Additional working space in the retroperitoneum is created with a trocar-mounted balloon (Fig. 2) dilator. Initially, the balloon device is distended adjacent to the lower pole and mid-portion of the kidney (Fig. 3A). Approximately 800 cc of air (i.e., 40 pumps of the sphygmomanometer bulb device) are instilled to inflate the balloon. Thereafter, the balloon is deflated and manually advanced higher up along the psoas muscle into the retroperitoneum. The stiff shaft of the balloon dilator permits precise manual repositioning of the balloon dilator. This secondary cephalad balloon dilation of the upper retroperitoneum is performed in the vicinity of the adrenal gland and the undersurface of the diaphragm (Fig. 3B). Balloon dilation outside Gerota's fascia in the upper retroperitoneum effectively displaces the kidney anteromedially and opens up the potential retroperitoneal space, allowing access to the kidney and the adrenal, and exposes the entire anterior aspect of the psoas muscle, the primary anatomic landmark, during retroperitoneoscopy. The balloon is then deflated and removed. The dilation process can be monitored by inserting the laparoscope within the clear, transparent balloon to observe the following landmarks: psoas muscle (posteriorly), Gerota's fascia (anteriorly), and diaphragm (superiorly).
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