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Background: Globally, patients presenting with acute surgical disease in rural areas have poorer outcomes when compared to urban areas; little data are available regarding outcomes for New Zealand (NZ) rural patients. This study aimed to compare the surgical management of appendicitis in a large metropolitan centre with its regional referral centres. Methods: In this retrospective cohort study, patient data were collated from the studied centres between November 2014 and October 2019. In addition to patient demographics, patterns of referral and presentation, the primary outcome was time to the theatre; secondary outcomes were perforation rates, length of stay and complications. Data are presented as medians (interquartile range). Results: A total of 3533 patients underwent appendicectomy over the period studied. For those presenting directly to the metropolitan centre, the median wait‐time to the theatre was 16 h (9.2–23.2); if patients were transferred, they waited for 20.8 h (13.6–27). Patients presenting to regional centres waited for 7.6 h (4.5–15.4, P < 0.001). Perforation rates for transferred patients were 31% which was greater than for those presenting to the metropolitan (20%) or regional centres (17%, P = 0.014). Complications were also highest in transferred patients (20%) when compared to the metropolitan (17%) or regional centres (10%, P < 0.001). Conclusion: Patients who were transferred to Christchurch Hospital from rural centres without surgical services had a longer wait‐time than those who presented to Christchurch Hospital directly or were treated in regional centres. This was associated with higher rates of perforated appendicitis. [ABSTRACT FROM AUTHOR]