Patient was given general anesthesia with endotracheal intubation. Lateral flank position was given with table broken in the center to stretch the flank. A 1.5-cm size incision was made at the tip of the 12 th rib dividing all muscle layers. Lumbodorsal fascia was opened and a space in the retroperitoneum behind the kidney but outside the Gerota's fascia was created. No anterior dissection to mobilize the peritoneum was carried out since it might have caused injury to the peritoneum.
Gaur balloon was introduced into the retroperitoneum and inflated by 600 ml of normal saline. Following removal of the balloon, 11-mm trocar was introduced and fixed to the skin.
Two other ports were placed under the guide of a laparoscope; a 5-mm port at the level of the posterior axillary line and, a 10-mm port at the angle between the 12 th rib and the lateral border of the erector spina muscle. Pneumatic pressure between 12-15 mm Hg is sufficient.
Gerota's fascia was divided and ureter was immediately identified and traced to the level of the stone. Often, inflammation around the ureter is found and careful use of monopolar and bipolar energy should control bleeding and at the same time avoid damage to the ureter.
An indigenously prepared knife was introduced to make a ureterotomy directly on the stone. Extension of ureterotomy was performed by a pair of endoshears and stone was extracted.
Stone was placed into a glove finger and removed through one of the ports. If stone is large, it may be placed in the retroperitoneum out of the vision and removed at the end of procedure by extending incision at the camera port site.
Placement of double J stent is optional. We do not advocate placing a double J stent routinely. However when required to place a stent, a stent with both ends closed was selected.
A guide wire was introduced at the shaft of the stent through one of the holes and the assembly of the stent and guide wire could pass through a suction canula with rubber seal (cap) at its tip. After inserting the stent at the lower part of the ureter the guide wire needs to be removed and re-inserted intracorporeally through one of the holes in the shaft of the stent towards its upper end. The upper end of the stent is subsequently pushed to the upper ureter towards the pelvis and the guide wire can be removed.
If this procedure is not successful then we close the ureter and subsequently, cystoscopy and ureteral catheterization and stenting is done under Fluoroscopic guidance. Ureterotomy was closed by several interrupted stitches with 4/0 polyglactin 910 suture.
A drain tube was introduced at the site of a 5-mm port under laparoscope vision.