Purpose To present the issue of incidental findings during routine acute laparoscopic appendectomy and the decision-making regarding management. Right iliac fossa (RIF) pain has a wide differential especially in young female patients including benign and malignant, bowel, ovarian and urological causes. Appendicitis is a common diagnosis and although advanced imaging techniques have improved accuracy you can still get surprises that require non-operative management and further workup to be safe and exclude malignancy. Methodology: A 33-year-old female presented acutely with RIF pain to ED. USS was equivocal, so a CT scan was ordered and suggested acute uncomplicated appendicitis with query reactive change of the caecum. The patient was booked for theatre and had no other red flags to suggest malignancy or inflammatory bowel disease. Intraoperatively the appendix was slightly dilated but normal and there was a solid mass at the caecum that felt hard and looked abnormal, so photos were taken and the procedure was abandoned. Results: Colonoscopy showed ulcerated Caecal mucosa with biopsies suggestive of active colitis. The cause was uncertain but could include Crohn’s disease or Bechet’s syndrome. CT didn’t suggest any abnormal lymph nodes or signs of malignancy. The patient was referred to Gastroenterology for further diagnostic workup and treatment. Conclusions: Laparoscopic appendectomy is a common routine procedure, often performed by a junior registrar. Abnormal, unexpected intraoperative findings can occur and it’s important to have a low threshold for senior review to prevent misdiagnosis and inappropriate treatment. Excluding malignancy and avoiding unnecessary appendectomy is key.