The rate of idiopathic spontaneous pneumoperitoneum is 2.36%Objective: Pneumoperitoneum often occurs following a visceral perforation, often seen with peritonitis, and requires urgent surgicalintervention. Non-surgical spontaneous pneumoperitoneum (not associated with organ perforation) is a rare condition caused byintrathoracic, intraabdominal, gynecologic, iatrogenic, and other causes, and may be treated conservatively. Spontaneous idiopathicpneumoperitoneum is not caused by visceral perforation, the cause may be extra-abdominal origin and sometimes cannot be determined.Material and Method: This study is a retrospective review of 338 patients who were examined in our clinic because of abdominal pain orif intraabdominal free air was determined in imaging. Patients whose cause of pneumoperitoneum was of surgical etiology were excludedfrom the study. Patients with abdominal pain were divided into two groups according to the absence or presence of acute abdomenfindings. Patients without acute abdomen findings were kept under observation for a minimum of 48-72 hours. Diagnostic laparoscopywas performed in patients with acute abdomen findings, according to leukocyte and C-reactive protein (CRP) values. The patients weremanaged with a specific protocol if any pathologic etiology was detected in the step-by-step laparoscopic or laparotomic exploration.Results: Of the 338 patients, 8 were diagnosed as having idiopathic spontaneous pneumoperitoneum (2.36%). Four patients werediagnosed as having non-surgical spontaneous pneumoperitoneum (1.18%), and 4 patients had surgical pneumoperitoneum (1.18%).Conclusion: Surgery was unavoidable in patients with spontaneous pneumoperitoneum and acute abdomen findings. Even though noinflammatory process has been determined, surgical exploration should be performed in a step-by-step protocol.