<p>Appendicitis represents a prevalent medical condition among pediatric and adolescent populations, often necessitating emergency surgical procedures. For nearly two hundred years, the management of appendicitis has been conceptualized as a surgical challenge. In contemporary practice, minimally invasive techniques enable appendix removal with reduced anesthetic and operative risks, as well as shorter hospitalization. Nevertheless, both anesthesia and surgical interventions carry potential adverse effects, such as surgical site infections, hemorrhage, herniation, and visceral injury. Furthermore, postoperative convalescence may lead to absence from educational or occupational activities, accompanied by considerable medical expenditures. Recent high-quality evidence in adults and children supports a shift away from routine surgical intervention toward nonoperative strategies for managing this condition. Studies involving adult patients have confirmed that non-surgical treatment of acute appendicitis is both safe and effective. Similarly, in pediatric cases characterized by acute appendicitis, initial conservative management has been associated with a lower incidence of complications, reduced recovery time, and decreased medical expenses, while circumventing surgical risks. There have been multiple prospective clinical trials including a recent multicenter international trial comparing surgery and nonoperative management. It has been established what the safety and effectiveness of non-operative management is and how it compares to surgery. Both are safe and effective options with different risks and benefits period; future studies should focus on pathway specific improvements for non-operative management or for surgery. This review evaluates the clinical outcomes and safety of three therapeutic strategies: traditional appendectomy, endoscopic retrograde appendicitis therapy (ERAT), and conservative pharmacological management.</p>