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Background and objective Appendicoliths are calcified deposits within the appendix and are often the cause of complicated appendicitis in children. Their presence is associated with appendicular perforation, abscess formation, and the need for immediate surgical intervention. Preoperative and intraoperative detection influence surgical decision-making and outcomes. This study aimed to evaluate the diagnostic accuracy of imaging, surgical management, and postoperative outcomes associated with appendicoliths in children with acute appendicitis. Methods We conducted a retrospective chart review of 198 children aged <18 years who were admitted to the Department of Pediatric Surgery and underwent appendectomy. The data included demographics, imaging findings on ultrasonography (USG) and CT, intraoperative findings, and postoperative outcomes. Results A total of 198 children were enrolled in this study. Laparoscopic appendectomy (LA) was performed in 83.3% (165) of the patients, with a laparoscopic-to-open conversion rate of 6.1% (12). Appendicoliths were identified in 15.2% (n=30) of cases on preoperative USG and in 44.9% (n=89) intraoperatively. In a comparison between children with appendicoliths (n=89) and those without (n=109), the presence of appendicoliths was significantly associated with higher rates of perforation (74.2% vs. 14.7%, p<0.001), abscess formation (91% vs. 17.4%, p=0.001), and postoperative wound infection (33.7% vs. 9.2%, p=0.001). Conclusions Appendicoliths significantly predispose children to complicated appendicitis. The sensitivity of USG in identifying appendicoliths is limited, and intraoperative detection is associated with a higher incidence of complications than preoperative detection. LA is an effective and safe management option. Conflict of interest statement

Human subjects: Informed consent for treatment and open access publication was obtained or waived by all participants in this study. Institutional Ethics Committee, SJMC issued approval 147/2025. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work