title: A modified access technique for retroperitoneoscopic renal surgery in children.
abstract: OBJECTIVE
  Present techniques for retroperitoneal endoscopic (RPE) access in children mimic those in adults but often result in peritoneal entry or gas leaks, both of which lead to a decrease in the retroperitoneal space. We describe a modification to the access technique that obviates these problems, thus, facilitating RPE in children.
  
  
  METHODS
  In the lateral decubitus position the initial port is placed immediately lateral to the paraspinal muscles, similar to open dorsal lumbotomy fascial incision. A 5 mm skin incision is made at the level of the costovertebral angle and an artery forceps used to tunnel bluntly past the lumbodorsal fascia. A 5 mm port is placed with a blunt trocar, and expansion of the retroperitoneal space performed with the telescope and gas insufflation. Ancillary ports are placed and the telescope then moved to an anterior subcostal port where popular RPE approaches place the initial port.
  
  
  RESULTS
  Eighteen procedures were performed in children with a mean age of 10.8 years, including 12 nephrectomies, 3 dismembered pyeloplasties, 1 partial nephrectomy, 1 nephroureterectomy and 1 parapelvic cyst decortication. No gas leaks occurred, with 1 minor peritoneal entry early in the series not related to the access. Average surgical time for nephrectomy was 178 minutes (range 120 to 240). No intraoperative complications occurred.
  
  
  CONCLUSIONS
  We present a safe and effective technique of initial port placement that follows the principles of open lumbotomy exposure. This approach to RPE minimizes peritoneal entry and gas leaks, thus, maximizing surgical exposure.
authors.affiliation: Division of Urology, Vermont Children's Hospital, Fletcher Allen Health Care, University of Vermont College of Medicine, 111 Colchester Avenue, Fletcher 4, Burlington, VT 05401, USA.
authors.forename: John-Paul
authors.initials: JP
authors.lastname: Capolicchio
authors.forename: Roman
authors.initials: R
authors.lastname: Jednak
authors.forename: Maurice
authors.initials: M
authors.lastname: Anidjar
authors.forename: João Luiz
authors.initials: JL
authors.lastname: Pippi-Salle
mesh_terms: D000293:Adolescent; D002648:Child; D004210:Dissection; D006801:Humans; D007674:Kidney Diseases / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods*; D016684:Prone Position