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The Niche Pick

Quick Recommendation by Level

Appendicitis: Step-by-Step Treatment Plan

Step 1 - Diagnosis & Workup

• Classic triad: periumbilical pain migrating to right lower quadrant (RLQ), nausea/vomiting, low-grade fever
• Tenderness at McBurney's point, guarding, rebound tenderness
• Positive Rovsing's, Psoas, and Obturator signs depending on appendix position

• CBC: leukocytosis (WBC >10,000), left shift
• CRP elevated
• Urinalysis to rule out urinary pathology
• Pregnancy test (beta-hCG) in women of childbearing age

• Children & pregnant women: Ultrasound first (avoids radiation); a normal appendix diameter is <6 mm - if visualized as >6 mm with periappendiceal change, appendicitis is confirmed
• Adults: CT abdomen/pelvis with contrast is the most reliable - look for appendix >7 mm diameter, periappendiceal fat stranding, free fluid, thickening of the caecal pole
• Retrocaecal appendicitis can escape ultrasound detection; CT is then the next step
• MRI is used where available, particularly for pregnant patients, with high sensitivity and specificity while avoiding radiation

Step 2 - Preoperative Resuscitation & Preparation

1. IV access - insert two large-bore cannulas
2. IV fluid resuscitation - correct dehydration from fever, vomiting, and poor oral intake
3. Make patient NPO immediately
4. IV antibiotics - administer preoperatively:
   • Monotherapy: piperacillin-tazobactam (preferred for simple and complicated appendicitis)
   • Alternatives: second-generation cephalosporin + metronidazole
   • For simple appendicitis: a single preoperative dose is sufficient; no postoperative continuation needed
5. Analgesia - opioid-sparing multimodal approach; withholding analgesia pending diagnosis is no longer supported
6. Foley catheter - placed after induction of general anesthesia to decompress the bladder and avoid port-placement injury
7. Nasogastric tube - consider if patient was not fasting (to decompress stomach)
8. Consent & marking - discuss laparoscopic approach, possibility of conversion to open, and risks (wound infection, intra-abdominal abscess, bleeding, bowel injury)

Step 3 - Decision: Operative vs. Nonoperative Management

Uncomplicated Appendicitis

Key update (2025): The World Society of Emergency Surgery Jerusalem Guidelines (2025) and a 2025 Lancet meta-analysis (PMID: 39827891) confirm that nonoperative antibiotic treatment is a valid option for uncomplicated appendicitis in adults, though recurrence and eventual appendectomy rates remain significant.

Complicated (Perforated/Gangrenous) Appendicitis

• Appendectomy + continue postoperative antibiotics for 4 days after source control
• Periappendiceal abscess (presenting >5 days): percutaneous image-guided drainage first, then interval appendectomy at 6-8 weeks
• Immunosuppressed patients or those with inadequate source control: extend antibiotic course

Step 4 - Laparoscopic Appendectomy (Standard Procedure)

4a. Operating Room Setup

• General anesthesia induced
• Patient positioned supine, left arm tucked
• Surgeon and assistant stand on the patient's left side
• Monitor positioned on the patient's right side at the level of the ASIS
• Standard sterile prep and drape of the abdomen

4b. Port Placement

• 12 mm infraumbilical port - camera port (primary access)
• 12 mm suprapubic port - stapler port
• 5 mm left lower quadrant port - working port (or right lateral 5 mm)

• Open Hassan technique (safest, most common): vertical incision just above umbilicus, fascia grasped with Kocher clamps, elevated, and incised; blunt 12-mm trocar inserted, pneumoperitoneum established with CO₂
• Alternatives: Veress needle or optiview technique

4c. Patient Positioning After Ports

4d. Identifying the Appendix

• Sweep small bowel out of the RLQ to expose the caecum and terminal ileum
• Anatomical landmarks to locate the appendix:
  • Teniae coli of the right colon all converge at the caecal base - the appendix arises here
  • Ileal sail (antimesenteric fat on terminal ileum) guides you toward the appendix
  • Ligament of Treves attaches from terminal ileum to the appendix base
• Mobilize the appendix as needed; a retrocaecal appendix requires mobilization of the caecum and ascending colon (identify and protect the ureter)

4e. Dissection of the Mesoappendix

• Retract the appendix toward the anterior abdominal wall with the left-hand instrument
• Use a Maryland dissector in the right hand to create a window between the appendix base and the mesoappendix - do this carefully under direct vision to avoid caecal injury
• Vary tension and angle as needed to see all sides during dissection

4f. Transection of the Appendix

• Once the window is established at the base:
  • Linear cutting stapler (endo-GIA, 3.5-mm staple height) introduced through the 12-mm port; smaller jaw passed through the window; ensure distal jaw tips are visible before firing
  • If the caecum is inflamed/perforated/gangrenous: transect above the area of involvement to include a normal rim of caecum on the proximal stump
  • Alternative: endoloop ligation (two loops distal, one proximal) and divide with laparoscopic scissors - requires mesoappendix division first

4g. Division of the Mesoappendix

• Divide along the length of the appendix using vascular load endo-GIA (2.5-mm staple height) - may need multiple loads
• Alternatives: laparoscopic clips on the appendicular artery, or energy device (LigaSure, Harmonic scalpel)

4h. Specimen Removal & Field Check

• Place the appendix in a laparoscopic retrieval bag
• Inspect for hemostasis; inspect the appendiceal stump for secure closure
• Remove the bag via the 12-mm port
• Irrigate the RLQ if contaminated; evacuate any purulent fluid (benefit of copious saline irrigation is unproven but commonly practiced)

4i. Closure

• Remove ports under direct vision
• Close the fascia at the 12-mm port site with absorbable suture (interrupted or figure-of-eight)
• Close all skin incisions subcuticularly with absorbable suture

Step 5 - Open Appendectomy (Grid-Iron / McBurney Incision)

• Lanz/McBurney incision in the RLQ (over McBurney's point)
• Grid-iron muscle-splitting approach through external oblique, internal oblique, and transversus abdominis
• Identify caecum, deliver appendix into wound
• Ligate and divide the mesoappendix (clamp - divide - ligate the appendicular artery)
• Crush the appendix base with a clamp, ligate with absorbable suture (e.g., 2-0 Vicryl), and divide
• Optional: invaginate the stump into the caecum with a purse-string or Z-suture (not universally practiced)
• Close in layers

Step 6 - Postoperative Care

Uncomplicated Appendicitis

• Remove Foley and NG tube before waking from anaesthesia
• No postoperative antibiotics needed
• Resume oral diet as tolerated upon waking
• Advance to solid food the next day
• Same-day discharge is possible in many patients with early disease
• Oral multimodal analgesia (NSAIDs + paracetamol); minimize opioids

Complicated Appendicitis

• Continue IV antibiotics for 4 days after source control; extend if febrile, leukocytotic, ileus persists, or immunosuppressed
• VTE prophylaxis based on risk stratification (LMWH + compression stockings)
• Pain control with opioid-sparing strategies + regional blocks as needed
• Monitor for clinical deterioration or failure to improve

Step 7 - Complications & Their Management

Special Populations

• Children: Laparoscopic appendectomy is standard; nonoperative management accepted in selected simple cases but 40% recurrence rate; children <5 years often present already perforated
• Pregnant patients: MRI or US preferred over CT; laparoscopic approach is safe throughout pregnancy and is still the preferred approach; highest risk of fetal mortality is in perforated/delayed cases
• Perforated appendicitis with phlegmon (>5 days symptoms): Drain first, interval appendectomy at 6-8 weeks

Recent Evidence Update

Three high-quality publications are relevant to current practice:

• SAGES 2024 Guideline (PMID: 38740595) - systematic review supporting laparoscopic appendectomy as standard and addressing indications for nonoperative management
• WSES Jerusalem Guidelines 2025 (PMID: 41604201) - the most current international guidelines on diagnosis and treatment
• Lancet Meta-Analysis 2025 (PMID: 39827891) - individual patient data meta-analysis confirming antibiotics are a viable alternative to appendectomy for uncomplicated appendicitis, but with meaningful recurrence rates