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General Surgery

Appendicitis Surgery

About This Department

 
General Surgery

Appendicitis surgery removes an inflamed appendix through three small incisions. Antibiotics alone work for some, and fail for many.

In a United States trial of 1,552 adults, 29 percent of patients treated with antibiotics needed their appendix out within 90 days, and in a Finnish trial 39 percent had a recurrence within five years. Keyhole appendectomy remains the standard treatment, with most patients home within a day or two. If you have pain in the lower right abdomen now, go to the nearest emergency department. For a second opinion on a scan, a recurrence or a pathology report, write to our general surgery team.

29%
Antibiotic-treated adults who needed surgery within 90 days
39%
Recurrence within five years after antibiotics alone
24 hours
Delay after admission with no rise in perforation
Free
Second opinion on your scan or pathology report
Free consultation

The appendix, a finger-sized pouch off the large bowel in the lower right abdomen, becomes blocked, swells and fills with bacteria. Left untreated, it bursts. Infection then spreads through the abdomen. Appendicitis strikes at any age and peaks between ten and thirty, and it remains the commonest reason for emergency abdominal surgery worldwide.

Signs of appendicitis and when to go now

The pattern of pain matters more than any single symptom.

This table scrolls sideways on a narrow screen. Swipe or drag to see every column.

Symptoms of appendicitis
Symptom What it suggests
Pain starting around the navel and moving to the lower right The classic pattern, over 12 to 24 hours
Loss of appetite and nausea Common early on
Pain worse with walking, coughing or bumps in the car Inflammation reaching the lining of the abdomen
Fever above 38 degrees Infection building
Pain that eases suddenly, then spreads and worsens A possible burst appendix, go now
Examination and blood tests
The surgeon presses on the abdomen and checks white cells and inflammation markers.
Scan
Ultrasound first in younger and slim patients, CT in most adults.
Decision
Surgery, or in selected cases antibiotics, discussed with you.
Operation
Within hours for a complicated appendix, and within 24 hours of admission for an uncomplicated one.

Diagnosis

A negative or unclear ultrasound does not rule appendicitis out. CT follows. In pregnancy, MRI avoids radiation. The scan also shows whether the appendix contains a hard stone, an appendicolith, and whether it has burst, both of which steer the treatment.

If it happens while you are in Istanbul

Visitors fall ill too, and an inflamed appendix does not wait for the flight home, so if abdominal pain starts during a trip to Istanbul, follow four steps.

  1. Stop eating and drinking.
  2. Come to our emergency department or call an ambulance, and do not take strong painkillers before a doctor examines you.
  3. Bring your passport and any travel insurance details.
  4. Message our international office on WhatsApp, and a coordinator in your language meets you in the emergency department.

Surgery or antibiotics

Uncomplicated appendicitis, without a burst, an abscess or a stone, can settle with antibiotics. The trials show what that choice costs and saves.

The CODA trial of 1,552 adults
Patients at 25 United States hospitals received either a ten-day course of antibiotics or an appendectomy, almost always keyhole. Health at 30 days came out the same. By 90 days, 29 percent of the antibiotic group had needed surgery, rising to 41 percent among those with an appendicolith, and complications in that subgroup ran at 20.2 per 100 against 3.6 after surgery.
Why the appendicolith matters
A hard stone of stool blocking the appendix keeps the blockage in place after the antibiotics stop. In the CODA trial, patients with a stone did markedly worse on antibiotics, and for them we recommend surgery.
Go to the emergency department now
Severe or spreading abdominal pain, pain with a fever and vomiting, a hard and tender abdomen, or pain that eased and then came back worse. Do not wait for a consultation.
Who suits antibiotics
Adults with CT-confirmed uncomplicated appendicitis and no appendicolith, who accept a high chance of needing surgery later. The antibiotic route avoids an operation now, at the cost of a recurrence that comes back in around one in three patients over five years.

The operation

Keyhole appendectomy runs under general anesthesia and takes thirty to sixty minutes.

Three small incisions
One at the navel for the camera and two of five millimeters low on the abdomen.
Finding the appendix
The abdomen fills with gas, and the surgeon inspects the appendix and the rest of the abdomen, including the ovaries in women.
Removal
The base of the appendix is sealed with loops or a stapler, and the appendix comes out in a bag through the navel incision.
Washout and closure
Pus, if present, is washed out, and dissolving stitches close the skin.

What the trials show

In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days.
CODA trial, 1,552 adults, New England Journal of Medicine, 2020

Five years after antibiotics

The Finnish APPAC trial
Salminen and colleagues randomized 530 adults with CT-confirmed uncomplicated appendicitis to antibiotics or appendectomy and followed them for five years. Of the patients who later had their appendix out for a recurrence, 76 of 85 still had uncomplicated appendicitis, so waiting rarely led to a burst.

For the 256 patients treated with antibiotics, recurrence built up year by year.

  1. 27.3 percent needed an appendectomy within the first year.
  2. 34.0 percent had a recurrence by two years.
  3. 37.1 percent by four years.
  4. 39.1 percent by five years.

Complications and time off work

Surgery against antibiotics at five years
Complications, wound infections, incisional hernias, abdominal pain and bowel obstruction symptoms, reached 24.4 percent after appendectomy and 6.5 percent after antibiotics, and appendectomy patients took 11 more days of sick leave. Those operations were open, and keyhole surgery lowers wound problems.
Among patients who were initially treated with antibiotics for uncomplicated acute appendicitis, the likelihood of late recurrence within 5 years was 39.1%.
APPAC trial, JAMA, 2018

Operating at night or the next morning

Does a few hours of waiting matter
A meta-analysis of 152,314 patients found no rise in burst or gangrenous appendicitis when surgery for an uncomplicated appendix waited up to 24 hours after admission, with antibiotics started on arrival. A burst or abscess still goes to theater straight away.

Keyhole or open surgery

Except for a higher rate of intra-abdominal abscesses after LA in adults, LA showed advantages over OA in pain intensity on day one, wound infections, length of hospital stay and time until return to normal activity in adults.
Cochrane review of 85 trials and 9,765 patients, 2018

This table scrolls sideways on a narrow screen. Swipe or drag to see every column.

Keyhole against open appendectomy in adults
Outcome Keyhole compared with open
Pain on day one 0.75 points lower on a 10-point scale
Wound infection Less than half as likely, odds ratio 0.42
Abscess inside the abdomen More likely, odds ratio 1.65
Hospital stay One day shorter
Return to normal activity Five days sooner

Recovery and the stay

Patients go home the next day after keyhole surgery for an uncomplicated appendix, and three to five days later after a burst one. Visitors who have their operation with us stay in Istanbul for a week before flying, and our coordinators, speaking English, Arabic, French, Russian, Serbian, Romanian or Spanish, arrange the hotel, the insurance paperwork and a letter for the airline. A companion can sleep in your room. Follow-up after you return home runs through the same coordinator, with a video call to go through the pathology result and the wound.

This table scrolls sideways on a narrow screen. Swipe or drag to see every column.

Recovery after keyhole appendectomy
Time What to expect
Same day Walking and drinking
Day 1 to 2 Home for an uncomplicated appendix
One week Desk work and short flights
Two to four weeks Lifting, sport and long-haul flights
Two weeks Pathology result, discussed by video if you have gone home

What the pathology report shows

Neoplasms are an uncommon finding after appendectomy, with malignant tumors occurring in less than 1% of the surgical specimens, and carcinoid being the most frequent malignancy.
Review, Advances in Surgery, 2013

Appendicitis surgery FAQ

Can appendicitis be treated without surgery?
Uncomplicated appendicitis without a stone often settles with antibiotics. Around three in ten need surgery within months and close to four in ten within five years.
How long does recovery take?
Home in one or two days after keyhole surgery, desk work in a week, and sport and heavy lifting after two to four weeks.
Can I fly after an appendectomy?
Short flights after a week and long-haul flights after two weeks for an uncomplicated operation, once the surgeon has checked you.
Do I need the appendix?
No. Living without it causes no known problem.
I had antibiotics and the pain came back. What now?
Send us your scans and discharge letters. A recurrence usually means planned keyhole removal, and we can review it for free.

References

  1. CODA Collaborative, Flum DR, Davidson GH, et al. A randomized trial comparing antibiotics with appendectomy for appendicitis. New England Journal of Medicine. 2020;383(20):1907-1919.
  2. Salminen P, Tuominen R, Paajanen H, et al. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC randomized clinical trial. JAMA. 2018;320(12):1259-1265.
  3. Jaschinski T, Mosch CG, Eikermann M, Neugebauer EA, Sauerland S. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database of Systematic Reviews. 2018;11:CD001546.
  4. van Dijk ST, van Dijk AH, Dijkgraaf MG, Boermeester MA. Meta-analysis of in-hospital delay before surgery as a risk factor for complications in patients with acute appendicitis. British Journal of Surgery. 2018;105(8):933-945.
  5. Teixeira PG, Demetriades D. Appendicitis: changing perspectives. Advances in Surgery. 2013;47:119-140.

Editor's note

Written by the Biruni Hospital medical editorial team. Reviewed by Op. Dr. Nadi Nazım ÖZTÜRK, General Surgery.

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