In a 35-year-old woman with acute appendicitis, fever, and stable asthma scheduled for laparoscopic appendectomy, which measure most improves surgical safety?

Preoperative IV Antibiotics Most Improve Surgical Safety

The single most important measure to improve surgical safety in this patient is administering preoperative IV antibiotics (Option B), which should be given 0-60 minutes before surgical incision. 1

Evidence-Based Rationale

Why Preoperative Antibiotics Are Critical

• A single preoperative dose of broad-spectrum antibiotics has been proven to significantly reduce wound infections and postoperative intra-abdominal abscesses in patients undergoing appendectomy, regardless of whether the appendix is uncomplicated or complicated. 1

• The 2020 WSES Jerusalem Guidelines provide a strong recommendation (1A - highest quality evidence) for preoperative antibiotic prophylaxis, based on meta-analyses including over 9,500 patients demonstrating clear benefit. 1

• The optimal timing is 0-60 minutes before surgical skin incision, and this timing does not affect the frequency of surgical site infections as long as it falls within this window. 1

• Broad-spectrum coverage (such as cefazolin or piperacillin-tazobactam) is appropriate for perioperative prophylaxis in appendectomy. 2, 3

Why the Other Options Are Inadequate or Harmful

Site marking and equipment preparation (Option A):

• These are baseline requirements for any surgery but do not independently improve outcomes in appendectomy. 4
• Site marking is primarily relevant for lateralized procedures; the appendix has a fixed anatomical location making additional marking unnecessary. 4

Ignoring asthma history (Option C):

• This breaches basic perioperative care standards and is dangerous. 4
• Even well-controlled asthma requires preoperative assessment to stratify anesthetic risk, especially since laparoscopic pneumoperitoneum alters respiratory mechanics. 4
• Coordination with anesthesia is essential to optimize bronchodilator therapy and avoid histamine-releasing agents that could trigger intraoperative bronchospasm. 4

Not obtaining consent (Option D):

• Informed consent is mandatory for all appendectomies regardless of complexity, and must include discussion of risks such as bleeding, infection, injury to adjacent structures, and possible conversion to open approach. 4

Clinical Context for This Patient

This 35-year-old woman presents with fever >38°C, which suggests she may have complicated appendicitis or be at higher risk for postoperative infectious complications:

• The presence of fever does not change the indication for preoperative antibiotics—it reinforces it. 1
• Surgery should be performed within 24 hours of admission to minimize complications. 1
• For uncomplicated appendicitis with adequate source control, postoperative antibiotics are not needed beyond the single preoperative dose. 1
• If intraoperative findings reveal complicated appendicitis (perforation, abscess), postoperative antibiotics should be continued but not beyond 3-5 days. 1

Common Pitfalls to Avoid

• Do not delay surgery to "accelerate the process" with antibiotics—while antibiotics are essential, delaying appendectomy beyond 24 hours from admission increases adverse outcomes. 1
• Do not skip the preoperative dose thinking you can give it intraoperatively—the evidence specifically supports administration 0-60 minutes before incision. 1
• Do not dismiss the asthma history as irrelevant—laparoscopic surgery with pneumoperitoneum requires careful anesthetic planning in asthmatic patients. 4