Abstract
Background
Failure to identify the appendix during laparoscopic appendectomy is uncommon but challenging. Complete subserosal embedding of the appendix-cecal complex is an exceptionally rare variant that may obscure all conventional laparoscopic landmarks. We describe this anomaly in a pediatric patient and describe a practical exploration strategy derived from this case.
Case presentation
A 7-year-old boy presented with acute right lower quadrant pain suggestive of appendicitis. Computed tomography showed appendiceal dilatation with periappendiceal inflammation. During laparoscopic appendectomy, the appendix could not be identified despite tracing the teniae coli and complete cecal mobilization. A targeted serosal incision at the teniae convergence revealed a completely embedded appendix-cecal complex. Subserosal dissection and appendectomy were completed successfully (operative time 45 min, blood loss 2 mL). Histopathology confirmed acute suppurative appendicitis. The patient recovered uneventfully with 6-month asymptomatic follow-up.
Conclusion
Complete subserosal embedding of the appendix-cecal complex is a rare variant presenting as a non-visualized appendix. Systematic exploration and awareness of unusual anatomical variants are essential. Targeted serosal incision may facilitate safe laparoscopic management and avoid unnecessary conversion to open surgery.