Editing Appendicitis (section)

==Management==
Acute appendicitis<ref>{{Cite web|title=appendicitis|url=https://www.healthnsurgery.com/appendicitis-symptoms-causes-and-treatment/|url-status=live|website=health n surgery|date=15 June 2020|archive-url=https://web.archive.org/web/20201025130423/https://www.healthnsurgery.com/appendicitis-symptoms-causes-and-treatment/ |archive-date=2020-10-25 }}</ref> is typically managed by [[surgery]]. While antibiotics are safe and effective for treating uncomplicated appendicitis,<ref name="BJS paper"/><ref name=Antibiotics2012/><ref>{{cite journal | vauthors = Sallinen V, Akl EA, You JJ, Agarwal A, Shoucair S, Vandvik PO, Agoritsas T, Heels-Ansdell D, Guyatt GH, Tikkinen KA | title = Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis | journal = The British Journal of Surgery | volume = 103 | issue = 6 | pages = 656–667 | date = May 2016 | pmid = 26990957 | pmc = 5069642 | doi = 10.1002/bjs.10147 }}</ref> 31% of people had a recurrence within a year and required an eventual appendectomy.<ref name="ReferenceB"/> Antibiotics are less effective if an [[appendicolith]] is present.<ref>{{cite journal | vauthors = Huang L, Yin Y, Yang L, Wang C, Li Y, Zhou Z | title = Comparison of Antibiotic Therapy and Appendectomy for Acute Uncomplicated Appendicitis in Children: A Meta-analysis | journal = JAMA Pediatrics | volume = 171 | issue = 5 | pages = 426–434 | date = May 2017 | pmid = 28346589 | pmc = 5470362 | doi = 10.1001/jamapediatrics.2017.0057 }}</ref> While 51% of patients who were treated with antibiotics did not need an appendectomy three years after treatment,<ref>{{Cite web |date=2024-05-06 |title=Comparing Surgery versus Antibiotics for Treating Adults with Uncomplicated Appendicitis - Evidence Update for Clinicians {{!}} PCORI |url=https://www.pcori.org/evidence-updates/comparing-surgery-versus-antibiotics-treating-adults-uncomplicated-appendicitis |access-date=2024-05-23 |website=www.pcori.org |language=en}}</ref> the cost effectiveness of surgery versus antibiotics is unclear<ref>{{cite journal | vauthors = Georgiou R, Eaton S, Stanton MP, Pierro A, Hall NJ | title = Efficacy and Safety of Nonoperative Treatment for Acute Appendicitis: A Meta-analysis | journal = Pediatrics | volume = 139 | issue = 3 | pages = e20163003 | date = March 2017 | pmid = 28213607 | doi = 10.1542/peds.2016-3003 | s2cid = 2292989 | url = http://discovery.ucl.ac.uk/1529248/1/Manuscript%20Pediatrics%20R1_with_figures.pdf | doi-access = free }}</ref>

Using antibiotics to prevent potential postoperative complications in emergency appendectomy procedures is recommended, and the antibiotics are effective when given to a person before, during, or after surgery.<ref>{{cite journal | vauthors = Andersen BR, Kallehave FL, Andersen HK | title = Antibiotics versus placebo for prevention of postoperative infection after appendicectomy | journal = The Cochrane Database of Systematic Reviews | issue = 3 | pages = CD001439 | date = July 2005 | volume = 2009 | pmid = 16034862 | doi = 10.1002/14651858.CD001439.pub2 | pmc = 8407323 }}</ref>

===Pain===
Pain medications (such as [[morphine]]) do not appear to affect the accuracy of the clinical diagnosis of appendicitis and therefore should be given early in the patient's care.<ref name=And2008>{{cite journal | vauthors = Anderson M, Collins E | title = Analgesia for children with acute abdominal pain and diagnostic accuracy | journal = Archives of Disease in Childhood | volume = 93 | issue = 11 | pages = 995–997 | date = November 2008 | pmid = 18305071 | doi = 10.1136/adc.2008.137174 | s2cid = 219246210 | url = http://www.bestbets.org/bets/bet.php?id=1404 | url-status = live | archive-url = https://web.archive.org/web/20130517121005/http://www.bestbets.org/bets/bet.php?id=1404 | archive-date = 2013-05-17 }}</ref> Historically there were concerns among some general surgeons that analgesics would affect the clinical exam in children, and some recommended that they not be given until the surgeon was able to examine the person.<ref name=And2008/>

===Surgery===
{{see also|Appendectomy}}
[[File:Apendixexternalview.jpg|thumb|Inflamed appendix removal by open surgery]]
[[File:Appendix-Entfernung.jpg|thumb|Laparoscopic appendectomy.]]
[[File:Lap apendix.jpg|thumb|Laparoscopic view of a phlegmonous cecal appendix with fibrinous plaques, located in the right iliac fossa.]]
The [[surgery|surgical]] procedure for the removal of the appendix is called an [[appendectomy]]. A negative appendectomy constitutes the removal of a normal appendix with no sign of inflammation in [[histopathology]] examination. The prevalence of negative appendectomy varies but has been estimated to 13%.<ref>{{Cite journal |last1=Henriksen |first1=Siri R. |last2=Christophersen |first2=Camilla |last3=Rosenberg |first3=Jacob |last4=Fonnes |first4=Siv |date=2023-05-23 |title=Varying negative appendectomy rates after laparoscopic appendectomy: a systematic review and meta-analysis |url=https://link.springer.com/10.1007/s00423-023-02935-z |journal=Langenbeck's Archives of Surgery |language=en |volume=408 |issue=1 |page=205 |doi=10.1007/s00423-023-02935-z |pmid=37219616 |issn=1435-2451}}</ref> Appendectomy can be performed through open or laparoscopic surgery. Laparoscopic appendectomy has several advantages over open appendectomy as an intervention for acute appendicitis.<ref>{{cite journal | vauthors = Jaschinski T, Mosch CG, Eikermann M, Neugebauer EA, Sauerland S | title = Laparoscopic versus open surgery for suspected appendicitis | journal = The Cochrane Database of Systematic Reviews | volume = 2018 | pages = CD001546 | date = November 2018 | issue = 11 | pmid = 30484855 | pmc = 6517145 | doi = 10.1002/14651858.CD001546.pub4 }}</ref>

====Open appendectomy====
For over a century, laparotomy (open appendectomy) was the standard treatment for acute appendicitis.<ref>{{cite journal | vauthors = Berry J, Malt RA | title = Appendicitis near its centenary | journal = Annals of Surgery | volume = 200 | issue = 5 | pages = 567–575 | date = November 1984 | pmid = 6385879 | pmc = 1250537 | doi = 10.1097/00000658-198411000-00002 }}</ref> This procedure consists of the removal of the infected appendix through a single large incision in the lower right area of the abdomen.<ref>{{cite web |url=http://digestive.niddk.nih.gov/ddiseases/pubs/appendicitis/ |title=Appendicitis |work=National Institute of Diabetes and Digestive and Kidney Diseases |publisher=U.S. Department of Health and Human Services |access-date=2010-02-01 |url-status=dead |archive-url=https://web.archive.org/web/20100201095103/http://digestive.niddk.nih.gov/ddiseases/pubs/appendicitis/ |archive-date=2010-02-01 }}</ref> The incision in a laparotomy is usually {{convert|2|to|3|in}} long.

During an open appendectomy, the person with suspected appendicitis is placed under general [[anesthesia]] to keep the muscles completely relaxed and to keep the person unconscious. The incision is two to three inches (76&nbsp;mm) long, and it is made in the right lower abdomen, several inches above the [[hip bone]]. Once the incision opens the abdomen cavity, and the appendix is identified, the [[surgeon]] removes the infected tissue and cuts the appendix from the surrounding tissue. After careful and close inspection of the infected area, and ensuring there are no signs that surrounding tissues are damaged or infected. In case of complicated appendicitis managed by an emergency open appendectomy, abdominal drainage (a temporary tube from the abdomen to the outside to avoid abscess formation) may be inserted, but this may increase the hospital stay.<ref>{{cite journal|vauthors=Li Z, Li Z, Zhao L, Cheng Y, Cheng N, Deng Y|date=August 2021|title=Abdominal drainage to prevent intra-peritoneal abscess after appendectomy for complicated appendicitis|journal=The Cochrane Database of Systematic Reviews|volume=2021|issue=8|pages=CD010168|doi=10.1002/14651858.CD010168.pub4|pmid=34402522|pmc=8407456}}</ref>{{Update inline|reason=Updated version https://www.ncbi.nlm.nih.gov/pubmed/34402522|date = October 2021}} The surgeon will start closing the incision. This means sewing the muscles and using [[surgical staple]]s or [[surgical suture|stitches]] to close the skin up. To prevent infections, the incision is covered with a [[Dressing (medical)|sterile bandage]] or surgical adhesive.

====Laparoscopic appendectomy====
Laparoscopic appendectomy was introduced in 1983 and has become an increasingly prevalent intervention for acute appendicitis.<ref>{{cite journal | vauthors = Semm K | title = Endoscopic appendectomy | journal = Endoscopy | volume = 15 | issue = 2 | pages = 59–64 | date = March 1983 | pmid = 6221925 | doi = 10.1055/s-2007-1021466 | s2cid = 45763958 }}</ref> This surgical procedure consists of making three to four incisions in the abdomen, each {{convert|0.25|to|0.5|in|mm}} long. This type of appendectomy is made by inserting a special surgical tool called a laparoscope into one of the incisions. The laparoscope is connected to a monitor outside the person's body, and it is designed to help the surgeon inspect the infected area in the abdomen. The other two incisions are made for the specific removal of the appendix by using [[surgical instrument]]s. Laparoscopic surgery requires [[general anesthesia]], and it can last up to two hours. Laparoscopic appendectomy has several advantages over open appendectomy, including a shorter post-operative recovery, less post-operative pain, and a lower superficial surgical site infection rate. However, the occurrence of an intra-abdominal abscess is almost three times more prevalent in laparoscopic appendectomy than open appendectomy.<ref>{{cite journal | vauthors = Siewert B, Raptopoulos V, Liu SI, Hodin RA, Davis RB, Rosen MP | title = CT predictors of failed laparoscopic appendectomy | journal = Radiology | volume = 229 | issue = 2 | pages = 415–420 | date = November 2003 | pmid = 14595145 | doi = 10.1148/radiol.2292020825 }}</ref>

==== Laparoscopic-assisted transumbilical appendectomy ====
In pediatric patients, the high mobility of the cecum allows externalization of the appendix through the umbilicus, and the entire procedure can be performed with a single incision. Laparoscopic-assisted transumbilical appendectomy is a relatively recent technique but with a long published series and very good surgical and aesthetic results.<ref>{{Cite journal |last1=Sekioka |first1=Akinori |last2=Takahashi |first2=Toshiaki |last3=Yamoto |first3=Masaya |last4=Miyake |first4=Hiromu |last5=Fukumoto |first5=Koji |last6=Nakaya |first6=Kengo |last7=Nomura |first7=Akiyoshi |last8=Yamada |first8=Yutaka |last9=Urushihara |first9=Naoto |date=December 2018 |title=Outcomes of Transumbilical Laparoscopic-Assisted Appendectomy and Conventional Laparoscopic Appendectomy for Acute Pediatric Appendicitis in a Single Institution |url=https://pubmed.ncbi.nlm.nih.gov/30088968 |journal=Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A |volume=28 |issue=12 |pages=1548–1552 |doi=10.1089/lap.2018.0306 |issn=1557-9034 |pmid=30088968|s2cid=51941735 }}</ref>

====Pre-surgery====
The treatment begins by [[Nil per os|keeping the person who will be having surgery from eating or drinking]] for a given period, usually overnight. An [[Intravenous therapy|intravenous drip]] is used to hydrate the person who will be having surgery. [[Antibiotic]]s given intravenously such as [[cefuroxime]] and [[metronidazole]] may be administered early to help kill bacteria and thus reduce the spread of infection in the abdomen and postoperative complications in the abdomen or wound. Equivocal cases may become more difficult to assess with antibiotic treatment and benefit from serial examinations. If the stomach is empty (no food in the past six hours), general anaesthesia is usually used. Otherwise, [[spinal anaesthesia]] may be used.

Once the decision to perform an [[appendectomy]] has been made, the preparation procedure takes approximately one to two hours. Meanwhile, the surgeon will explain the surgery procedure and will present the risks that must be considered when performing an appendectomy. (With all surgeries there are risks that must be evaluated before performing the procedures.) The risks are different depending on the state of the appendix. If the appendix has not ruptured, the complication rate is only about 3% but if the appendix has ruptured, the complication rate rises to almost 59%.<ref>{{cite encyclopedia |url=http://www.surgeryencyclopedia.com/A-Ce/Appendectomy.html |title=Appendicitis |encyclopedia=Encyclopedia of Surgery |access-date=2010-02-01 |url-status=live |archive-url=https://web.archive.org/web/20100209031325/http://www.surgeryencyclopedia.com/A-Ce/Appendectomy.html |archive-date=2010-02-09 }}</ref> The most usual complications that can occur are pneumonia, [[hernia]] of the incision, [[thrombophlebitis]], bleeding and [[adhesion (medicine)|adhesions]]. Evidence indicates that a delay in obtaining surgery after admission results in no measurable difference in outcomes to the person with appendicitis.<ref>{{cite news |url=http://www.cbc.ca/news/technology/emergency-appendix-surgery-can-wait-mds-1.921386 |work=CBC News |title='Emergency' appendix surgery can wait: MDs |date=2010-09-21 |url-status=live |archive-url=https://web.archive.org/web/20160630014355/http://www.cbc.ca/news/technology/emergency-appendix-surgery-can-wait-mds-1.921386 |archive-date=2016-06-30 }}</ref><ref>{{cite journal | vauthors = Ingraham AM, Cohen ME, Bilimoria KY, Ko CY, Hall BL, Russell TR, Nathens AB | title = Effect of delay to operation on outcomes in adults with acute appendicitis | journal = Archives of Surgery | volume = 145 | issue = 9 | pages = 886–892 | date = September 2010 | pmid = 20855760 | doi = 10.1001/archsurg.2010.184 | quote = Delay of appendectomy for acute appendicitis in adults does not appear to adversely affect 30-day outcomes. | doi-access =  }}</ref> Most patients undergo emergency surgery, but delayed surgery (interval appendectomy) has been investigated for certain patients.<ref name=":1">{{Cite journal |last1=Zhou |first1=Shiyi |last2=Cheng |first2=Yao |last3=Cheng |first3=Nansheng |last4=Gong |first4=Jianping |last5=Tu |first5=Bing |date=2024-05-02 |editor-last=Cochrane Colorectal Group |title=Early versus delayed appendicectomy for appendiceal phlegmon or abscess |journal=Cochrane Database of Systematic Reviews |language=en |volume=2024 |issue=5 |pages=CD011670 |doi=10.1002/14651858.CD011670.pub3 |pmc=11064883 |pmid=38695830}}</ref> Delaying surgery for weeks may increase the risk of intra-abdominal abscess in patients suffering from appendicitis and presenting with an appendiceal mass (e.g., [[phlegmon]] or [[abscess]]).<ref name=":1" /> The harms and benefits of delaying surgery for other complications are uncertain.<ref name=":1" /> 
[[File:Scarlapappendix.jpg|thumb|Laparoscopic-assisted transumbilical appendectomy scar on a pediatric patient. Anesthetic result one month after surgery.]]
The surgeon will explain how long the recovery process should take. Abdomen hair is usually removed to avoid complications that may appear regarding the incision.

In most cases, patients going in for surgery experience nausea or vomiting that require medication before surgery. Antibiotics, along with pain medication, may be administered before appendectomies.

====After surgery====
[[File:Stitches post appendicitis surgery.jpg|thumb|The [[surgical suture|stitches]] the day after having the appendix removed by laparoscopic surgery]]
Hospital lengths of stay typically range from a few hours to a few days but can be a few weeks if complications occur. The recovery process may vary depending on the severity of the condition: if the appendix had ruptured or not before surgery. Appendix surgery recovery is generally much faster if the appendix does not rupture.<ref>[http://appendixsurgery.net Appendicitis surgery, removal and reco very] Retrieved on 2010-02-01  {{webarchive|url=https://web.archive.org/web/20100111221304/http://appendixsurgery.net/ |date=January 11, 2010 }}</ref> It is important that people undergoing surgery respect their doctor's advice and limit their physical activity so the tissues can heal. Recovery after an appendectomy may not require diet changes or a lifestyle change.

The length of hospital stays for appendicitis varies on the severity of the condition. A study from the United States found that in 2010, the average appendicitis hospital stay was 1.8 days. For stays where the person's appendix had ruptured, the average length of stay was 5.2 days.<ref name=Barrett2013/>

After surgery, the patient will be transferred to a [[postanesthesia care unit]], so their vital signs can be closely monitored to detect anesthesia- or surgery-related complications. Pain medication may be administered if necessary. After patients are completely awake, they are moved to a hospital room to recover. Most individuals will be offered clear liquids the day after the surgery, then progress to a regular diet when the intestines start to function correctly. Patients are recommended to sit on the edge of the bed and walk short distances several times a day. Moving is mandatory, and pain medication may be given if necessary. Full recovery from appendectomies takes about four to six weeks but can be prolonged to up to eight weeks if the appendix has ruptured.  <ref><p> <a href="https://aeliussurgery.com.sg/conditions/appendicitis-surgery-in-singapore/">Appendicitis surgery in Singapore</a>
is commonly performed using laparoscopic techniques to ensure faster recovery and minimal scarring.</p></ref>