Objective To compare the clinical efficacy and safety of endoscopic direct-vision appendicitis therapy (EDAT) versus laparoscopic appendectomy (LA) in the treatment of acute uncomplicated appendicitis.Methods 160 patients with acute uncomplicated appendicitis from December 2022 to November 2023 were selected. The patients were divided into the EDAT group (endoscopic direct vision for appendiceal cavity irrigation, drainage and fecalith removal, n = 80) and the LA group (standard three-port LA, n = 80) by the random number table method. The surgery-related conditions, postoperative recovery situation, incidence of postoperative complications and postoperative recurrence rate of the two groups of patients were compared.Results The technical success rate of the EDAT group was 96.25% (77/80), and compared with 100.00% (80/80) of the LA group, the difference was not statistically significant (χ² = 3.06, P = 0.080). The clinical cure rate of the EDAT group was 95.00% (76/80), compared with 98.75% (79/80) of the LA group, the difference was not statistically significant (χ² = 1.86, P = 0.173). The operation time, recovery time of gastrointestinal function, time of anal exhaust and hospital stay in the EDAT group were significantly shorter than those in the LA group, the intraoperative blood loss was significantly less than that in the LA group, and the visual analogue scale (VAS) score 24 hours after operation was significantly lower than that in the LA group. The differences were all statistically significant (P < 0.05). The incidence of short-term complications in the EDAT group was 3.75% (3/80), significantly lower than 13.75% (11/80) in the LA group, and the difference was statistically significant (χ² = 5.01, P = 0.025). There was no statistically significant difference in the incidence of long-term complications between the two groups (P > 0.05). During the postoperative follow-up period of the EDAT group, 3 cases (3.75%) of patients relapsed 3 to 8 months after the operation. After confirmation by CT, all of them received LA treatment.Conclusion EDAT outperforms traditional LA in both postoperative recovery and short-term complication control. Although EDAT has a certain risk of recurrence, as an organ-preserving minimally invasive technique, it offers a new option for patients with acute uncomplicated appendicitis.