Appendicitis is defined as an inflammation of the vermiform appendix which results from an obstruction of the appendix lumen either mechanically or through fecalith impaction resulting in bacterial overgrowth. It is one of the most common surgical emergencies with a global incidence rate of 1%. [9] The classical presentation of the disease manifests as periumbilical abdominal pain that migrates to the right lower quadrant, in association with anorexia, nausea, vomiting, and fever. Appendicitis is most often diagnosed clinically, however, a diagnostic computed tomography (CT) scan of the abdomen carries a sensitivity of 98.5% [10]. Management is typically surgical, either through laparoscopy, or through open laparotomy reserved for complicated cases. Furthermore, conservative management through antibiotics and supportive measures can also be adopted. Complications may include appendicular abscess, perforation, and peritonitis. Following the emergence of SARS-CoV-2, the declaration of the COVID-19 pandemic had an immense impact on healthcare systems worldwide. Surgical procedures were affected through major delays or cancellations as hospitals sought to decrease surgical caseload and capacity pressures as a result of the pandemic. Non-emergent or elective surgeries were similarly cancelled in our facilities due to the emergence of COVID-19 cases. However, appendicitis was managed in a very compelling way. Diagnosis was reliant on CT scans rather than clinical diagnosis and scans were performed for every patient regardless of their age group, in an effort to treat the case appropriately.

A conservative approach using antibiotics was instilled in our facility whenever possible in treating uncomplicated cases of acute appendicitis in accordance with national guidelines [11]. On the other hand, complicated cases, along with those patients who did not respond to conservative management, were treated operatively with appendicectomy. Patients managed conservatively were given empiric broad-spectrum antibiotics (metronidazole and ceftriaxone) for a duration of 10 days.  86% of patients in this group were COVID-19 negative; with 50% of them being hemodynamically unstable, according to the normal ranges of vital signs established by the American College of Emergency Physicians (ACEP) guidelines. The mean LOS was 2.5± 1.38. The remaining 14% of patients were COVID-19 positive, hemodynamically stable, with normal laboratory parameters and a mean LOS of 16 days due to the isolation period of 14 days being included in the calculation. Furthermore, both groups had abnormal inflammatory marker values and neither group had long lasting complications. These findings are consistent with existing published articles stating that conservative management is an effective means of treating appendicitis in patients that are COVID-19 positive [12-14].

50% of the population who tested positive underwent open laparotomy in comparison to only 9% of those who did not. This notable difference could be attributed to early guidelines set in place during the start of the pandemic, as many sources encouraged surgeons to minimize laparoscopic procedures for COVID-19 positive patients in fear of viral transmission through aerosolization. However, as ongoing research is being conducted regarding the matter, many recent publications have since revealed that there is no strong evidence of increased risk [15-17]. Our data revealed only one COVID-19 negative patient who developed postoperative complications out of all the patients included in this study who were surgically managed for AA, regardless of COVID status. The patient, a 71 years old male known to have diabetes mellitus and hypertension treated with regular medication, developed pulmonary complications requiring ventilation and ICU admission which increased his length of hospital stay to 12 days. This comes in contrast to the expected outcomes of increased postoperative complications in COVID-19 positive patients who underwent emergency surgery according to a report [18]. However, it is worth noting that most of our patients are young and had no previous comorbidities, therefore, decreasing their chance of developing postoperative morbidity or mortality.

Keeping in mind that open appendicectomy can increase the length of hospital stay, thus placing COVID-19 negative patients at an increased risk of developing the infection during hospitalization, we recommend that the length of hospital stay be reduced to the minimum to decrease this risk. In addition, as our results show no difference in outcome between conservative and surgical management, we also recommend that the choice of treatment be made on a case-by-case basis and evaluation of the risk-to-benefit ratio for each individual, as well as taking into consideration the performing surgeon's expertise and comfort. As is now standard in many hospitals, incorporating pre-operative swabbing as part of routine procedures allows the physician to plan accordingly. Furthermore, we highly recommend for surgeons to adamantly follow protective measures to reduce the risk of contracting the virus as much as possible; this includes proper handwashing and hygiene as well as the proper use of personal protective equipment (PPE). Limitations in our research included lack of postoperative follow up and inadequate information about the patients’ past medical and social history.