Background: Acute appendicitis is one of the most common surgical emergencies encountered in routine practice, and emergency appendectomy has long been regarded as the definitive standard of care. Emerging evidence, largely from Western antibiotic-first trials, suggests that select patients with uncomplicated appendicitis may be safely managed conservatively with intravenous antibiotics, but data validating this approach in an Indian tertiary-care setting remain limited. Aims and Objectives: To prospectively compare conservative (antibiotic-first) management with operative management (appendectomy) in patients presenting with acute uncomplicated appendicitis, with respect to treatment success, hospital stay, complication rate, recurrence, and overall cost. Materials and Methods: This prospective comparative observational study was conducted over a 24-month period in the Department of General Surgery of a tertiary-care teaching hospital. A total of 120 patients with clinico-radiologically confirmed uncomplicated acute appendicitis (Alvarado score ≥7, no evidence of perforation, abscess, or generalized peritonitis) were enrolled and allocated into two groups of 60 each: Group A received conservative treatment with intravenous antibiotics, and Group B underwent emergency appendectomy. Outcomes were compared using Chi-square, unpaired t-test and Mann-Whitney U test, with p<0.05 considered statistically significant. Results: Conservative management was successful in 52 of 60 patients (86.7%), with 8 patients (13.3%) requiring interval or emergency appendectomy for treatment failure. Mean hospital stay was shorter in the conservative group (3.1 ± 0.9 days) than the operative group (4.6 ± 1.2 days) initially, though total treatment-related stay over one year was comparable. Complication rates were lower in the conservative group (6.7%) than the operative group (15.0%), while recurrence at one-year follow-up occurred in 11 patients (21.2%) successfully treated conservatively. Return to normal activity was faster in the conservative arm (mean 4.8 ± 1.1 days versus 9.6 ± 2.0 days, p<0.001). Conclusion: Conservative antibiotic therapy is a safe and effective first-line alternative to appendectomy in carefully selected patients with uncomplicated acute appendicitis, offering earlier return to activity and fewer immediate complications, at the cost of a clinically relevant recurrence rate. Operative management remains the more definitive treatment and should remain the standard for complicated disease or where follow-up cannot be assured.