In a 35‑year‑old woman with acute appendicitis, fever >38 °C, and a history of well‑controlled asthma, which of the following improves surgical safety? A) proper site marking and preparation of surgical equipment B) omission of pre‑operative intravenous antibiotics C) ignoring the asthma history D) not obtaining informed consent because the procedure is minor.

Proper Site Marking and Surgical Equipment Preparation Improve Surgical Safety

In this 35-year-old woman with acute appendicitis, fever, and controlled asthma, option A (site marking and preparation of surgical equipment) represents the only acceptable practice among the choices offered, though it constitutes baseline surgical safety rather than an independent safety enhancement. 1

Why the Other Options Are Dangerous

Omitting Preoperative Antibiotics (Option B) Is Contraindicated

• A single preoperative dose of broad-spectrum antibiotics administered 0–60 minutes before surgical incision is mandatory and significantly reduces wound infections and postoperative intra-abdominal abscesses. 1, 2

• The presence of fever (>38°C) in this patient reinforces rather than negates the need for preoperative antibiotics; it does not alter timing or choice of regimen. 1

• The 2020 World Society of Emergency Surgery (WSES) Jerusalem Guidelines issue a strong recommendation (Class 1, Level A evidence) for preoperative antibiotic prophylaxis in appendectomy, based on meta-analyses of >9,500 patients demonstrating clear benefit. 1

• Recommended regimens include cefazolin 1–2 grams IV or piperacillin-tazobactam, administered within the critical 0–60 minute window before incision. 1, 3

• Omitting this dose to "accelerate the process" would increase surgical site infections and abscess formation, directly harming patient outcomes. 1

Ignoring Asthma History (Option C) Breaches Basic Perioperative Care

• Ignoring a patient's asthma history violates fundamental perioperative care standards; even well-controlled asthma warrants preoperative assessment to stratify anesthetic risk. 1

• Laparoscopic appendectomy creates pneumoperitoneum, which alters respiratory mechanics—making documented asthma clinically relevant for intra-operative ventilation planning. 1

• Coordination with anesthesia is essential to optimize bronchodilator therapy and avoid histamine-releasing agents, thereby reducing the risk of intra-operative bronchospasm. 1

Not Obtaining Consent (Option D) Is Legally and Ethically Unacceptable

• Obtaining informed consent is mandatory for all appendectomies, regardless of procedural complexity, and must include discussion of risks such as bleeding, infection, injury to adjacent structures, and possible conversion to open approach. 1

• Appendectomy is not a "minor surgery"—it carries significant risks including perforation, abscess formation, and potential mortality, particularly in the setting of fever suggesting complicated disease. 4

Why Option A Is the Correct (Though Baseline) Answer

Site Marking and Equipment Preparation

• While routine site marking and equipment preparation are baseline requirements rather than independent outcome enhancers, they represent the only safe practice among the four options. 1

• Site marking is primarily relevant for lateralized procedures; the appendix has a fixed anatomical location, making additional marking less critical for this specific operation. 1

• However, proper surgical equipment preparation—including availability of laparoscopic instruments, backup open surgery equipment, and appropriate suction/irrigation devices—is essential for safe appendectomy. 4

Critical Surgical Timing and Approach

• Surgery should be performed within 24 hours of admission to minimize complications; delays beyond this timeframe increase adverse outcomes. 1, 2

• Laparoscopic appendectomy is the treatment of choice due to less pain, lower surgical site infection rates, decreased hospital stay, and earlier return to work compared to open appendectomy. 4, 1

Common Pitfalls to Avoid

• Never delay or omit preoperative antibiotics under the mistaken belief that it will expedite the surgical process—this single dose is the most evidence-based intervention to prevent postoperative infections. 1

• Always document and communicate the asthma history to the anesthesia team, even when well-controlled, to prevent intra-operative bronchospasm. 1

• Obtain proper informed consent in all cases; the medicolegal and ethical consequences of proceeding without consent are severe regardless of surgical complexity. 1

• For uncomplicated appendicitis with adequate source control, no postoperative antibiotics are required beyond the single preoperative dose. 1, 2