Authors: Saito H et al.
Journal: Cureus, Volume 18, Issue 1, Article e102611
Summary
This case report describes airway management for prolonged robot-assisted laparoscopic surgery in a 78-year-old man with saber-sheath trachea, an anatomic deformity associated with COPD that combines elements of fixed tracheal stenosis and dynamic tracheomalacia. The major anesthetic concern was the risk of tracheal narrowing, cuff sealing failure, airway edema, and tracheal collapse during emergence if standard endotracheal intubation were used.
Preoperative chest CT identified a markedly narrowed intrathoracic tracheal segment with a coronal diameter of approximately 7.6 mm and preserved sagittal diameter, beginning 30 mm distal to the glottis and extending for 35 mm. Based on these findings, the anesthesia team elected to avoid tracheal intubation and instead manage the airway using a second-generation supraglottic airway device, the ProSeal laryngeal mask airway (PLMA), combined with thoracic epidural anesthesia.
After epidural placement, general anesthesia was induced and a size 5 PLMA was inserted without difficulty. Fiberoptic bronchoscopy confirmed severe tracheal narrowing. Mechanical ventilation remained stable throughout the nearly 10-hour anesthetic, with acceptable peak airway pressures, tidal volumes, and end-tidal CO₂ during pneumoperitoneum. Gastric decompression was achieved via the PLMA drainage port, and no surgical difficulties related to ventilation or gastric distension were reported.
Emergence from anesthesia was smooth. Spontaneous ventilation resumed without airway obstruction or collapse, and the PLMA was removed uneventfully following neuromuscular blockade reversal. The postoperative course was uncomplicated, with no respiratory adverse events, and the patient was discharged home eight days after surgery.
This case highlights that second-generation supraglottic airway devices may reduce risks associated with tracheal intubation in patients with saber-sheath trachea by avoiding prolonged cuff pressure, minimizing airway stimulation during emergence, and preserving more physiologic airway dynamics during the transition to spontaneous breathing.
What You Should Know
• Saber-sheath trachea combines fixed narrowing with dynamic airway behavior, increasing risk during intubation and extubation.
• Tracheal intubation can worsen edema, cuff sealing, and collapse in severely narrowed intrathoracic tracheas.
• Second-generation supraglottic airway devices can provide effective ventilation even during laparoscopic surgery.
• Avoiding tracheal stimulation may reduce coughing, bucking, and collapse during emergence from anesthesia.
• Careful case selection and experienced airway management are critical when using supraglottic devices in laparoscopy.
Key Points
• Condition: saber-sheath trachea associated with COPD.
• Surgery: robot-assisted laparoscopic total gastrectomy.
• Airway strategy: ProSeal laryngeal mask airway instead of tracheal intubation.
• Outcome: stable ventilation intraoperatively and smooth emergence without airway complications.
• Clinical message: second-generation supraglottic airways may be a useful alternative in selected patients.
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