Purpose Acute appendicitis (AA) is increasingly diagnosed in the elderly due to rising life expectancy. As elderly patients often present with atypical symptoms and are prone to complications, we compared perioperative outcomes between patients younger than 65 years and those aged 65 years and older. Methods A total of 488 patients who underwent appendectomy between January 2023 and January 2025 were included in the study. Patients younger than 18 years were excluded. The study population was divided into two groups: Group 1 (18–64 years, n=445) and Group 2 (≥65 years, n=43). Demographic characteristics, comorbidities, symptoms, surgical features, postoperative outcomes, and histopathological findings were compared between the two groups. Surgical approach and its association with perioperative outcomes were also analyzed. Statistical significance was set at p<0.05. Results Laparoscopic appendectomy was performed in 325 patients (66.6%) and was associated with shorter operative times, fewer complications, and shorter hospital stays (p<0.05 for all). Elderly patients presented more frequently with diffuse abdominal pain (25.6% vs. 8.1%, p<0.001) and had significantly higher postoperative complication rates (65.1% vs. 21.6%, p<0.001), longer hospital stays (p<0.001), and higher readmission rates (18.6% vs. 2.2%, p<0.001). Appendiceal malignancy was significantly more frequent in elderly patients (9.3% vs. 2.0%; p=0.005). Conclusions Elderly patients with acute appendicitis frequently present with atypical clinical manifestations, which may delay surgical management and lead to more advanced disease at presentation. These delays, together with age-related factors, are associated with an increased risk of perioperative complications and morbidity. Given the significantly higher appendiceal malignancy rate (9.3% vs. 2.0%; p=0.005), surgical treatment remains the preferred approach; non-operative management risks missing life-threatening neoplasms in this population.