For pneumomediastinum to occur during transperitoneal laparoscopy, the abdominally insufflated CO2 has to track through the aortic and esophageal hiatus into the mediastinum (2,4).

During retroperitoneal laparoscopy, the lack of subdiaphragmatic peritoneum may facilitate cephalad tracking of CO2 along the aorta and cava toward the mediastinum (2,4). Therefore, pneumomediastinum may be more likely to occur during retroperitoneoscopy.

In reviewing 63 chest X rays following laparoscopic renal surgery, Wolf et al. identified asymptomatic pneumomediastinum not related to iatrogenic pleural injury in eight cases (13%) (9). Incidental pneumomediastinum occurred more commonly after extraperitoneal procedures (30%) compared to transperitoneal laparoscopy (4.6%). The same finding is reported by the Cleveland Clinic study where 18 (93%) of the 19 patients with pneumomediastinum had undergone retroperitoneal laparoscopy (1).

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