Approach

The goal of treatment is to remove the infected appendix. com.bmj.content.model.Caption@1fa85fc0 [Figure caption and citation for the preceding image starts]: Acute appendicitis - intraoperative specimen. Nasim Ahmed, MBBS, FACS; used with permission [Citation ends].

Uncomplicated presentation

Once the diagnosis of acute appendicitis is made, patients should be given nothing by mouth.

Intravenous fluids, such as lactated Ringer solution, should be started. Use of prophylactic intravenous antibiotics postoperatively is controversial; however, the use of cefoxitin (one dose preoperatively and 2 doses postoperatively) is recommended for uncomplicated appendicitis to reduce the risk of wound infection. [55] Appendectomy should be performed without delay.

Complicated presentation

Complications of acute appendicitis occur in 4% to 6% of patients and include gangrene with subsequent perforation or intra-abdominal abscess. [10]

Initial management includes keeping the patient nothing by mouth and starting intravenous fluids. Patients who are in shock should be given a bolus of intravenous fluid, such as lactated Ringer solution, in order to maintain a stable pulse rate and BP. [56] [57]

Intravenous antibiotics (e.g., cefoxitin or piperacillin/tazobactam) should be started immediately and continued until the patient becomes afebrile and the leukocytosis is corrected. For more severe infections, a carbapenem antibiotic may be used as a single agent. Combination antibiotic regimens may also be used based on local sensitivities and protocols. [10]

In patients with acute peritonitis, appendectomy should be performed without delay.

Patients presenting with right lower quadrant abscess should be managed with intravenous antibiotics and drainage either by interventional radiology (CT-guided drainage) or by operative drainage. If there is clinical improvement and the signs and symptoms are completely resolved, then there is no need for interval appendectomy. [58] [59] [60] Interval appendectomy is performed after 6 weeks if the symptoms are not completely resolved. [61] There is evidence to suggest that laparoscopic appendectomy may be a feasible first-line option over conservative treatment for appendiceal abscess in adults; however, this is not currently recommended. [62]

Surgical options

There are 2 operative options for appendectomy: open and laparoscopic.

In adults, the choice of appendectomy generally depends upon the experience of the surgeon. Studies have shown laparoscopic appendectomy to have better cosmetic results, shorter length of hospital stay, reduced postoperative pain, and reduced risk of wound infection, when compared with open appendectomy. Laparoscopic appendectomy is recommended for uncomplicated appendicitis, [37] as well as complicated and perforated appendicitis. [63] It is also considered the safest approach in obese patients. [64] However, open appendectomy is considered to be the safest approach in pregnant women. [65]

In children, laparoscopic appendectomy decreases the incidence of overall postoperative complications, including wound infection and duration of total hospital stay, but does not reduce the postoperative pain compared with open appendectomy. [66] [67] However, another study has shown no significant difference. [68]


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