This study compared the efficacy of a stepwise versus a standard approach for laparoscopic appendectomies in children. A total of 378 children with appendicitis were randomized into either the stepwise or standard laparoscopy groups. In the stepwise approach, the operating telescope was first inserted, and ports were added according to pathology. In the standard approach, three ports were inserted for all patients. The groups had similar characteristics. The stepwise approach resulted in a shorter operation time (although not statistically significant) and reduced the number of ports by more than 50%. Stepwise management of appendicitis showed comparable outcomes to evidence-based management while minimizing trauma associated with incisions, operating times, and costs. However, further study is needed to assess the reduction in post-operative analgesic requirements.