Nearly every appendectomy can be safely performed laparoscopically. I prefer the laparoscopic approach because the outcomes have been shown to be the same or better than those of traditional appendectomy, and I have found it to be a superior when the appendix is retrocecal or stuck way down in the pelvis. The only shortcoming of the technique is its greater overall cost, which might someday become an important factor. I prefer to avoid instrumentation including Foley catheters and nasogastric tubes unless absolutely necessary.
The only reason to perform an appendectomy in the middle of the night is the inability to secure a guaranteed early start the next morning. The benefits of nonoperative therapy outweigh the risks only in patients who present with a well-defined abscess, usually more than 5 days after the onset of symptoms. Antibiotics use is excessive in most patients with appendicitis. All patients undergoing an appendectomy need prophylactic antibiotics, preferably given within 60 min of making an incision, but removal of a normal appendix requires no additional doses, removal of a suppurative appendix warrants perhaps one more dose and certainly no more than 24-h worth, and gangrenous or frankly perforated cases need intravenous antibiotics until afebrile and asymptomatic unless they develop an abscess, in which case a 10–14-day course of intravenous antibiotics and a PICC line are justified. I also believe that the risk of postoperative abscess is lower when patients with perforated appendicitis take oral antibiotics (trimethoprim/sulfamethoxazole and metronidazole, or ciprofloxacin and metronidazole) for 7–10 days after discharge.
If an open appendectomy is performed in a child with perforated appendicitis, it is never necessary to leave the wound open to heal by secondary intention. In fact, I use cyanoacrylate on all incisions in every patient with appendicitis and, if anything, the risk of a superficial surgical site infection appears to be much lower than with steri-strips.