Management of Lateral Spreading Tumors (LSTs) involving the appendiceal orifice is technically challenging. While Endoscopic Full-Thickness Resection (EFTR) is an option, deep appendiceal involvement sometimes necessitates appendectomy and is a technique with a significant rate of appendicitis. We present the case of a 63-year-old male with a recurrent 18x10mm homogeneous LST-G completely covering the appendiceal orifice. The patient, presenting with multiple comorbidities and a "hostile abdomen" due to prior surgeries, refused further surgical intervention. This scenario compelled us to explore a purely endoscopic transcecal appendectomy as a salvage therapy.

We describe a Transcecal Endoscopic Appendectomy adapting the technique recently described by Aslan et al. (2025). The primary innovation in this case is the strategic use of the Pathfinder® (Neptune Medical) rigidizing overtube. Unlike previous reports, we utilized the Pathfinder to overcome marked cecal instability and to facilitate the repetitive insertion and removal of suturing needles. Additionally, we employed SutuArt® (Olympus)  for intraluminal traction of the appendix and planned muscular closure, combining standard ESD techniques with deep mesoappendix dissection to achieve a complete scarless appendectomy.

The lesion was initially circumscribed using ESD (DualKnife J). SutuArt was anchored to the lesion to provide traction into the colonic lumen, and two contralateral sutures were pre-placed in the muscular layer to allow an easy closure in later stages. Following cecal wall perforation, we proceeded with mesoappendix dissection using DualKnife J and IT Nano. The procedure was technically demanding due to marked scope instability (despite the rigidizing overtube) and the unexpected appendix length (10 cm), which required extensive dissection. During this phase, appendicular artery bleeding occurred; hemostasis was challenging as the abundant mesoappendix fat hindered the precise application of the Coagrasper, though control was eventually achieved.

After complete inversion and resection of the specimen, the pre-placed muscular sutures had been accidentally cut during the resection. Consequently, mechanical closure was achieved using an OTSC® (Ovesco) clip, confirming no air leakage. The total procedure time was 6 hours. The patient was discharged on day 4 with oral antibiotics and no complications.

Endoscopic transcecal appendectomy is a feasible procedure for complex appendiceal lesions in patients who are unfit for or refuse surgery. The use of a rigidizing overtube (Pathfinder) is highly recommended to stabilize the cecum and manage accessories. However, this technique is extremely labor-intensive and time-consuming (6h) compared to laparoscopic surgery. Therefore, while feasible, it should be reserved for highly selected cases, acknowledging that surgical appendectomy remains the faster and likely safer standard of care.