Background: Acute appendicitis is a condition characterized by inflammation of the vermiform appendix. If untreated, mortality is high, mainly because of rupture leading to peritonitis and shock. There is limited evidence about operative management outcomes of acute appendicitis and associated factors. Objective: The objective of the study is to assess the operative management outcomes of acute appendicitis and associated factors among patients operated for acute appendicitis in Felege Hiwot Comprehensive Specialized Hospital. Methods: Institutional based cross-sectional study design was undertaken for patients who were managed surgically. Data were collected from surgical registration books and patient’s medical card. Systematic sampling technique was employed to select charts for review. The collected data was checked for its completeness, entered, edited and cleaned using EPIinfo version 7 and analyzed by Statistical Package of Social Science version 25.0. Logistic regression analysis was employed. Results: Among 300 patients operated with a diagnosis of acute appendicitis with its complication 51 (17%) developed unfavorable treatment outcomes. Patients who had perforated appendicitis (adjusted odds ratio= 5.3; 95% confidence interval (2.07, 13.51)), intraoperative appendiceal mass (adjusted odds ratio = 6.7; 95% confidence interval (1.78, 25.18)) and generalized abdominal tenderness (adjusted odds ratio = 3.7; 95% confidence interval (1.64, 8.38)) were significantly associated with an unfavorable appendicitis treatment outcome. Conclusion and recommendation: Nearly one-sixth of the patients developed unfavorable treatment outcomes. Perforated appendicitis, intraoperative appendiceal mass and generalized abdominal tenderness were significantly associated with unfavorable appendicitis treatment outcome. Therefore, for health professional’s early detection and treatment of acute appendicitis is crucial for a better outcome. Keywords: Appendicitis; Appendectomy; Operative outcomes