Pneumoperitoneum In Children Research Articles

Diagnosis, risk factors, and treatment of pediatric benign pneumoperitoneum: A single‐center retrospective study

AbstractPneumoperitoneum is one of the common acute abdominal emergencies that leads to surgical exploration in children, but not all pneumoperitoneum require emergency surgery. This study evaluated the diagnostic methods, predisposing risk factors, and therapeutic options in children with benign pneumoperitoneum for accurate diagnosis and reducing the risk of adverse surgical consequences. A total of 63 cases of pneumoperitoneum diagnosed by the radiographs were involved in this study and were divided into the surgical pneumoperitoneum and benign pneumoperitoneum groups, respectively, from 2009 to 2021. The general information, abdominal signs, laboratory examination, therapies and outcomes, total hospitalization time, and comorbidities were analyzed. Logistic regression analysis assessed the risk factors and protective factors of benign pneumoperitoneum. Promising biomarkers underwent receiver operating characteristic curve analysis. Children with surgical pneumoperitoneum were younger than those with nonsurgical pneumoperitoneum in the study. The C‐reactive protein (CRP) level in the surgical pneumoperitoneum group was higher than that in the other group, albumin (ALB) was lower than that in the benign pneumoperitoneum group, and the ratio of ALB to CRP can be used as an effective indicator to predict whether the pneumoperitoneum is benign or whether surgery is needed. Pulmonary injury, pneumonia, and blunt abdominal injury are the major causes in patients with benign pneumoperitoneum. The establishment and management of clinical criteria for the diagnosis of benign pneumoperitoneum in children will be important for the treatment and recovery of children diagnosed with pneumoperitoneum.

Effect of two different levels of positive end-expiratory pressure (PEEP) on oxygenation and ventilation during pneumoperitoneum for laparoscopic surgery in children: A randomized controlled study.

Positive end-expiratory pressure (PEEP) is used to attenuate the changes in respiratory parameters because of pneumoperitoneum during laparoscopic (LAP) surgery. As the ideal level of PEEP during LAP in children is not known, this study compared the effect of 5- and 10-cm H2O of PEEP on oxygenation, ventilator, and hemodynamic parameters during pediatric LAP. After obtaining approval from the Institute Ethics Committee and written informed parental consent, 30 American Society of Anesthesiologists (ASA) I and II children aged 2-10 years, undergoing LAP were randomized to receive PEEP of 5- or 10-cm H2O during pneumoperitoneum. Baseline hemodynamic and ventilatory parameters, PaO2, and PaCO2 were measured 2 min after tracheal intubation, 2 min and 1 h after pneumoperitoneum, and after deflation of pneumoperitoneum. Oxygenation index, dynamic compliance, and alveolar-arterial oxygen gradient (D (A-a) O2) were calculated at the above-mentioned time points. Data were analyzed using Student's t-test and repeated measures ANOVA with Bonferroni correction. The oxygenation index and D(A-a)O2 decreased in PEEP 5 Group and increased in PEEP 10 Group after pneumoperitoneum, the difference between the two groups being statistically significant (P = 0.001). The dynamic compliance decreased in PEEP 5 Group and increased or remained the same in PEEP 10 Group after pneumoperitoneum, the difference between the two groups being significant (P = 0.001). There were no significant changes in the hemodynamic parameters in the two groups. Use of 10-cm H2O PEEP during pneumoperitoneum in children improves ventilation and oxygenation, without significant hemodynamic changes.

Abdominal wall elasticity of children during pneumoperitoneum

ObjectiveLaparoscopic surgery in children is often hampered by limited working space. This is partially compensated by stretching the child's abdominal wall. The volume of space that can be gained and changes to abdominal wall elasticity with respect to age are unknown. In the current research, we studied the extent of abdominal wall elasticity while establishing pneumoperitoneum in children. MethodsOne hundred and sixty three children less than 18 years of age, undergoing elective laparoscopic surgery were recruited for the study. After induction of general anesthesia with a standardized muscle relaxant dose, a length of 5 cm was marked above, below and lateral to the umbilicus. The length of the marking was measured under increasing intraabdominal pressure (IAP of 0, 4, 6, 8, 10, 12 mmHg). The measurements were repeated to assess the effect of prestretching. The patients were divided into two groups: infants (less than one year of age) and older children (more than one year of age). ResultsDepending on the age and axes of the measurements, a child's abdomen stretches up to 17% on average, with induction of pneumoperitoneum. The percentage of stretch tapers off as the IAP approaches peak pressure. As children become older, the longitudinal abdominal wall elasticity decreases, but the transverse abdominal wall elasticity increases. Regardless of age, prestretching results in a statistically significant increase in the elasticity over the transverse and lower sagittal abdominal wall. ConclusionA child's abdominal wall has considerable expandability. The characteristics of elasticity change depending on the axis and age. Prestretching can improve intraabdominal working space. This knowledge is helpful in port position design for minimally invasive surgery in children. Level of evidenceLevel II.

Pneumatosis intestinalis and pneumoperitoneum secondary to Sapovirus colitis

Pneumatosis intestinalis (PI) with pneumoperitoneum are radiographic findings that may be associated with severe bowel compromise. Asymptomatic patients with benign pneumoperitoneum are well described and can typically be observed. Among symptomatic patients, these findings are more concerning and often mandate operative intervention. The common etiologies of PI with pneumoperitoneum in children can typically be determined by history, physical and imaging findings. Viral enteritis and colitis is an infrequent cause. Sapovirus is in the family Caliciviridae . It is similar to norovirus, a more common pathogen in acute gastroenteritis, but typically presents with less severe symptoms. Here, we describe the presentation of an 11 year old, immune competent boy with severe abdominal pain, PI and pneumoperitoneum. Diagnostic laparoscopy revealed viable bowel without the need for resection or diversion. Stool pathogen panel revealed Sapovirus infection. He made a complete recovery. To our knowledge, this is the first description of PI with pneumoperitoneum caused by Sapovirus infection. • To our knowledge, the first description of pneumatosis intestinalis and pneumoperitoneum from Sapovirus infection. • A helpful description of Sapovirus, a common, but mostly innocuous cause of mild acute gastroenteritis. • A useful review of the interpretation and management of pneumatosis intestinalis and pneumoperitoneum in children. • Successful use of laparoscopy to confirm bowel viability in the setting of a worrisome abdominal exam and imaging.

Radiological diagnosis of pneumoperitoneum in children with typhoid intestinal perforation

Background: Typhoid fever is a severe systemic illness caused by the gram-negative bacillus Salmonella typhi and transmitted by the faecal-oral route. This study sought to determine the value of plain abdominal and chest radiographs in detecting pneumoperitoneum in children with typhoid intestinal perforation (TIP). Methods: A retrospective review of plain abdominal and chest radiographs of children who had surgery for TIP between June 2009 and December 2011 in our unit. All the films were reviewed by the same radiologist who was blinded to the intraoperative findings, for the presence or absence of various signs of pneumoperitoneum. Data were collected on a structured questionnaire and analysed using SPSS version 15.0. Results: Radiographs of 54 children were reviewed. Their ages ranged from 3 years to 13 years (median 7 years). Thirty-three of them were boys and 21 were girls (male-to-female ratio 1.57:1). Pneumoperitoneum was detected in 47 patients (87%). In the erect abdominothoracic films, air under the right hemidiaphragm was detected in 16 of 41 cases (39%), and extraluminal or intraperitoneal air-fluid levels in 31 of 41 cases (75.6%). In the supine abdominal films, the commonest sign of pneumoperitoneum was the right upper quadrant gas sign (23 of 50 cases; 46%). Conclusions: A careful interpretation of plain abdominal and chest radiographs in the child suspected to have TIP, would lead to more accurate diagnosis of pneumoperitoneum. Keywords: pneumoperitoneum; typhoid intestinal perforation; radiographs; children; air–fluid levels

The conservative management of pneumoperitoneum in children

Objective Pneumoperitoneum is usually the result of hollow visceral perforation and requires emergent laparotomy.However,about 10％ of patients lack a pathologic cause requiring surgical intervention and can be resolved with conservative management.The aim of this study is to discuss the indications for conservative management of pneumoperitoneum in children.Methods We retrospectively reviewed the data of 5 children with pneumoperitoneum without peritonitis treated in our pediatric surgery department between January 2009 and December 2010.Results There were 5 children with an average age 5.4 years.Radiologic examinations demonstrated pneumoperitoneum and visceral perforations were suspected in the local hospitals.The abdominal examination revealed no peritoneal signs in all patients.Among them,peritoneal aspirations were implemented in 4 patients and the results were negative.One of five patients underwent laparotomy that demonstrated no visceral perforation.The remaining four were successfully managed conservatively and the pneumoperitoneum was completely resolved between 3 and 9 days.All children were without abdominal symptoms and signs throughout at least 2 years follow-up.Conclusion The presence of free intraperitoneal air does not always indicate hollow visceral perforation and the need for emergent laparotomy.It appears that therapeutic effectiveness can be readily achieved with conservative management in children with pneumoperitoneum without peritonitis. Key words: Pneumoperitoneum; Conservative management; Peritonitis; Children

A prospective assessment of renal oxygenation in children undergoing laparoscopy using near-infrared spectroscopy

This study was designed to determine whether a decrease in renal oxygenation occurs during CO2 pneumoperitoneum in children with normal renal function undergoing laparoscopy. Near infrared spectroscopy (NIRS) probes were applied to both the lateral flank (T10-L2) and lateral cerebral area of all patients with normal renal function undergoing a laparoscopic procedure. Information was recorded in 5-s intervals for 15-min before, during, and for 15-min after pneumoperitoneum insufflation and desufflation. Simultaneously, additional hemodynamic parameters (arterial saturation, mean arterial pressure, end tidal CO2, and urine output) were recorded every 5-min. Pneumoperitoneum pressures used were: 0-1month old, <6mmHg; 2-12months old, <8mmHg; 1-2years old, <10mmHg, and 2-8years old, <12mmHg. The lowest possible pressure was used to obtain adequate vision. Twenty-nine patients were enrolled in the study. Renal regional oxygen saturation (rSO2) did not decrease significantly between baseline (preinsufflation), insufflation, and desufflation of the pneumoperitoneum (p=0.343). Meta-analysis of this data demonstrated a pooled weighted difference of -1.4 (-3.5 to 0.54), confirming no significant change. A significant increase in cerebral rSO2 occurred during the insufflation period of the CO2 pneumoperitoneum (p=0.001). Heart rate (F=11.05; p<0.001) and mean arterial pressure (MAP) (F=19.2; p<0.001) also increased significantly during the laparoscopy. No significant correlation was identified between fluid input and urine output during the laparoscopy (r=0.012; p=0.953). Renal hypoxia does not occur during laparoscopic surgery in children if the minimum age-appropriate intra-abdominal pressures are used. Alternative causes must account for the oliguria and anuria demonstrated in children undergoing laparoscopy.

Perforated Peptic Ulcer in an Adolescent Girl

A perforated peptic ulcer in a child is a rare entity. Severe abdominal pain in an ill-appearing child with a rigid abdomen and possibly with signs of shock is the typical presenting feature of this life-threatening complication of peptic ulcer disease. We present a case of a 14.5-year-old adolescent girl who developed abdominal and shoulder pain that resolved after 1 day. She was then completely well for 2 days until the abdominal and shoulder pain recurred. On examination, she appeared well, but in pain. A chest radiograph revealed a large pneumoperitoneum. She underwent emergent laparoscopic omental patch repair of a perforated ulcer on the anterior wall of her stomach. Result of a urea breath test to detect Helicobacter pylori was negative. The differential diagnosis of pneumoperitoneum in children is discussed, as are childhood perforated peptic ulcer in general, and the unique clinical features present in this case in particular.

Physiological Impact of Pneumoperitoneum on Gastric Mucosal CO2 Pressure During Laparoscopic Versus Open Appendectomy in Children

Funded knowledge about the physiological impact of laparoscopic surgery in children is sparse. Although there are data on hemodynamic compromise after creation of a pneumoperitoneum in children, little is known about microcirculatory changes at the mucosa level. Therefore, the aim of this study was to assess gastric microcirculation by continuous gastric air tonometry in the setting of laparoscopic versus open appendectomy. Twenty children 5-17 years old undergoing laparoscopic and 7 children undergoing open appendectomy were included in the study. Gastric intramucosal CO(2) pressure (pCO(2)i) was measured under standardized flow and intraperitoneal pressure using continuous air tonometry (TONOCAP(®), Datex Ohmeda), and ΔpCO(2) (pCO(2)i - end-expiratory CO(2) pressure [pCO(2)e]) was obtained for the time course of surgery. ΔpCO(2) increased significantly from the baseline value not only in the laparoscopic group but also in the open surgery group. Even though ΔpCO(2) was higher in the laparoscopic group at all time points, the overall increase in ΔpCO(2) for both groups was uniform. The largest differences were observed during the initial 20 minutes of the operation. The changes observed were exclusively due to an increase of pCO(2)i in relation to a constant pCO(2)e. In the setting of a standardized, simple operation in an otherwise healthy child above the age of 5 years, our data suggest that the effect of a pneumoperitoneum on splanchnic perfusion is comparable to the compromise caused by open surgery. Further research must be obtained when evaluating the full impact of laparoscopy in children.

Cardiovascular and respiratory changes in children during diagnostic laparoscopy and laparoscopic surgery

Information concerning the cardiopulmonary effects of pneumoperitoneum in children is lacking. Twenty eight patients were assigned to receive diagnostic laparoscopy (n = 12) or laparoscopic surgery (n = 16). Before insufflation of CO2, tidal volume was set at 10 ml/kg and respiratory rate was adjusted to achieve an end-tidal CO2 (P(ET)CO2) of 30-35 mmHg. Abdominal pressure was maintained at 10-15 mmHg by a CO2 insufflator. We measured the changes of systolic arterial pressure (SAP), heart rate (HR), P(ET)CO2 and peak airway pressure (PAP) at 5 min before (control value) and after CO2 insufflation and 5 min after CO2 deflation. SAP and PAP were increased significantly after pnemoperitoneum compared with the control both in diagnostic laparoscopy and laparoscopic surgery (P < 0.05). P(ET)CO2 was increased significantly after pneumoperitoneum and after CO2 deflation in laparoscopic surgery compared with the control and also with diagnostic laparoscopy (P < 0.05). Driving pressure (the difference between peak airway pressure and abdominal pressure) was increased significantly after pneumoperitoneum in laparoscopic surgery compared with diagnostic laparoscopy (P < 0.05). SAP, PAP and P(ET)CO2 increases during diagnostic laparoscopy and laparoscopic surgery, but this effect appears to be of smaller magnitude in diagnostic laparoscopy compared to laparoscopic surgery. We found that these changes had no clinically deleterious effects in healthy children.

Safety of the Veress Needle in Pediatric Laparoscopy

To better establish the complication rate with the Veress needle technique for establishing a pneumoperitoneum in pediatric laparoscopy. We reviewed all pediatric laparoscopy cases performed by a single surgeon from 1996 to 2003. There were 257 patients ranging in age from 4 months to 19 years. Infraumbilical placement of the Veress needle was used to create a pneumoperitoneum. All instances of preperitoneal insufflation, vessel/viscus injury, and forced conversion to open surgery were recorded. The length of time required to establish pneumoperitoneum was reported in the last 139 patients. The average length of time required to gain access to the peritoneum was <2 minutes. Of these procedures, 138 were performed for nonpalpable undescended testicles, 101 for varicoceles, 13 for duplication anomalies, and 5 for intersex disorders. There were 18 cases (7.0%) of preperitoneal insufflation. No cases resulted in vessel/visceral injury, conversion to open surgery, conversion to use of the Hassan trocar technique, or inability to complete the procedure because of complications in establishing a pneumoperitoneum. In all cases of preperitoneal insufflation, proper access was achieved by pulling the needle out and reinserting it at a different angle, with pneumoperitoneum being achieved easily in each case. The use of the Veress needle to establish pneumoperitoneum in children of all ages is safe, fast, and efficacious.

Minimal Access Surgery in the Neonate

After completing this article, readers should be able to: 1. Review physiologic, anatomic, and technical issues related to minimal access surgery in the neonate. 2. Describe conditions in which minimal access surgery can be used in neonates. Historically, pediatric surgeons were slow to adapt to minimal access surgery (MAS) techniques compared with the adult surgical community. However, MAS now is widely established in infants and children. Differences in size and physiology have necessitated a number of surgical and technological modifications to apply MAS techniques to this population. This review outlines the important differences between children and adults with respect to MAS and provides examples of the use of MAS for diseases seen in infants. ### Physiologic Issues The physiologic response to pneumoperitoneum in children is more pronounced than in adults. Peritoneal insufflation with carbon dioxide has been shown to cause hypercarbia, acidemia, and decreased oxygenation in the pediatric piglet model. (1) In infants, however, there is no detrimental effect on blood pressure, heart rate, or oxygen saturation during short periods of pneumoperitoneum, and elevations in end-tidal CO2 can be counteracted readily by increasing the minute ventilation. (2) Hypercarbia-induced pneumoperitoneum in infants is associated with changes in cerebral blood flow and cardiac output. Nevertheless, laparoscopic procedures have been performed safely with proper anesthetic management in children who have even severe congenital cardiac abnormalities such as hypoplastic left heart syndrome. (3) Hypothermia also can be a concern due to rapid insufflation of unwarmed CO2 gas, mandating the moderation of flow rates. (4) ### Anatomic Issues A number of anatomic factors set children apart from adults and must be accounted for when performing laparoscopic surgery in this age group. Young children and infants have thinner abdominal walls than adults, so extreme care must be exercised when placing trocars. Due to the small size of the abdomen, the working …

Anuria during pneumoperitoneum in infants and children: a prospective study

Introduction Transient oliguria during laparoscopic surgery is a known phenomenon. Currently, no data on the impact of pneumoperitoneum on renal function in children are available. Patients and Methods Thirty children with normal kidney function, who underwent laparoscopic surgery, were included in a prospective study. A transurethral catheter was placed to measure urine output during and 6 hours after operation. Renal blood flow (resistive index) was evaluated by Doppler ultrasound of a segmental renal artery before surgery, every 15 minutes during laparoscopy, and after 24 hours. Blood and urine samples were studied before and 24 hours after surgery. Hemodynamic parameters were monitored continuously during standardized anesthesia, including a standardized intravenous infusion regimen. Results Urine output decreased within 45 minutes of pneumoperitoneum in all patients. Of 8 children younger than 1 year, 7 (88%) developed anuria vs 3 of 22 (14%) children aged 1 to 15 years ( P < .001). Nine children 1 year and older (32%) developed oliguria. There was a significant recovering in the mean urine output until 5 to 6 hours after pneumoperitoneum in both age groups. No significant alterations of the renal blood flow (resistive index) and the serum and urine levels of cystatin C, creatinine, and urea nitrogen were evident until 24 hours postoperatively. The volume of infusion during pneumoperitoneum did not correlate with urine output. Conclusion Pneumoperitoneum leads to anuria in most children younger than 1 year and to oliguria in about one third of older children. This is a completely reversible phenomenon. Urine output should not be taken into consideration for calculating intravenous fluid administration during pneumoperitoneum in children.

Left Ventricular Regional Wall Motion Abnormalities during Pneumoperitoneum in Children

Left Ventricular Regional Wall Motion Abnormalities during Pneumoperitoneum in Children

Left ventricular regional wall motion abnormalities during pneumoperitoneum in children

In adult patients, certain levels of PEEP (16 and 20 cm H(2)O) have been associated with left ventricular (LV) regional wall motion abnormalities. Since any increase in intra-abdominal pressure (IAP) exerted by a pneumoperitoneum is transmitted to the intrathoracic cavity, similar effects on LV regional wall motion cannot be ruled out. To investigate the effects of pneumoperitoneum on LV regional wall motion, we performed a post hoc analysis of a transoesophageal echocardiography study in eight small children (mean age 3 yr, range 15-63 months) undergoing laparoscopic herniorrhaphy under anaesthesia with sevoflurane in nitrous oxide/oxygen and a PEEP of 5 cm H(2)O. During carbon dioxide insufflation, end-tidal carbon dioxide concentration ()was kept constant by increasing minute volume. An IAP of 12 mm Hg caused significant septal hypokinesia compared with baseline, while anterior and posterior wall motion was not affected. In addition, a lateral hyperkinesia occurred, though this change was not statistically significant. Pneumoperitoneum may affect LV regional wall motion in paediatric patients undergoing laparoscopic surgery.

Use of impedance cardiography to monitor haemodynamic changes during laparoscopy in children.

Haemodynamic changes were measured noninvasively using impedance cardiography (ICG) in 30 ASA I children during laparoscopic varicocelectomy under general anaesthesia. After induction and intubation, mechanical ventilation was started, then pneumoperitoneum (PP) was created. During the course of anaesthesia, values of endtidal CO2 pressue (PECO2), peak inspiratory airway pressure (PIP), heart rate (HR), mean arterial blood pressure (MABP), stroke volume index (SVI), cardiac index (CI) and systemic vascular resistance index (SVRI) were recorded at 1 min intervals. We analysed four periods: T1, before induction; T2, after induction; T3, during PP; T4, after desufflation of PP until awake. After induction of anaesthesia a significant reduction of HR, MABP and CI was recorded. Creating PP together with the use of a 15 degrees head down tilt resulted in a further drop in CI, mainly caused by the reduction of SVI, and an elevation of MABP and SVRI. We measured a 25% total decrease of CI. Our patients tolerated this significant reduction of cardiac output well. We have demonstrated that ICG can be used to track the haemodynamic changes caused by PP in children, and suggest that this type of monitoring is useful in this group of age during laparoscopy.

Cardiocirculatory changes during videolaparoscopy in children: an echocardiographic study.

We examined cardiovascular changes associated with intra-abdominal insufflation in 20 children (mean age 6.1+/-4.7 years, ASA physical status I or II) undergoing laparoscopic surgery with general anaesthesia using echocardiography with a transthoracic approach. Intra-abdominal pressure never exceeded 10 mmHg. Systolic blood pressure, diastolic blood pressure, endtidal CO2, peak, and mean airway pressure increased during intra-abdominal insufflation (P < 0.001). Pneumoperitoneum was associated with increases (P<0.001) in left ventricular enddiastolic volume, left ventricular end-systolic volume and left ventricular endsystolic meridional wall stress. In addition, before, during and after intra-abdominal insufflation, left ventricular fractional shortening and left ventricular ejection fraction, underwent slight, insignificant changes. Pneumoperitoneum in children has a major impact on cardiac volumes and function, mainly through the effect on ventricular load conditions. The sharp increase in intra-abdominal pressure affects both preload and afterload, while systolic cardiac performance remains unchanged.

Transumbilical open laparoscopy: a simple method of avoiding complications in pediatric surgery

The author reports his experience with a new procedure, transumbilical open laparoscopy (TUOL), to obtain the pneumoperitoneum in children operated upon laparoscopically. TUOL was designed to avoid complications related to closed introduction of the first trocar, and consists in the visually-guided introduction of the first trocar transumbilically without any need for a pursestring suture, with an operative time of about 1 min. The author recommends TUOL as it is easier, less expensive, and less time-consuming compared to other techniques.

Transumbilical open laparoscopy: a simple method of avoiding complications in pediatric surgery

The author reports his experience with a new procedure, transumbilical open laparoscopy (TUOL), to obtain the pneumoperitoneum in children operated upon laparoscopically. TUOL was designed to avoid complications related to closed introduction of the first trocar, and consists in the visually-guided introduction of the first trocar transumbilically without any need for a pursestring suture, with an operative time of about 1 min. The author recommends TUOL as it is easier, less expensive, and less time-consuming compared to other techniques.

Retroperitoneal Laparoscopic Nephrectomy and Other Procedures in the Upper Retroperitoneum Using a Balloon Dissection Technique

This article describes a hydraulic balloon dissection technique. The retroperitoneum is developed via a small lumbodorsal incision between the edges of the musculus latissimus dorsi and musculus obliquus externus and then after visualization of its correct position the balloon catheter is filled with 500-1,200 ml of warm normal saline (according to patient size). The device consists of the finger of a surgeon's glove ligated around the end of a rigid bladder catheter. The balloon insufflation is maintained for 5 min to guarantee adequate hemostasis. Recently, we have replaced the balloon catheter by a balloon trocar sheath allowing direct endoscopic control of the hydraulic dissection. After retrieval of the balloon the CO2 insufflator is connected to the first trocar. All secondary trocars are placed under endoscopic control. The hydraulic dissection techniques also enable optimal creation of an effective pneumoperitoneum in children. Until now, we have used this technique for twelve procedures in the upper retroperitoneum including five nephrectomies, two nephroureterectomies, one tumor nephrectomy, one nephropexy, one renal cyst marsupialization and two renal biopsies. Up to now we have encountered no major complications. Three of the nephrectomized patients had undergone multiple previous abdominal surgical interventions. The retroperitoneal approach allows the surgeon to apply similar dissecting techniques as used in respective open procedures. It has become the routine approach for laparoscopic procedures in benign renal disease. This procedure can be performed even in cases with previous abdominal surgery.