Analysis of pediatric appendicitis mortality across 169 countries from 2000-2019 reveals striking geographic clustering, with 66% of variation explained by unobserved regional factors rather than individual country characteristics. Persistent hotspots concentrated in sub-Saharan Africa and South Asia showed minimal change over two decades, despite global improvements in surgical care. Higher physician density emerged as the strongest predictor of lower mortality, while economic factors like GDP showed weaker associations. The spatial spillover effect suggests neighboring countries significantly influence each other's surgical outcomes through shared healthcare systems, training networks, or resource flows. This finding challenges the traditional country-by-country approach to global surgery initiatives. Regional coordination strategies may prove more effective than isolated national investments, particularly given that surgical capacity often transcends borders through medical education and referral systems. The persistent geographic patterns indicate structural healthcare inequities that resist change without coordinated intervention. However, this preprint analysis awaits peer review, and the observational design cannot establish causation between regional factors and outcomes. The findings represent an incremental but important contribution to global surgery planning, suggesting policymakers should prioritize regional surgical workforce development over broad economic interventions in identified mortality hotspots.