Introduction <p>Emergency appendectomy is no longer the only treatment option for uncomplicated appendicitis. Currently, there is no scoring system to determine whether acute appendicitis requires surgical intervention. This study aimed to develop a scoring system for emergency surgery in acute appendicitis (SESAA).</p> Methods <p>Acute appendicitis cases from five primary hospitals were retrospectively analyzed. Clinical and imaging characteristics were selected for multivariate logistic regression analysis and transformed into a scoring system. A small-scale clinical case validation was conducted.</p> Results <p>A total of 1788 cases were ultimately included, with 341 in the unnecessary operation group and 1447 in the necessary operation group. Based on clinical and imaging characteristics, a scoring system with a maximum score of 14 points was established. Patients with scores of 9 or above had a 91.9% likelihood of requiring emergency appendectomy, while 77.6% of those with scores of 4 or below could be managed with conservative treatment using antibiotics. A clinical case application test of 48 cases verified that the sensitivity and specificity of this scoring system were 94.8% and 63.6%, respectively.</p> Conclusion <p>The scoring system aids clinicians, particularly in primary hospitals, in rapidly identifying patients who require emergency appendectomy.</p>