Use of the laryngeal mask is not contraindicated for laparoscopic cholecystectomy
Bibliographic record
Abstract
We question the premises on which Asai bases his opinion that use of the laryngeal mask airway is contraindicated during laparoscopic cholecystectomy (Asai. Anaesthesia 2001; 56: 187). His opinion that tracheal intubation is mandatory for laparoscopic surgery, or that the laryngeal mask airway is contraindicated, could equally be applied to gynaecological laparoscopy. The popularity of the laryngeal mask airway in gynaecological laparoscopy, despite the head-down position that might be expected to facilitate passive regurgitation, stands in sharp contrast to the rarity of reported pulmonary aspiration [1, 2]. This suggests that the danger is more apparent than real. Asai quoted one case report from 10 years ago to justify his concern of ‘high risk’ of pulmonary aspiration [3]. No large-scale randomised study has compared the incidence of clinically significant pulmonary aspiration between tracheal intubation and laryngeal mask, but the incidence appears to be similar (1 in 5–10 000) in the general population of healthy patients undergoing elective surgery [1, 4, 5]. Pulmonary aspiration has not been reported in studies that compare efficacy and safety of these methods of airway management for laparoscopic cholecystectomy [6, 7]. Active vomiting under inadequate depth of anaesthesia can force gastric contents past and into the laryngeal mask airway to reach the pharynx and lungs. However, passive regurgitation occurs at baseline intragastric pressure of 9–15 mmHg [8], which is less than the pressure needed to bypass a correctly placed laryngeal mask airway [9]. Distension of the abdomen by gas insufflation does not increase the risk of regurgitation unless the patient has an incompetent lower oesophageal sphincter. Rather, it causes a reflex increase in the tone and therefore the barrier pressure of the lower oesophageal sphincter [10]. Cholangiogram dye is emetogenic and, unless gastric suction is used following intra-operative cholangiography, ‘regurgitation’ (active vomiting) of bile-stained gastric fluid is common during emergence from anaesthesia when anaesthesia is light. We have not seen vomiting during the surgical procedure for which we maintain anaesthesia at 1.0–1.5 MAC. Georgiou's concern in his case report [11] about inflation of the stomach is relevant if the laryngeal mask airway is not the correct size, or if it is incorrectly positioned and causes airway obstruction. We found that gastric distension was not a problem when we used the laryngeal mask airway for airway management with positive pressure ventilation during laparoscopic cholecystectomy [7]. We randomised 104 healthy, non-obese patients with no history of gastro-oesophageal reflux to tracheal intubation or laryngeal mask airway. The surgeons, who were blinded to the airway device, scored the size of the stomach 0–10 at entry of the laparoscope and before its removal at the end of surgery. The degree of change in stomach size was similar in both groups, and the surgeon only requested deflation of the stomach in one patient – in the intubation group!
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.000 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".