Gastric distension and ventilation during laparoscopic cholecystectomy: LMA-classic vs. tracheal intubation

Abstract

Purpose: The standard laryngeal mask airway LMA-Classic was designed as an alternative to the endotracheal tube (ETT) or the face mask for use with either spontaneous or positive pressure ventilation. Positive pressure ventilation may exploit leaks around the LMA cuff, leading to gastric distension and/or inadequate ventilation. We compared gastric distension and ventilation parameters with LMA vs ETT during laparoscopic cholecystectomy.Methods: One hundred and one, ASA I-II adults scheduled for elective laparoscopic cholecystectomy were randomly assigned to LMA-Classic or ETT. Patients with BMI >30 kg·m -2 , hiatus hernia or gastroesophageal reflux were excluded. Following induction of anesthesia, an in-and-out orogastric tube was passed to decompress the stomach before insertion of the LMA (women size #4, men size #5) or ETT (women 7 mm, men 8 mm). Anesthesia was maintained with isoflurane in nitrous oxide and oxygen (FIO 2 0.3-0.5), rocuronium and fentanyl. The surgeon, blinded to the type of airway, scored gastric distention 0-10 at insertion of the laparoscope and immediately before removal at the end of the surgical procedure.Results: Incidence and degree of change in gastric distension were similar in both groups. Ventilation parameters during insufflation (mean ± SD) for LMA and ETT were: S P O 2 98 ± 1 vs 98 ± 1, P ET CO 2 38 ± 4 vs 36 ± 4 mm Hg and airway pressure 21 ± 4 vs 23 ± 3 cm water. Conclusion:Positive pressure ventilation with a correctly placed LMA-Classic of appropriate size permits adequate pulmonary ventilation. Gastric distension occurs with equal frequency with either airway device.Objectif : Le masque laryngé classique (ML) a été conçu comme une solution de remplacement au tube endotrachéal (TET) ou au masque lors de ventilation à pression positive ou de ventilation spontanée. La ventilation à pression positive accentue les fuites autour du ballonnet du ML. Nous avons comparé la distension gastrique et les paramètres de la ventilation avec le ML vs le TET pendant la cholécystectomie laparoscopique.Méthode : Cent un patients d'état physique ASA I-II, dont la cholécystectomie laparoscopique avait été planifiée, ont été répartis au hasard en deux groupes : ML et TET. Les patients dont l'IMC était >30 kg·m -2 , ou qui présen-taient une hernie hiatale ou du reflux gastro-oesophagien ont été exclus de l'étude. Après l'induction de l'anesthésie, un cathéter orogastrique (placé et enlevé) a été introduit pour décompresser l'estomac avant l'insertion du ML (modèle 4 pour les femmes, 5 pour les hommes) ou un TET (7 mm pour les femmes, 8 mm pour les hommes). L'anesthésie a été maintenue avec de l'isoflurane dans un mélange de protoxyde d'azote et d'oxygène (FIO 2 0,3-0,5), du rocuronium et du fentanyl. Le chirurgien, qui ne connaît pas le type de canule utilisée, a coté la distension gastrique de 0 à 10 à l'insertion du laparoscope et immédiatement avant son retrait à la fin de l'intervention chirurgicale.Résultats : L'incidence et le degré de changement de distension gastrique ont été similaires ...

The LMA-ProSeal™ is an effective alternative to tracheal intubation for laparoscopic cholecystectomy

“…Stomach size at insertion of the laparoscope and change in stomach size during surgery were similar in both groups. These results are similar to those in our previous study 7 in which we compared LMA-C vs ETT in non-obese patients and did not pass a gastric tube. The only statistically significant differences in this study were related to smoother emergence from anesthesia in the LMA-PS group.…”

“…In a previous study in non-obese patients undergoing laparoscopic cholecystectomy with PPV, 7 we confirmed that there were no clinically significant differences in pulmonary ventilation measurements or gastric distension between the LMA-C and ETT. In this study, we compared pulmonary ventilation measurements, gastric distension and emergence outcomes between the LMA-PS and ETT in non-obese and obese patients for laparoscopic cholecystectomy.…”

“…Other investigators have used PPV with the LMA-C with minimal morbidity. [2][3][4][5][6][7] Widespread acceptance of the LMA-C for gynecologic laparoscopic procedures 8 in the United Kingdom suggests that the risks of an unprotected airway, hypoventilation and gastric distension are no more frequent than with tracheal intubation. However, use of the LMA-C is not recommended in obese patients and those with reduced pulmonary compliance because leak of gases to atmosphere may occur with airway pressure > 20 cm water.…”

LMA-Classic™ and LMA-ProSeal™ are effective alternatives to endotracheal intubation for gynecologic laparoscopy

“…Furthermore, we had previously shown that the LMA-C and ETT with PPV were equally effective during laparoscopic cholecystectomy in non-obese patients, when mean peritoneal insufflation time was 47 min. 7 The PLMA permitted higher airway pressures without leak in all obese patients, satisfactory pulmonary ventilation without clinically significant gastric distension, and use of basal or near-basal FGF. Our inclusion of obese patients with a history of GER may be controversial.…”

“…Patients fasted according to current Canadian Anesthesiologists' Society Guidelines (minimum two hours after clear liquid, six hours after a light meal). 7 No sedative premedication was given unless requested by the patient.…”