Treatment of Appendicitis

Uncomplicated Appendicitis

Laparoscopic appendectomy is preferred over open appendectomy due to less postoperative pain, lower incidence of surgical site infections, decreased length of hospital stay, earlier return to work, and better quality of life 1
Surgery should be performed within 24 hours of admission, as delays beyond this timeframe are associated with increased risk of complications 1, 2
A single preoperative dose of broad-spectrum antibiotics should be administered 0-60 minutes before surgical incision 2, 3
Postoperative antibiotics are not recommended for uncomplicated appendicitis with adequate source control 2, 3

For patients with periappendiceal abscess where laparoscopic expertise is not available: non-operative management with antibiotics and percutaneous drainage (if available) is recommended 3, 4
Laparoscopic management is associated with fewer readmissions and fewer additional interventions than conservative treatment 3, 5
Postoperative antibiotics should not be continued beyond 3-5 days when adequate source control has been achieved 2, 3

Simple ligation of the appendiceal stump is recommended over stump inversion in both open and laparoscopic appendectomy 6
Drains are not recommended following appendectomy for complicated appendicitis in adults as they provide no benefit in preventing intra-abdominal abscess and lead to longer hospitalization 6
Routine histopathology after appendectomy is recommended to identify unexpected findings 6

Delaying appendectomy beyond 24 hours from admission increases risk of adverse outcomes 1
Single-incision laparoscopic appendectomy is associated with longer operative times, higher analgesic requirements, and higher wound infection rates compared to conventional three-port laparoscopic appendectomy 1
Routine use of intraoperative irrigation for appendectomies does not prevent intra-abdominal abscess formation and may be avoided 4

In cases of complicated appendicitis with shock, maintain a low threshold for conversion to open surgery if technical difficulties arise, particularly in the setting of complicated appendicitis with shock 7, 8
The presence of shock suggests complicated appendicitis (perforation, abscess, or peritonitis), which requires surgical source control 9
Remove the appendix even if it appears normal during exploration, as surgeon's macroscopic judgment is inaccurate and 27.8% of "normal" appendices are inflamed histologically 7, 8
Use an intraoperative grading system (WSES or AAST) to guide postoperative management 7, 8

Delays beyond 48 hours significantly increase surgical site infections and adverse events 10, 11
In a young female patient with shock, do not delay surgery attempting prolonged conservative management, and proceed with appendectomy within 24 hours of admission once the patient is hemodynamically stable 10, 11
Preoperative antibiotics are mandatory and should be administered as a single dose 0-60 minutes before incision 9
Postoperative antibiotics are required in this case of complicated appendicitis with shock, and should be continued for 3-5 days postoperatively when adequate source control is achieved 9

In young women, maintain high clinical suspicion as female sex is associated with higher perforation rates 10, 12
At 28 years old, this patient does not require routine interval colonoscopy or CT follow-up (only recommended for patients ≥40 years old) 8
Routine histopathology is mandatory after appendectomy to identify unexpected findings 7, 8

In centers with advanced laparoscopic expertise, a laparoscopic appendectomy should be performed as the first‑line treatment for a ruptured appendix with peri‑appendiceal abscess or phlegmon because it results in fewer readmissions and fewer additional interventions than conservative management. 13
In patients with confirmed COVID‑19 infection and perforated appendicitis, an open approach is preferred unless aerosol‑reducing equipment and full personal protective equipment are available to safely perform laparoscopy. 14

Delaying surgery beyond 48–72 hours after admission markedly increases the risk of surgical‑site infection, major complications, and mortality. 15
When the patient presents with shock, gangrene, or free perforation with diffuse peritonitis, immediate operative intervention is mandatory; prolonged conservative management must be avoided. 13

After adequate source control, postoperative intravenous antibiotics should be continued for a maximum of 3–5 days.
Transition to oral antibiotics is appropriate once the patient shows clinical improvement (defervescence, tolerates oral intake, and has a normalized white‑blood‑cell count). 15

If bowel resection is required in a perforated case, a Hartmann procedure is recommended rather than primary anastomosis because of the high risk of anastomotic complications. 16
The appendix should be removed even when it appears macroscopically normal, as histology reveals inflammation in approximately 28 % of such specimens. 17

For adults aged ≥ 40 years with a ruptured appendix, both colonoscopy and an interval contrast‑enhanced CT scan are advised because of a 3–17 % incidence of appendiceal or colonic neoplasms. 13
Routine histopathologic examination of the removed appendix is mandatory to detect unexpected pathological findings. 13

When laparoscopic expertise is unavailable, non‑operative management consisting of intravenous antibiotics plus percutaneous drainage (for accessible abscesses larger than 3 cm) is acceptable. 18
Percutaneous drainage achieves 70–90 % efficacy for mature abscesses and should be performed promptly when technically feasible. 18
Failure of non‑operative management occurs in roughly 26 % of cases; patients with failed therapy should be taken promptly to open appendectomy. 17
During non‑operative treatment, close clinical and radiologic monitoring every 12–24 hours is required; emergence of persistent pain, fever, or shock mandates immediate surgical intervention. 16