Evolving Surgical Approaches to Adult Perforated Appendicitis: A Systematic Narrative Review.

Perforated appendicitis is the most severe form of acute appendicitis and is associated with significant postoperative morbidity. Advances in laparoscopic surgery and perioperative care have transformed its management, yet the optimal surgical strategy remains debated. This systematic narrative review, conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 and registered in PROSPERO (CRD420251125936), evaluated original studies on adult perforated appendicitis published between January 1, 2000 and June 1, 2025. Six studies encompassing 139,269 patients were included. Three compared laparoscopic and open appendectomy, while others examined prophylactic drainage, timing of drain removal, and immediate versus delayed surgery. Across studies, laparoscopic appendectomy was associated with shorter hospital stays (4-9.2 vs. 6-10.5 days) and lower overall complication rates (8.3-18.8% vs. 12.5-26.8%) compared with open surgery, though operative times were longer (114-121 vs. 94-106 minutes). Intra-abdominal abscess rates were variable: one early cohort reported similar rates (27.8% vs. 29.2%), the randomized trial showed higher risk with laparoscopy (11.7% vs. 4.5%), and a large database analysis showed lower risk (1.65% vs. 3.57%). Prophylactic drainage did not reduce abscess formation and was associated with increased complications and longer stay, whereas early drain removal following laparoscopy reduced morbidity (3.4% vs. 17.9%) without increasing abscess risk. Immediate surgery, although associated with lower drain utilization (14% vs. 42%), achieved fewer organ-space infections (14.0% vs. 23.8%) and shorter hospital stay (3.1 vs. 9.4 days) compared with delayed surgery. Overall, the evidence supports laparoscopic appendectomy as the preferred surgical approach for perforated appendicitis, with routine drainage discouraged and early removal favored when drains are placed. Future multicenter randomized studies are needed to refine perioperative strategies and establish standardized best practices in this high-risk subgroup.