and should be performed promptly when technically feasible 1
• If non-operative management fails (occurs in 25.7% of cases), proceed expeditiously to open appendectomy 1

Critical Timing Considerations

• Surgery should not be delayed beyond 24 hours from admission once the patient is hemodynamically stable 2, 3
• Delays beyond 48-72 hours significantly increase surgical site infections, major complications, and mortality 1, 2
• For patients with signs of shock, gangrene, or free perforation with diffuse peritonitis, immediate surgical intervention is mandatory—do not attempt prolonged conservative management 1, 3

Postoperative Antibiotic Management

• Continue postoperative IV antibiotics for 3-5 days maximum when adequate source control has been achieved 2, 3
• Transition to oral antibiotics based on clinical improvement (defervescence, tolerating diet, normalized white blood cell count) 1
• Do not continue antibiotics beyond 5 days in complicated appendicitis with adequate source control 2, 3

Special Surgical Considerations

• Perform Hartmann procedure rather than primary anastomosis if bowel resection is required, as anastomosis should be avoided in perforated cases due to high complication risk 1
• Remove the appendix even if it appears macroscopically normal during exploration, as surgeon judgment is inaccurate (27.8% of "normal" appendices show inflammation histologically) 1, 3
• Use simple ligation rather than stump inversion for appendiceal stump closure 3
• Drains are not recommended following appendectomy for complicated appendicitis as they provide no benefit and prolong hospitalization 3

Age-Specific Follow-Up

• For patients ≥40 years old with ruptured appendix, perform both colonoscopy and interval contrast-enhanced CT scan due to 3-17% incidence of appendicular or colonic neoplasms 1, 2
• Routine histopathology is mandatory after appendectomy to identify unexpected findings 1, 3

Common Pitfalls to Avoid

• Never delay surgery attempting prolonged conservative management in patients with shock, diffuse peritonitis, or free perforation—these require urgent appendectomy 1, 3
• Do not rely on clinical assessment alone to determine perforation status—CT findings of appendicolith, mass effect, or appendiceal diameter >13mm indicate higher risk and warrant surgical management 4
• Avoid routine intraoperative irrigation as it does not prevent abscess formation 3
• In non-operative management, plan close clinical and radiological surveillance at 12-24 hour intervals—if persistent pain, fever, or shock develops, surgery cannot be postponed 1