In case of discharge before 7 days of intravenous antibiotics, patients are put on oral amoxicillin (50mg/kg/dose every 12hrs) and metronidazole (7.5mg/kg/dose every 8hrs) to complete a whole week of therapy. All appendiceal masses (symptoms selleck Enzalutamide lasting for at least 72 hours before presentation and US confirming the presence of a consolidated appendiceal abscess) are admitted to the ward and treated conservatively with an antibiotic regimen of ampicillin plus sulbactam (50mg/kg/dose every 8hrs), metronidazole (7.5mg/kg/dose every 8hrs), and tobramicina (5mg/kg/die in one administration). After 48 hours of antibiotics, the patients are evaluated clinically, and inflammatory markers (CRP and WBC) are repeated: if laboratory and clinical improvements are observed, the antibiotic therapy is continued until the patients are afebrile for at least 48 hours, inflammatory markers are progressively diminishing, and oral diet is resumed.

After 8 weeks, an interval TULAA is performed. If no improvements are seen after 48 hours of antibiotics, the patients are offered TULAA. Appendiceal abscesses with US evidence of a fecalith are treated with immediate TULAA since the fecalith is a known risk factor for abscess persistence [7]. Patients are started on a liquid diet 12 hours after the operation and on semiliquid diet in the first postoperative day. Gradually, in 48 hours, full oral diet is restored in uncomplicated cases. Criteria for discharge are patient afebrile for at least 24 hours, restoration of full oral diet, and decreasing inflammatory markers. 2.2.

Surgical Technique The patient is placed in the supine position under general anesthesia and mechanical ventilation. No bladder catheterization is used since all patients are asked to void before entering the operatory theatre. A single-infraumbilical incision is performed, and an 11mm balloon trocar is inserted under direct visualization. Capnoperitoneum is maintained within a range of 8 to12mmHg according to the bodyweight of the patient with insufflation of CO2 at a rate of 1.5L/min. A single-operative laparoscope (Karl Storz Endoskope, Hopkins optical devices) with a side-arm viewing is inserted through a single, transumbilical port (Figure 1), and a grasper is used to identify the appendix and to dissect retroperitoneal adhesions: when the tip of the appendix is freed, it is exteriorized through the umbilicus. An extracorporeal appendectomy is performed by dividing and ligating the mesoappendix, suture ligation, and inversion with purse string of the appendiceal base. No endomechanical devises are used. In case of difficult Batimastat dissection, one or two further additional 5mm trocars for additional graspers or cautery hook might be introduced.