Retroperitoneal access for transperitoneal laparoscopy in patients at highrisk for intra-abdominal scarring

Background and Purpose: Adhesions from prior extensive open abdominal surge ry can make initial transperitoneal access for laparoscopy hazardous. An al ternative to open port placement is a retroperitoneal approach to the perit oneal cavity, We describe our retroperitoneal access for transperitoneal la paroscopy and evaluate the success of the subsequent laparoscopic procedure . Patients and Methods: Eight patients with a history of abdominal surgery ha ve undergone retroperitoneal access to the peritoneum prior to a laparoscop ic urologic procedure. With the patient in a lateral decubitus position, th e retroperitoneum is entered with a 10-mm Visiport device (US Surgical Corp ., Norwalk, CT) along the posterior axillary line, A working space is blunt ly created, the peritoneum identified anterior to the colon, and the endosc ope passed through a peritoneotomy, The abdomen is then inspected, transper itoneal ports are strategically placed under direct vision, and the intende d procedure is commenced. Results: In all cases, retroperitoneal access to the peritoneum and subsequ ent trocar placement was successful. In five cases, the intended procedure was completed laparoscopically, In a case of bilateral ureterolysis, one si de was completed laparoscopically; however, the other required open convers ion. In two nephrectomies for xanthogranulomatous pyelonephritis (XGP), ope n conversion was necessary because of fibrosis. Conclusion: Retroperitoneal access to the peritoneal cavity permits safe an d effective port placement when previous abdominal surgery makes initial tr ansabdominal access difficult. However, despite successful access, in patie nts at risk for extensive perinephric fibrosis (e.g., XGP), a high incidenc e of open conversion may be expected.