Pneumoperitoneum has a wide differential diagnosis and presents with varying degrees of severity; however, not all etiologies require operative intervention. It is imperative that all patients with this diagnosis are evaluated by a surgeon. A thorough history, physical examination, and workup, aimed at localization of the source of pneumoperitoneum will ultimately determine the necessary treatments, including the need for operative intervention. We aim to provide the reader with a working knowledge regarding the evaluation and treatment of patients with pneumoperitoneum.