Classification of supraglottic airways.
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More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
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Chapters 1 to 11 deal with the study of different synthetic pathways of certain herbicides and the physical and chemical properties of other synthesized herbicides. The other 14 chapters (12-25) discussed the different methods by which each herbicide controls specific weed population. The overall purpose of the book, is to show properties and characterization of herbicides, the physical and chemical properties of selected types of herbicides, and the influence of certain herbicides on soil physical and chemical properties on microflora. 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Carlos Award (18th edition), and winner of the CHOICE Prize - outstanding academic title award 2016 - Book title: Edible Seaweeds of the World , CRC Press.",institutionString:"University of Coimbra",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"University of Coimbra",institutionURL:null,country:{name:"Portugal"}}}],coeditorOne:{id:"279792",title:"Dr.",name:"João",middleName:null,surname:"Cotas",slug:"joao-cotas",fullName:"João Cotas",profilePictureURL:"https://mts.intechopen.com/storage/users/279792/images/system/279792.jpg",biography:"Graduate and master in Biology from the University of Coimbra.\n\nI am a research fellow at the Macroalgae Laboratory Unit, in the MARE-UC – Marine and Environmental Sciences Centre of the University of Coimbra. My principal function is the collection, extraction and purification of macroalgae compounds, chemical and bioactive characterization of the compounds and algae extracts and development of new methodologies in marine biotechnology area. \nI am associated in two projects: one consists on discovery of natural compounds for oncobiology. The other project is the about the natural compounds/products for agricultural area.\n\nPublications:\nCotas, J.; Figueirinha, A.; Pereira, L.; Batista, T. 2018. An analysis of the effects of salinity on Fucus ceranoides (Ochrophyta, Phaeophyceae), in the Mondego River (Portugal). Journal of Oceanology and Limnology. in press. 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The immediate restoration of the breast is considered as the most favourable treatment for women undergoing a primary mastectomy since many years, but it is is not always true as it can occur in case of radiation therapy. Nowadays many patients care the aesthetics of the breast more than only ten years ago. An immediate definite reconstruction is unfrequently achievable using flaps or implants due to both clinical and surgical reasons. In our institution, a one-stage reconstruction embraces a minor part of patients. The first improvement of the cosmetic outcome starts with the preservation of native skin envelope in the immediate breast reconstruction (IBR) when this event is followed by less visible scars and reduced risk for skin necrosis. Toth and Lappert [1] described a skin-sparing mastectomy in 1991. The reconstructions without nipple are less pleasant as already suggested by Wellisch et al. [2] Furthermore the nipple is often difficult to be restored with the same charactheristics present before a skin-sparing mastectomy (SSM). Moreover preserving nipple and areola is much more grateful for the patients.The problem can arise if the breast is ptotic or large breast where the maintainance of redundant skin and nipple is risky. A moderate periareolar deepithelization or a skin-reducing mastectomy would be helpful trying to maintain more blood supply to the nipple-areola complex and skin around. [3] By the way, apart of the plastic surgery’s implications, nipple-sparing mastectomy (NSM) is already the gold standard in the women at high genetic risk (BRCA1-2) as risk-reducing mastectomy. [4-6] Based on the expectations of more conservative approaches, NSM is progressively extending the indications in the treatment of the breast cancer, such as multifocal IDCS, T1-T2 IDC, T3 after tumor regression by neoadjuvant therapy. [7] The local recurrence risk is acceptable after peripheral tumors smaller than 3 cm. [8-11]
The challenging goal of any IBR is given by the chance for a one-stage procedure with the same complication rate and aesthetic outcome as the two-stage reconstruction. In the past the single-stage reconstruction with implants was consistently considered more complicated and risky than the reconstruction with autologous flap. [12] However complications were reported in all the immediate reconstructions, not only using permanent implants. [13] In addition poor IBR results were strictly related to both the inadequate surgical skill and the unsatisfactory selection for the right patient or breast implant as well. [14] Also the permanent expander alone or combined to the latissimus dorsi flap was extensively considered in some institutions as demonstrated by Gui et al. [15] The current standard for the implant reconstruction after mastectomy is the two-stage reconstruction with temporary expander followed by permanent implant, and secondarly the reconstruction using autologous free and pedicled flaps.
In the last decade the Acellular Dermal Matrix (ADM) has been used and successfully reported into the expander-based reconstruction especially in US, even if associated to higher incidence of seroma (3.9%), infection (2.7%) and total failure (3.0%) as underlined in a meta-analysis of complications recently published. [16] Moreover ADM significantly adds a cost to the two-stage IBR and hence but only few publications suggest single-stage implant-based IBR with ADM in a positive way. [17, 18] Theoretically it would be expected that ADM can facilitate the IBR in one stage, i.e. without using temporary expander. The oncoplastic surgeons that are still using successfully the two-stage reconstruction with expander but with no kind of mesh, frequently occurring in Europe, cannot understand the real advantage of ADM in two steps. The need for ADM or synthetic mesh in case of expander-based reconstruction may be due to the behaviour of the breast surgeon that does not spare both muscular fascia and a strip of soft tissues along the submammary fold during mastectomy. The one-stage procedure offers significant advantages: reducing recovery costs, avoiding the fixed second operation, decreasing the days of convalescence (including the series of tissue expansion) and achieving a more prompt restoration of body image and perception. [19]
The key point of any single-step IBR is the correct selection of patients where a satisfactory grade of symmetry can be reached. The patient expectations for the best and most prompt cosmetic result have greatly increased compared to only ten years ago. Nevertheless the ideal procedure is still far from being found.
In the meantime, based on the refusal for dermal matrix derived by cadaver human-tissue like Alloderm (Lifecell Corp., Branchburg NJ USA) mainly in Europe, the marketing system is proposing new biomeshes [20-22], like the Strattice (Lifecell Corp., Branchburg NJ USA) and the Meso Biomatrix (Kensey Nash Corp. Exton PA USA) derived by porcine dermis and mesothelium respectively as well as alloplastic meshes, i.e. the TiLOOP made of titanized polypropylene (Pfm medical titanium, GfE Medizintechnik GmbH, Nurnberg Germany) or the Seriscaffold of biodegradable silk (Allergan Inc. Irvine CA USA).
In our opinion far from commercial inputs, on the contrary, the breast meshes should have a limited use in case of IBR while a well-tailored surgical technique can still achieve more physiological outcomes. The dual-plane technique here illustrated is an example how a feasible autologous pocket for silicone implant allows to reach the goal of a breast reconstruction in a single procedure.
Breast reconstruction should ideally be both immediate and definitive so as to avoid patients undergoing further surgery later. It is generally considered, from an oncological and psychological point of view, that there are no contraindications to immediate reconstruction excepting particular cases but it is not so clear about the definite single stage, whereas it is already established for the breast cancer conservative treatment. [23]
One-stage reconstruction after skin-sparing-mastectomy and specially nipple-sparing mastectomy (NSM) is performed thanks to several procedures: a) autologous flaps (DIEP, TRAM, Latissimus dorsi + implant); b) autologous preparation of the pocket used for permanent implant (saline or silicone)/expandable permanent implant (Becker or other types), c) preparation of an implant pocket with support of eterologous (tissue biomatrix) or alloplastic meshes tailored for breast surgery. The one-stage IBR might not always be indicated, e.g. in presence of local radiated tissues where a delayed reconstruction is often formerly discussed with the patient. The example of the autologous flaps may be paradigmatic. Flaps have the great benefit of restoring the breast with soft and well-vascularized tissues, and this advantage becomes essential when breast tissues were before irradiated. Nevertheless when reconstruction is immediate, there are side effects that withdraw from the elective choice of a distant flap for several reasons: a) longer operation and recovery time with all the related medical complications; b) misunderstanding of the real implications of that kind of surgery in patients much more worried of cancer implications at the moment of the pre-op consultation; c) higher hazard for postponement of the oncological care (chemotherapy or irradiation) in case of flap failure and wound complications, that are more severe if compared with reconstruction by silicone implant, although their occurrence is infrequent. Flap failure after IBR strongly compromises patient body image and self-esteem, and moreover complicates any further reconstruction. Some review studies recommend delayed flap reconstruction in patients at high risk for adjuvant radiation therapy. [24, 25] On the contrary, in case of expander or protsthesis, also the worst complication could be treated by an easier removal of the device, with a limited delay of the cancer therapy. Moreover this failure can be solved afterward by using a flap or a tissue expander another time.
IBR does not interfere with the progress of the disease but it should be chosen the less risky procedure to reconstruct the breast. The ideal treatment must reduce at a minimum the occurrence of major surgical complications that can significantly delay the following chemotherapy and/or radiotherapy in breast cancer patients. In such a way, also the ADM, the other kinds of biomatrix, and in particular the alloplastic meshes can conceal higher incidence of complications, seroma and implant extrusion as first, then extreme thinning of the lower pole soft tissue above the implant compared with an autologous IBR performed only through a special preparation of the muscular and fascial pocket for implant.
We believe that the permanent implant pocket must retain these special features to have a final success: a) to be well vascularized, b) to be resilient, pliable, and adequately large; c) to be separated from the subcutaneous mastectomy pocket and the axillary cavity, as to decrease the risk for seroma or infection; to be partially free of the active contractions and reactive stiffness of the pectoralis maior muscle but contemporarily avoiding any malposition and malrotation of the implant.
Since mastectomy interferes with the psychologic, social, and sexual well-being of the women, it should be proper that the final statement about the kind of breast reconstruction is going to be realized by a well-informed patient. She must have the right of opting for both the immediate and easiest type of reconstruction, also the patient with a radiation to be post-operatively planned or that with a poor cancer prognosis. In that case she may promptly have something looking like a breast. It does not matter if the implantable device will be a permanent implant or a “temporary” saline expander as well.
Contrary to prior surgical approaches to implant-based IBR and without use of dermal matrix and alloplastic mesh, the technique here described permits to extend the one-stage reconstruction to patients with larger breast or minimal ptosis, even satisfying the demand of bilateral enlargement of the breast. The technique is easier to be used in bilateral mastectomies either for those sparing the nipple or those sparing only skin, in unilateral mastectomy, preferably if nipple-sparing.
Some of the patients undergoing skin- or nipple-sparing mastectomy can be eligible for this kind of IBR, nearly the 30%. The ideal breast is the breast without ptosis, with weight less than 500 g, with good skin elasticity or at least moderate redundancy as occurring in the skin after pregnancy. The last is the most favourable condition in order to plan augmentation of the prior breast size. Women with large breast (D/DD breast cup size) or severe ptosis and the obese patients must be excluded. Cautious contraindications are given by the heavy smoker patient (>30 cigarettes a day) or by the breast with multiple prior scars. However the primary evaluation is addressed towards the expectations of the single women about the breast shape and size. It is not psychologically easy to explain all the plastic and cosmetic aspects to a women often worried by the cancer just discovered and distressed thinking about the incoming oncological treatments. The mood of many patients may not allow good understanding of some among the following queries: 1-stage vs. 2-stage reconstruction; implant vs. autologous flap; expander vs. permanent implant; best shape vs best symmetry of the breast; timing of the complimentary contra-lateral surgery and hence choice for augmentation, mastopexy or reduction respectively.
Immediate aesthetic correction of the healthy breast is suggested in the majority of the patients requiring total augmentation. On the contrary, if required, pexy is much better to be carried out at a second stage. Adequate symmetry is very difficult to be attained in case of contralateral reduction as well as pexy alone or with augmentation. The nipple-areola position and breast size cannot be well planned during mastectomy because the definitive shape of the new breast and the same nipple/areola position are to be evaluated after healing. The risk for asymmetric displacement is real in case of every nipple-sparing mastectomy. Moreover, it is well known that the nipple/areola complex can be barely placed in another position after mastopexy or breast reduction. For this type of patients the contralateral surgery should be delayed regardless of the possibility of IBR in a single step. The decision to plan a larger implant size and also decide the ultimate augmentation of the healthy breast can be taken at the time of the pexy or reduction as well.
On the other hand, permanent implant can also be changed with another of better shape and volume corresponding to the contra-lateral breast at a second stage that becomes possible, but not necessary, if symmetry is already satisfactory following the previous immediate reconstruction. It should be clear to the patient that the one-stage reconstruction with a permanent implant gives a prompt and definitive result but is not unchangeable. In fact a surgical revision may always take place improving all the breast, if the result is not satisfactory.
Another preoperative valuation regards the preservation of soft tissues in the lower section of the breast, which means not only in the inner plane but also in the outer, i.e. the skin. The dual-plane technique cannot match up with those surgical approaches planning inframammary or vertical incision for the mastectomy. [26] These incisions can compromise any natural refilling of the lower breast, and hence lead to the insertion of expander instead of permanent implant, or to the aid of ADM with higher costs for the hospital. The overall preference for a lateral radial, even in presence of previous areola scars, is supported by data reported in literature, Riggio et al. [27] reported 1% of areola necrosis in a preliminary clinical study. Garwood et al. [28] decreased the same risk to a 5% rate, and pointed out that the incision of at least 30% of areola circumference is already to be considered as independent risk factor for necrosis. Of course, the lateral radial incision is preferred because of lower risk of skin ischemia and of more accurate dissection behind nipple and areola, but it is not enough if the mastectomy does not spare the whole subcutaneous layer and its vascular network. Sometimes incision can include earlier lumpectomy scars and partial areolar incision are performed in presence of prior scars. The periareolar deepithelialization is rarely carried out if there is vertical skin excess.
Any preparation for a full-coverage autologous pocket, i.e. made of local tissues of the breast, first bases on the thorough preservation of the inframammary fold frame during mastectomy. The real anatomy of the superficial fascial system inside the submammary fold unit was finely described by Riggio et al. (2000), Fig.1. [29]
The inframammary fascial system: s.r.c.,superficial retinacula cutis into the superficial subcutaneous (adipose) layer between skin and superficial fascia and its annex (the breast gland envelope); d.r.c., deep retinacula cutis into the deep subcutaneous (areolar/adipose) layer between superficial fascia and deep fascia (the musculo-fascial plane). The density and thickness of the connective frame is here particular, the dotted red encircle. There is also thin areolar tissue between muscle and rib cage.
The fine anatomy is made of multiple subcutaneous attachments, i.e. thickened retinacula between the superficial and deep fascia (zone of adherence), where contiguous connective micro-frames of the superficial and deep subcutaneous layers persist as different anatomical microunits of the same fascial frame, as according to the functional concept of skin-superficial fat-superficial fascial system described by Lockwood in the trunk and extremities (1991) and to the study of Nava et al. (1998) that already explained the fascial system in the surgical reconstruction of the inframammary fold. [30, 31]
Maintaining the attachments of the inframammary fascial system at the deep plane (fasciomuscular layer) is mandatory along all the inframammary contour (Fig.2). The breast surgeon has to avoid any cut or undermining at the submammary level, in both the superficial and deep subcutaneous layers. Maintaining a few millimeters of soft tissues above the inframammary line can totally spare the connections, also called (deep retinacula) between the superficial system and muscular plane. This care allows the mastectomy field to be maintained far from the submuscular pocket for implant.
The inframammary superficial fascia, direct prolongation of the abdominal fascia (Scarpa’s fascia), extends to the retromammary space and properly links the superficial connective frame to the deep fascia (the pectoralis maior and serrate anterior muscular plane) along all the inframammary fold. The mastectomy must preserve this strip of soft tissue after dissecting off the breast gland. Intra-operative view.
The preservation of the pectoralis fascia is viable and its resection is not justified by any evidence-based oncological reason in routine modified radical mastectomy for invasive breast cancer. [32] On the other hand, sparing this fascia is also important that occurs at two levels: 1) at the inferomedial portion because it allows to release the muscle insertions preserving the stability of the implant coverage; 2) close to the free border of the pectoralis maior and above the serratus anterior because it allows correctly to suture the pocket above the implant without dehiscence.
Before starting with reconstruction (Fig.3), the plastic surgeon must check the following topics: a) the anatomical quality of the surgical field (some conditions interfere with the pocket preparation, e.g. cranial insertions of the pectoralis maior muscle far from the inframammary level); b) a prior mastectomy dissection carefully preserving both the inframmamary fascial system and the deep fascia along the lower border of the pectoralis maior muscle. Any leakage should be sutured using vicryl 2/0 stitches but, if the musculofascial layer is going to tear again, the plan for permanent implant must be discontinued pro expander, avoiding the saline inflation intra-operatively. All patients have before to be warned that the insertion of a permanent implant is not sure until the end of the surgical procedure.
The surgical field of the submammary zone after radical modified mastectomy with preservation of: a) the inframammary unit, made of subcutaneous fatty tissue, superficial fascia and related retinacula; b) both aponeurosis of the pectoralis maior and serratus anterior muscle and likely the fascia between the two muscles (this layer, if discontinued by the prior dissection must be rebuilt using some stitches or occasionally a small patch of absorbable material; c) the muscles and proper fascia (deep fascia). The surgeon that destroys the submammary fascial frame precludes the immediate chance for any satisfying 1-stage reconstruction with silicone implant.
The best presentation in IBR is given by the aesthetic preservation of the nipple-areola complex when oncologically safe. The removal of skin around the nipple limits the use of the same technique in the skin-sparing group of mastectomy. Maintaining all the breast skin envelope results in skin redundancy which becomes too wide in case of larger or pendant breast. The skin, after the Cooper’s ligaments resection, is free to extend, especially when skin is less elastic (after weight loss, pregnancy, aging). Side effect of the skin excess is the growing risk for the necrosis of the inner skin. This complication is uncommon if patient selection and subcutaneous dissection are correct whilst, on the other hand, other complications are common as skin folding, scar retraction, and NAC displacement. They are difficult to be solved secondarly and really compromise breast aesthetics and body perception. IBR gives an answer to this problem related to skin excess and tries immediately to replace as much as possible the volume loss after parenchyma excision with larger implants. A prompt expansion volume is able of filling, or better overfilling, the skin envelope and stabilizing the nipple position. The cutaneous envelope of the breast is consistently major than the respective volume breast only except the teenager’s breast. On the contrary, a T-inverted skin reduction together with the nipple preservation, jeopardize the vascular supply to the same nipple and areola apart from the implant dimensions. Breast shape can be outlined by a tear-drop device with high-cohesive silicone and then better maintained through the gel memory. Highly cohesive implants generate a certain strain strength on the envelope at the same way as a rapid expansion does. This is more stable than the strenght produced by saline expander or low-cohesive gel devices. Highly cohesive gel withstands external pressures, e.g. muscular strenght or scar-tissue retraction, with poor inner displacement of the filling gel. Bio-mechanics of the forces acting on the female breast and the physical properties of breast tissues are strictly related to every plastic surgery procedure but, unfortunately, their knowledge is still less than average. [33, 34] We can take advantage from the bio-mechanical properties of the high-cohesive gel, soft tissue and muscle too, preparing a full-vascularized, partially sub-muscular, complete coverage for the implant. The pocket must not be the same as the pocket prepared for an expander to be inflated progressively after surgery and then substituted. Surgical refinements must be maximized in a single-stage reconstruction. In addition, the planning for implant size and shape is more and more challenging in IBR in order to achieve the best symmetrical outcome.(Fig 4)
Preoperative planning for nipple-sparing mastectomy (DCIS) + IBR with anatomical implant (natrelle high-cohesive 410MX 290g) in the right breast and submuscular augmentation (natrelel high-coesive 410MM 185g)
The selection for tear-drop implants will depend on the anatomic landmarks of breast and chest wall in the same way as planned in aesthetic surgery. Width, height, and projection are to be measured choosing shape and size of the implant. Here width and height of implant are difficult to be planned accurately compared to the selection for a temporary expander or to the 2-stage reconstruction (expander substitution). Only bilateral reconstruction makes easier the choice, here the preliminary indications are consistently maintained during surgery. Intra-operatively plastic surgeon must evaluate the limits of breast removal and the remaining soft-tissue thicknesses in order to change the implant in width or height usually by about 0.5-1 cm more or less. It is also recommended to weigh the specimen after mastectomy and compare the breast weight with the implant weight taking into account that is better to choose an implant a little bigger than the breast weight. Soft-tissue retraction and atrophy can occur after normal healing or radiotherapy. When contemporary enlargement of the contralateral breast is planned, augmentation is preferably sub-muscular with the aim of improving implant symmetry and better screening of the healthy breast.
After harvesting the free edge of the pectoralis maior muscle, with identification of the deeper pectoralis minor muscle (Fig. 5), dissection begins from the lateral part of the proper fascia of pectoralis minor and carries below the of the serratus anterior muscle and proper fascia laterally and downward (Fig. 6).
Along the upper lateral border of the pectoralis maior muscle, scoring the deep muscular fascia towards the pectoralis minor muscle.
Harvest of the serratus anterior fascia and muscle, never only fascia, but trying to split the muscular fibers
Serratus anterior muscle can be split using an intramuscular dissection when the thickness is adequate and the proper fascia has been spared during mastectomy. The aim is leaving a layer of muscle fibers above the rib cage with the following effects: a) a more pliable coverage in the lateral side of the device pocket; b) maintenance of some active work of the deeper part of the muscle; pain reduction after surgery. The lateral limit of the pocket must exactly correspond to the implant width at the aim of avoiding implant malposition.
Then the upper and medial undermining is carried out under the pectoralis maior muscle and the extension will depend on the implant size. The pocket width must precisely correspond to the device width in order to avoid any lateral malposition (Fig. 7)\n\t\t\t\t
The submuscular dissection in the midpart of the implant coverage
Dissection carries on towards the lower fibers of the serratus anterior and the lower insertions of the pectoralis maior and (Fig.8). As usual in breast surgery, the lower medial insertions of the pectoralis muscle are scored. The submuscular undermining reaches the visible submammary line (Fig.9).
Scoring fibers and insertions of the muscles towards the inframammary zone
The submuscular pocket ends into the inframammary fold, any downward over-dissection should be avoided.
In a two-stage reconstruction with tissue expander, the submuscular pocket is complete when partial or total release of the deep fascia is performed at the same inframammary line, also called pectoralis fascia or muscular fascia, overlaying the muscles (Fig.10, 11). The superficial fascia must be preserved because it will expand progressively and physiologically. Also the deep fascia, if thin, can expand as well. On the other hand, in case of ADM-based IBR, the deep fascia is totally dissected just above the inframammary level and then the lower edge of the biomatrix is sutured along the inframammary fold.
The deep fascia along the inframammary fold observed behind the section of the muscle fibers
Total release of the deep fascia and deep retinacula cutis along the inframammary fold
Summarizing the first part, the submuscular pocket results:
partially scored medially, close to the sternal border, from the 4th rib down to the inframammary level;
completely scored, including the whole musculo-fascial plane, along all the inframammary fold under the pectoralis maior and serratus anterior as far as the most lateral portion of the submuscular pocket. The final maneuver gives access to the deep adipose layer infero-laterally where fat is generally thicker.
Dissection allows to achieve a vertical enlargement of the lower pocket about 2-3 cm, seldom wider after scoring the deep retinacula cutis. This is that for more than a decade the Authors have been used to perform in the one-stage IBR with permanent implants, even some series of patients were recently published by other authors. [35] Expandable devices, Becker’s or other types, were never used in these patients. Devices were tear-drop shaped and pre-filled with silicone gel highly cohesive. The patients were few compared with the patients with 2-stage reconstruction. Breast size was small to medium and weight lower than 300 grams. Because the possible results were not so satisfactory and the demand for sparing mastectomy was growing up, since 2008 the possibilities of transposing the former knowledge upon the inframammary reconstruction (Nava et al., 1998) were taken into account, in order to define the details of a proper technique for IBR in over 130 cases (Riggio et al., 2012). [27, 31]
The surgical anatomy of the inframammary fascial system of connective tissue: a, superficial retinacula cutis; b, deep retinacula cutis; Co-L, Cooper’s Ligaments; S-F, superficial fascia (horizontal white line); D-F, deep fascia overlying the muscles (horizontal red line); C, the levels of the electrosurgical scores in the dual-plane technique: green arrows into the superficial fascial plane and red arrow into the deep plane. It is possible to release the deep fascia a few millimeters beneath the fold, whereas the superficial fascia must be scored a few millimeters above.
The modified technique improves the enlargement of the lower breast substantially through the total release of the superficial fascia together with the superficial retinacula cutis above the whole inframammary line (Fig.12). It is fundamental that every surgeon may notionally understand, practically recognize, and surgically respect the fine anatomy of the submammary fold.
The multiple scores can obtain a better enlargement of the lower breast compared to the same manoeuvre performed in the second stage of reconstruction after expander because soft tissues can here contain some grade of fibrosis and the pre-existing connective frame be distorted. The scores must be performed behind the skin plane perpendicularly, avoiding any dermal bruising, and just above the corresponding external submammary line, a few millimeters, so as to avoid the bottoming-out of the pocket (Fig. 13, 14, 15, 16)
The vertical scoring of the superficial fascia through the previous deep fasciotomy and access to the deep subcutaneous layer, along the inframammary fold. The upper and lower free borders are part of the deep fascia already scored.
The tip of the electrical scalpel indicates where the superficial fascia layer is placed, above the inframammary fold, and the advancement of the pocket enlargement.
The submammary pocket after superficial fasciotomy, a few millimeters above the inframammary fold. The scored borders of the superficial fascia are visible below the middle retractor.
The dual-plane technique is able to add further 3-4 cm of height in the lower pocket, made of soft and vascularized tissue (Fig.16), totally integrated to the upper coverage made of muscular tissue (pectoralis maior and serratus anterior muscles). The total release of the connective inframammary frame can reach the 7 cms including the previous deep-fascial. It lets free skin and adipofascial layer spontaneously to reach the top of extensibility. This extension is to be compared with a rapid expansion. In the meantime, muscles are free to move upwards and so accomplishing the ultimate dual-plane costruction of an implant coverage that is totally and continuosly vascularized: the lower third of pliable soft tissue and the upper two thirds of firmer muscular tissue (Fig.17, 18).
The autologous composite pocket is completing.
The insertion of the permanent anatomical implant behind the dual-plane coverage. This pocket is totally isolated by the subcutaneous pocket of the removed parenchyma. A drain is inserted under the implant and another between the axillary and subcutaneous compartments. The closure of the pocket is carried out between the free border of the pectoralis maior and the surgical edge of the serratus anterior, using several figure-to-eight stitches of vicryl 2.0.
The composite coverage, skin-adipo-fascial tissue downwards and muscular upwards is nourished by a continuous vascular network, preventing complications related to reduced vascular supply and to biomatrix. The blue line illustrates the implant envelope divided in muscular (A) and subcutaneous-subfascial coverage (B).
Of course, the breast shape will be given by the anatomical implant but only the high-cohesiveness of the silicone gel can maintain and hence stretch the pocket in the following weeks (Fig.19). A saline implant or expander does not retain any true form; even if totally inflated it will never be the same of a “gummy-bear” implant. The different bio-mechanical effect also helps in re-establishing the true projection of implant that initially appears to be constricted by the tension of the muscular coverage.
The one-stage immediate reconstruction of a nipple-sparing mastectomy using a permanent silicone implant (Natrelle 410MX 370-grams by Allergan Inc.) in dual-plane autologous pocket. No ADM or synthetic mesh was used. High profile and fullness of this implant-based reconstruction are already visibile after skin closure compared with the healthy breast. Intra-operative bird\'s-eye view, patient in supine position.
The fixation of the central inframammary fold. After scoring the superficial fascia above the inframammary fold, even if the symmetry was totally respected, the level inside appears to be bottomed out inside in some patient. It ought to be due to the abdominal superficial tension which pulls down the lower edge of the fascia already resected. The following procedure can solve the defect according to the former technique of inframammary redefinition already introduced by the same Author Nava. One or two stitches of absorbable material, usually vicryl 0, fix the lower edge of the superficial fascia already scored at the midpoint of the inframammary line into the residual deep fascia or deeper fibers of the serratus anterior or, if necessary, the intercostal fascia (Fig.20). Sometimes, when mastectomy is unilateral, the same procedure is performed for major definition of the central fold as to create a minimal folding to the inframammary line at the aim of a better symmetry with the contralateral breast or only to avoid even minimal descent of the implant.
The lower edge of the superficial fascia is identified corresponding to the central point of the inframammary line and then pinched and fixed to the muscular fascia using a single stitch of vicryl 0, after Nava et al..
The external partial myotomies. This is a technical detail introduced by the first Author Riggio, and specifically used in the new one-stage dual-plane IBR for those cases where the central strain strength of the pectoralis maior muscle is higher than usual. The muscle scoring must be carried out after the closure of the device pocket and after estimating the grade of compression produced by the muscle force against the implant. By this way two effects come out: 1) reducing the tension along the suture line of the device pocket, 2) decompressing the lower pole of the high-cohesive implant and improving the immediate profile of the lower breast. The correct placement, length, and direction of the partial sections are illustrated in the following Fig.21 and 22. The scores includes fascia and superficial fibers of the pectoralis maior muscle, close to the central part of the coverage.
One or two lines of incision are drawn with blue 4 cm far from the suture of the pocket, in this figure visible near the lateral skin border. They are parallel to the suture line but usually crossing the oblique orientation of the muscle fibers.
The internal lateral myotomies. Similar incisions (one-two scores) can be carried out along the inner surface of the harvested serratus anterior muscle, that means inside the pocket laterally, before the implant insertion. The scoring must be vertical and is useful to release and lengthen the inferior-lateral pocket much better. They can be partial or total depending on the stiffness more than the thickness of the serratus fibers.
Scoring the fascia and the most superficial fibers of the mid-lower portion of the pectoralis maior muscle corresponding to the central part of the dual-plane pocket. This fine procedure was named by Riggio as external partial myotomy for the tension discharge.
The dual-plane technique can be indicated for a selected group of patients, the others follow different guidelines for reconstruction (Fig.23, 24).
Here are the cases of two sisters affected by BRCA2, 35-year-old and 37-year-old respectively, with similar breast but different cancer history, pre-op views. The first underwent bilateral risk-reducing without sparing the nipple bilaterally, no prior cancer (left column). In the meantime, also the second sister underwent risk-reducing mastectomy but the prior conservative cancer treatment (quadrantectomy + radiation therapy + chemotherapy) changed the reconstructive perspectives in the left breast (right column).
The same two patients, post-op views. The first sister received one-stage IBR with full-height/full-projection implants, Allergan Natrelle 410FF 375g, result after five months (left column). The second received IBR with expander insertion on the right whilst the left reconstruction was posposed because of previous radiotherapy and the refusal for DIEP flap (right column); she preferred to be treated with serial lipofilling and then expander. Pocket preparation and following outcome are different if used the dual-plane composite pocket for stable implant instead of a standard submuscular pocket for saline expander. Expander in the right breast inflated about 400cc, after the first lipofilling in the left side, nine months after mastectomy.
The presence of the following features bring together to perform a safe IBR with the technique described in the chapter: a) low to medium size; b) absent to poor ptosis; c) intra-operative careful respect for the deep fascia along the lateral borders of pectoralis maior and serratus anterior muscles; d) intra-operative preservation of the submammary fascial system Both risk-reducing and oncological sparing mastectomies can be equally reconstructed with the technique. Nipple-sparing and/or bilateral mastectomies can achieve better results (Fig.25). As well the unilateral mastectomy combined to contralateral augmentation. More than the 30% of IBR involves either immediate (Fig.26) or delayed augmentation of the healthy breast (Fig.27).
A 38-year-old patient with small breast, no ptosis, affectd by right breast cancer in BRCA1. Right nipple-sparing total mastectomy + left risk-reducing bilateral mastectomy and one-stage IBR with Allergan Natrelle implants 410FX 495g. The breast was largely augmentated. Preop (line 1), post-op views after 3.5 months (line 2), post-op views after 8 months (line 3), post-op views after 3 years and 9 months (line 4). The Baker’s grade of capsular contracture was consistently 2 in both sides.
A 37-year-old patient with right breast cancer. Nipple-sparing mastectomy and one-stage IBR with Allergan Natrelle 410MX 290g + breast submuscular augmentation with 410MF 195g. Pre-op and post-op views after 7 months.
A 49-year-old patient with leftt breast cancer. Nipple-sparing mastectomy and one-stage IBR with Allergan Natrelle full-height/full projection 410FX 315g. The contralateral augmentation was postponed because contemporary correction of the healthy breast in presence of both moderate ptosis and lower constricted pole was evaluated to have few chances of achieving symmetrization safely in a single stage.
Although some surgeon disagrees, no tension spreads on the skin cover using the dual-plane technique. Fast reaching of the definite volume and related major pressure of the device top do not represent a distinct risk for skin necrosis. The technique was safely used in moderate smokers. This is possible because the device volume discharges pressure along the muscular cover at the first moment and, only after some weeks, the muscle is stretching. However skin cover is never tightened by the cohesive implant because skin surface after mastectomy is generally loose and larger than the parenchyma volume, especially in the lower half. Therefore the mammary skin could envelop a bigger prosthesis with poor tension. The largest implant was of 580g. Immediate increase of the previous breast size carry advantages as the overfilling of the breast boundaries, reduction of skin folding, and minor areola-nipple displacement because better stabilizes its position. The volume correction of minor differences were deliberately postponed after complete healing, i.e. at least six months later, and concerned 10% as minimal. The choice for a delayed operation of the healthy breast was prudently dictated by the most predictable evaluation of breast symmetry and shape. This became mandatory if the contralateral breast had need for some mastopexy with augmentation or alone.
In spite of tremendous advances in contemporary anaesthetic practice, advances in airway management continue to be of paramount importance to anaesthesiologists. Till some time ago, the cuffed tracheal tube was considered as the gold standard for providing a safe glottic seal [1]. The disadvantages of tracheal intubation, which involves rigid laryngoscopy, are the concomitant hemodynamic responses and damage to the oropharyngeal structures. Postoperative airway morbidity is also a serious concern. This precluded the global utility of the tracheal tube and there was a perceived need for better alternatives [2].
Dr. Archie Brain, a British anaesthesiologist, introduced the laryngeal mask airway (LMA) in 1983 for the first time, designed to be positioned around the laryngeal inlet. LMA is a supraglottic airway (SGA) device with an inflatable cuff forming a low-pressure seal around the laryngeal inlet and permitting ventilation.
Supraglottic Airways (SGAs) have revolutionised the airway management [3]. Besides serving as a rescue device in the difficult airway, and as a conduit for the endotracheal tube insertion, SGAs provide a less invasive and less traumatic means of securing the airway in surgical patients [4, 5].
Careful observations and clinical experience have led to several modifications of the LMA leading to development of newer supraglottic airway devices with better features for airway maintenance [3]. Over a period of time, new airway devices have been added to the anaesthesiologist‘s armamentarium to address specific needs. A wide variety of airway devices are available today which are employed to protect the airway in both elective as well as emergency situations [6].
In 2001, Dr. Archie Brain came up with a modification of the LMA. This device was called the Proseal-Laryngeal mask airway™ (Teleflex®, USA) [7]. This double lumen, double cuff LMA has some clear advantages over its predecessor. The double tube design separated the respiratory and alimentary tracts, providing a safe escape channel for the regurgitated fluids.
Since then, several devices that are able to accommodate nasogastric tubes have been invented. Newer features like better sealing pressures, reduced risk of pulmonary aspiration by stomach contents, single use devices, integrated bite blocks, and the ability to act as conduits for endotracheal tube (ETT) placement have rendered these devices more reliable for routine use. The last decade has seen a rapid rise in the number of clinical studies evaluating these second-generation SGAs.
LMAs are especially useful when mask fit is difficult as in edentulous or bearded patients. It also frees the hands of the anaesthesia care giver.
The LMA may be used in the spontaneously breathing patient with adequate sedation and topical anaesthesia, or the paralysed, anaesthetised patient with assisted mechanical ventilation.
The indications for use of the supraglottic airway devices are expanding. Their routine use in laparoscopic surgeries has almost replaced the endotracheal tubes. Second generation SGAs have proved to provide adequate sealing pressure required to provide adequate ventilation and maintain airway safety [8]. Also, pharyngolaryngeal morbidity (sore throat, dysphagia, dysphonia) are less as compared to endotracheal tube [9, 10].
In today’s era, the number of obese patients undergoing surgeries is increasing. Intubation is known to be more difficult in obese patients [11, 12]. Closed claims analysis shows that obesity, difficult intubation and intubation by inexperienced personnel are risk factors for severe airway injuries and pharyngo-oesophageal perforation [13].
In such cases, SGAs after successful placement can provide better postoperative pulmonary performance if used in very well selected patients. Hence, SGAs may be a simple alternative to intubation in short-term elective surgery in obese patients, as suggested by some randomised controlled trials (RCTs) [14]. These maybe used as conduits for tracheal intubation in obese patients with failed laryngoscopy and expected/unexpected difficult airways [15].
Maternal morbidity from failed intubation and aspiration remains the biggest concern with general anaesthesia. SGAs can be lifesaving in caesarean deliveries where scenarios of cannot ventilate and cannot intubate is faced. Second generation SGAs have become the gadget of choice in such scenarios [16, 17, 18].
Being user-friendly, SGAs are now more commonly used in children. They obviate the use of ETTs and avoid many complications associated with endotracheal intubation [19, 20]. The LMA Classic™ and the LMA Proseal™ have established their safety and efficacy for routine as well as in emergency cases in paediatric patients [21, 22, 23, 24, 25]. The presence of a drain tube, which helps to empty the stomach in the Second-generation SGAs, has removed the fear of distension of the stomach with gas during controlled or spontaneous ventilation, leading to impairment of respiration, especially in a smaller child.
Surgery performed in the prone position require significant OT time and necessitate additional manpower for proper positioning of the patient. Induction and device placement in the prone position avoids the displacement of OT personnel from other tasks as significantly less number of people is required in shifting the patient. Anaesthetic induction of the patient and SGA insertion can be done in prone position, unlike endotracheal intubation. A large cohort study included 1000 patients undergoing surgery under general anaesthesia in prone position where SGAs were safely used to secure the airway [26].
SGAs can be used as a conduit for blind and fiberoptic-guided intubation for rescue of failed direct laryngoscopy or failed intubation [27, 28, 29]. After inserting the LMA, a well lubricated ETT with deflated cuff is passed over the fiberscope. The fiberscope is then advanced through the LMA. The ETT is advanced around 1.5 cm past the mask aperture. The tip of the ETT lifts the fiberscope away from the bowl of the mask and exposes the glottis. The fiberoptic scope is then advanced up to the distal end of the tracheal tube. The ETT is advanced until the glottis is brought into view and then further advanced into the trachea.
A specific advantage of using an SGA is the ability to continue ventilating and anaesthetising the patient through the SGA until formal tracheal intubation is achieved. The Aintree catheter, a modification of the Cook’s airway exchanger may be used to intubate through the SGA. It is loaded over a fiberoptic bronchoscope (FOB) and the trachea is visualised through the SGA [30, 31]. Leaving the Aintree catheter in place, the SGA is then removed. The ETT is then loaded over the catheter and advanced into the trachea.
The difficult airway algorithm made by the American Society of Anesthesiologists (ASA) has a prominent place for the use of SGAs in airway rescue [32]. The Difficult Airway Society (DAS) 2015 guidelines suggests the use of SGAs as first line rescue airway for management of a failed intubation [33]. Several case reports support the use of SGAs for supporting ventilation in difficult airways with failed intubation [34, 35, 36, 37]. SGAs also aid successful tracheal intubation in situations in which conventional methods have failed.
Flexible bronchoscopies comprise the major airway procedures performed including bronchoalveolar lavage, transbronchial biopsies, and foreign body removal [38]. LMA use during paediatric bronchscopies is associated with ease of insertion during general anaesthesia with spontaneous or assisted ventilation, as well as a net decrease in procedure time.
Certain patients who cannot tolerate the procedure with conscious sedation (i.e., excessive gag response or discomfort) may require general anaesthesia. An LMA is an ideal device in such a scenario.
Percutaneous tracheostomies are increasingly performed in the critical care setting. It is indicated in patients who are ventilator dependent due to acute illnesses, or if duration of ETT use is expected to exceed 2 weeks [39]. Cattano et al. conducted a study on patients undergoing percutaneous tracheostomy using dilating forceps approach where ETT was replaced by an SGA [40]. They concluded that intubation through SGAs offered a superior view of the trachea without the risk of the bronchoscope or the ETT getting needle punctured.
Since SGAs cause less cough and rise in intracranial or intraocular pressures compared to the ETT, they may be used for smooth emergence from anaesthesia. The device may be placed after removal of the ETT. This is helpful in situations in which airway and hemodynamic reflexes are undesirable.
In the field, securing an airway is of paramount importance. SGAs are lifesaving in the “can’t ventilate, can’t intubate” situation. An SGA can be used for transport until a definitive airway can be obtained [41]. The placement of an SGA is easily mastered by the inexperienced hands with minimal training.
During cardio pulmonary resuscitation (CPR), the first part of the secondary survey includes securing an airway device as soon as possible [42]. SGA use during CPR has increased since SGA insertion is easier to learn than tracheal intubation and feasible with fewer and shorter interruptions in chest compression [43]. Use of SGAs during CPR is associated with a lower incidence of regurgitation of gastric contents than bag-mask ventilation [44].
Patients with risk of gastric aspiration (non-fasted, Gastro Oesophageal Reflux Disease, hiatus hernia)
Patients with airway morbidities (Respiratory tract infections, COPD etc.)
Restricted mouth opening (< 2.5 cm)
Distorted airway anatomy and airway obstruction
Prolonged duration of surgery (>2 hrs)
Surgery involving the upper airway
Maxillo facial trauma
Morbidly obese patients
Regurgitation and aspiration
Misplacement of mask and airway obstruction
Malposition or dislodgement of LMA
Upper airway trauma
Inadequate sealing of airway and leaks
Cough and laryngospasm
Gastric insufflation
Vocal cord palsy and nerve injuries (Lingual nerve, Recurrent Laryngeal Nerve, Hypoglossal Nerve, Glossopharyngeal Nerve)
All LMAs consist of four parts, a hollow tube (shaft) continuous with a hollow mask or cuff, inflation line with pilot balloon and drain (gastric access) tube. The broad elliptical inflatable cuff has a smooth upper surface that prevents pharyngeal secretions from entering the airway and an under surface that sits over the larynx to create a seal.
The patient’s neck is flexed and head is extended (sniffing position) (Figure 1). The LMA is partially deflated and the backside of the LMA is lubricated. The shaft is grasped with the dominant hand like a pen, as near to the mask as possible. The deflated flattened mask is inserted against the hard palate downward into the mouth along the curvature of the back of the pharynx. The index finger follows the tube into the mouth to keep pressing “back” and “down” until the aperture faces the laryngeal inlet. If at any time during insertion the mask fails to stay flattened or starts to fold back, it should be withdrawn and reinserted. Another technique is to allow the dominant hand to guide the shaft and use the nondominant hand to push the tube with or without an introducer [45, 46, 47].
Technique of LMA insertion. (a) The deflated and lubricated LMA is held by the index finger and thumb of right hand. (b) The left hand stabilizes the occiput. LMA is inserted in the mouth pressed against the hard palate. (c) Using the index finger, it is advanced behind the tongue. (d) It is further pushed into the hypopharynx with the index finger. (e) After removing the index figure, the airway tube of the LMA is pushed further inside with the left hand till a resistance is felt.
Proper placement of the airway is prudent. Cuff should be inflated to achieve adequate tidal volumes with minimal leaks. The cuff inflation pressure should never exceed 60 mm Hg. Higher Cuff pressures may lead to increased pharyngeal mucosal pressures which may lead to mucosal ischemia and airway morbidities [48].
Marjot showed that intracuff pressure increased as cuff volume increases [49]. The pressure exerted on the pharynx by the SGA is usually higher than that of mucosal capillary perfusion pressure when the cuff is inflated with the recommended maximum volume of air.
However, if the cuff is deflated excessively, it may not protect the airway from soiling, due to the regurgitated fluid from the stomach [50]. Therefore. it is desirable to inflate the cuff of the SGA with minimum volume of air which provides a seal around the mask.
In case of malpositioning of the mask, it may have to be replaced or other manoeuvres may have to be tried. A partially or fully inflated SGA cuff may ease insertion [8, 9, 10]. Wakeling et al. claim that inserting an SGA with a fully inflated cuff causes less mucosal trauma and leads to fewer airway morbidities. If an assistant is available, he can apply a jaw thrust manoeuvre which moves the tongue forward and prevents compression of the epiglottis [14]. In case of a single operator, a tongue depressor or a laryngoscope may be used to assist insertion of the LMA [15].
Weight-based selection as per the manufacturer’s guideline is done. If unsure, check the package cover for size information. More than one size should always be available, because the correct size cannot always be predicted. Weight-based selection has given way to sex-based selection, especially in adults. The consensus seems to be that the correct size would be a size 4 for most adult women and a size 5 for most adult men [51, 52, 53, 54, 55, 56, 57]. Whatever the initial size selected, if malposition or an inadequate seal is present, a larger size LMA should be considered. Alternative formulas based on weight have been proposed [58, 59]. For children, the width of the second to fourth fingers can be matched to the widest part of the mask [60]. If repeated attempts with one type of LMA are unsuccessful, changing to another type may help.
Wait for full recovery from anaesthesia. Do not try to pull out the SGA if the patient is biting down on the shaft. Usually, patients emerge smoothly with SGAs.
It is recommended to use a bite block with the LMA in order to prevent damage to the airway tube or pilot balloon during emergence. Manufacturers usually recommend using a wad of gauze swabs rolled into a cylindrical shape and placed along the LMA. Some anaesthesiologists prefer to place the Guedel’s airway. The LMA should never be removed if patient is in a light plane of anaesthesia as it may precipitate a laryngospasm.
SGAs have been conventionally classified based on the following characteristics by Miller [61].:
Whether it is inflatable or anatomically pre-shaped
Where in the hypopharynx it provides a seal
Whether or not the sealing effect is directional and
Whether or not oesophageal sealing occurs
In recent years, devices with oesophageal sealing (Second Generation SGAs) have gained popularity due to presence of a gastric port which allows drainage of stomach contents and reduces the incidence of regurgitation and aspiration pneumonitis.
Modern classification of SGAs is given in Table 1.
The airway sealing pressure or the oropharyngeal leak pressure (OLP) is the pressure at which gas leak occurs around the device. It indicates the degree of airway protection. After the successful placement of airway device, OLP can be determined by turning off the ventilator and closing the adjustable pressure limiting valve of the circuit. A fixed gas flow of 3 L/min is started and the pressure allowed to rise.
There are various methods of assessment of OLP [62].:
Audible noise over the patient’s mouth
Auscultation just lateral to the thyroid cartilage for an audible noise
Manometer stability test- The fresh gas flow is set at 3 l/minute of oxygen and the adjustable pressure limiting valve of the circle system is closed. As the pressure from the breathing system increases, the aneroid manometer dial is observed to note airway pressure at which the dial attains stability and no further rise in pressure is seen. A maximum pressure of 40 cm H2O is allowed.
Correct placement of the LMA can be checked by a simple test. A soap bubble solution is placed over the tip of the drain tube. If the tip of the LMA is in the laryngopharynx, bubbling or bursting of soap solution column will occur during positive pressure ventilation.
The original Laryngeal Mask Airway (cLMA, Intavent Direct, Maidenhead, UK) was the first SGAs introduced into clinical practice. It was invented by Dr. Archie Brain in the United Kingdom 1981 and was introduced into clinical practice in 1988.
In 1992 a task force was commissioned by the ASA to establish practice guidelines for management of difficult airway scenarios. In 1993, the ASA published the algorithm for difficult airways. They stressed on an early attempt at LMA insertion in case of inadequate face mask ventilation. cLMA has revolutionised anaesthetic practice ever since [63].
The cLMA consists of the following parts (Figure 2):
Curved airway tube (shaft)
Pilot tube
Elliptical mask
Classic LMA.
The angle between the mask and shaft is 30°. The machine end of the shaft has a standard 15-mm adapter. Two flexible vertical bars at the junction of the shaft and mask prevent obstruction of the ventilating lumen by the epiglottis (Figure 3). Reusable devices are constructed of medical grade silicone designed to provide an oval seal around the laryngeal inlet and act as a sleeve joint at the upper oesophagus. The single use devices have a cuff constructed of polyvinyl-chloride.
Classic LMA in-situ.
The classic laryngeal mask is available in eight sizes, as shown in Table 2.
Oesophageal sealing | Pharyngeal sealer | Perilaryngeal sealers |
---|---|---|
None (1st generation) | VBM Laryngeal Tube (VBM, Germany) | LMA Classic (Teleflex, USA) |
Cobra PLA (Pulmodyne, USA) | LMA Unique (Teleflex, USA) | |
LMA Flexible (Teleflex, USA) | ||
AuraOnce LMA (Ambu, Denmark) | ||
Aura-i LMA (Ambu, Denmark) | ||
Air-Q ILA (Mercury Medical, USA) | ||
Gastric channel (2nd generation) | Combitube (Covidien-Nellcor USA) | LMA ProSeal (Teleflex, USA) |
Rusch Easy Tube (Teleflex, USA) | LMA Supreme (Teleflex, USA) | |
VBM LTS II (VBM, Germany) | LMA Guardian (Teleflex, USA) | |
King LTS-D (Ambu, Denmark) | LMA Protector (Teleflex, USA) | |
AuraGain LMA (Ambu, Denmark) | ||
i-gel (Intersurgical, UK) | ||
Gastric channel + self-energising mechanism of seal | Baska mask (Baska Versatile Laryngeal Mask Pvt. Ltd., Australia) |
Classification of supraglottic airways.
LMA: laryngeal mask airway, ILA: intubating laryngeal airway, LTS: Laryngeal Tube Suction, LTS-D: Laryngeal Tube Suction disposable, PLA: perilaryngeal airway.
Mask size | Patient weight | Maximum cuff volume of air (ml) |
---|---|---|
1 | Neonates/infants up to 5 kg | 4 |
1.5 | Infants 5–10 kg | 7 |
2 | Infants/children 10–20 kg | 10 |
2.5 | Children 20–30 kg | 14 |
3 | Children 30–50 kg | 20 |
4 | Adults 50–70 kg | 30 |
5 | Adults 70–100 kg | 40 |
6 | Large adults over 100 kg | 50 |
Available classic LMAs.
Although the cLMA is used in a large number of cases requiring airway management, it has some limitations
It has a moderate pharyngeal seal (∼20 cm H2O)
It may be associated with pulmonary aspiration of regurgitated fluid
First generation SGAs have only a single lumen for ventilation. There is risk of regurgitation of gastric contents and aspiration with positive pressure ventilation. To combat this risk, a separate channel was incorporated into this design to allow for gastric drainage and provide better seal. Several modifications of the Classic LMA were done and lead to the invention of second-generation SGAs.
A second-generation SGA is one with design features (higher oropharyngeal seal pressures and oesophageal drain tubes) specifically intended to reduce the risk of aspiration [33].
The Proseal LMA™ (Teleflex®, USA) designed by Dr. Archie Brain, is based on the cLMA. It was introduced in the year 2001. In comparison to the cLMA, it has a larger and deeper bowl without aperture bars, second drainage tube placed lateral to the airway tube that ends at the tip of the mask, posterior extension of the mask cuff, integral silicone bite block, and an anterior pocket for seating an introducer or finger during insertion.
The pLMA has four main components (Figure 4):
Mask
Inflation line with pilot balloon.
Airway tube
Drain tube.
Parts of Proseal LMA.
The mask conforms to the contours of the hypopharynx. The mask has a main cuff that seals around the glottic aperture. The rear cuff pushes the mask anteriorly which helps to increase the seal. A pilot balloon with valve is used to inflate or deflate the device.
A drain tube (DT) passes parallel and lateral to the airway tube. It continues to enter the cuff bowl and terminates at the mask tip. Cuff tip lies at the origin of the upper oesophageal sphincter if device is positioned correctly. The wire reinforced airway tube prevents collapse and terminates with a standard 15 mm connector [7]. The pLMA can also be used for FOB guided intubation.
Sizes 3 to 5 were introduced in 2000 and sizes 1½-2½ in 2004. Sizes 1½-2½ have no dorsal cuff. Device properties and recommendations for use are given in Table 3. The pLMA is reusable and recommended product life is 40 sterilisations. Not all protein material can be removed by routine cleaning of laryngeal masks and this raises theoretical concerns over cross-infection risk, hence steam autoclaving is the recommended method of sterilising this device.
Mask size | Patient weight | Maximum cuff volume of air (ml) | Gastric tube size (French) | Largest ETT ID (mm) |
---|---|---|---|---|
1 | Neonates/infants up to 5 kg | 4 | 8 | 3.5 |
1.5 | Infants 5–10 kg | 7 | 10 | 4 |
2 | Infants/children 10–20 kg | 10 | 10 | 4.5 |
2.5 | Children 20–30 kg | 14 | 14 | 5 |
3 | Children 30–50 kg | 20 | 16 | 6 |
4 | Adults 50–70 kg | 30 | 16 | 6 |
5 | Adults 70–100 kg | 40 | 18 | 7 |
Available Proseal LMAs.
The pLMA is accompanied by a cuff deflator (Figure 5) and insertion tool (Figures 6 and 7). The cuff deflator assists complete deflation and flattening the device tip before insertion to improve insertion success.
PLMA cuff deflator.
pLMA with insertion tool.
Insertion tool.
LMA Supreme™(Teleflex®, USA) is a second generation, single use, SGA device which facilitate ease of placement and in-situ airway stability. It forms an effective seal first with the oropharynx (oropharyngeal seal) and a second seal with the upper oesophageal sphincter (the oesophageal seal). This devise is designed incorporating features of a cLMA, pLMA, and LMA Fastrach [64, 65, 66]. SLMA delivers measured oropharyngeal leak pressures up to 37 cm H2 O [67].
The SLMA has following components (Figure 8):
Modified cuff
Elliptical airway tube
Drain tube
Integrated bite block
Inflation line with pilot balloon
Fixation tab
Parts of LMA supreme.
The device is preformed and anatomically shaped. The stiffness of SLMA is intended to guide the airway into the correct position during insertion (Figure 9). This also eliminates the need for placing the clinician’s fingers into the patient’s mouth. Also, rotational mal-positioning of the airway becomes unlikely owing to this feature. The integrated bite block reduces the potential for damage to, or obstruction of the airway tube in the event of biting. The airway also has a fixation tab designed to facilitate easy fixation and improve drain tube position. These improvisations render it suited for inexperienced users in an emergency situation.
LMA supreme in-situ.
Primarily, the SLMA has been recommended for securing airway in routine and emergency surgical procedures. It may also be used to secure an immediate airway when tracheal intubation is precluded by lack of available expertise or equipment, or when attempts at tracheal intubation have failed.
There is increasing evidence that suggests that it may be used for airway rescue in emergency situations and in hostile environments, particularly when tracheal intubation may be challenging or may delay oxygenation [68, 69, 70].
Size 1 to 5 are commercially available (Table 4). A weight-based size selection is suggested by the manufacturer. The cuff is inflated with air as recommended for that specific size. The intra-cuff pressure should never exceed 60 cm H₂O. The cuff should be inflated with just enough air to achieve a seal sufficient to permit ventilation without leaks, if no manometer is available.
Mask size | Patient weight | Maximum cuff volume of air (ml) | Gastric tube size (French) |
---|---|---|---|
1 | Neonates/infants up to 5 kg | 5 | 6 |
1.5 | Infants 5–10 kg | 8 | 6 |
2 | Infants/children 10–20 kg | 12 | 10 |
2.5 | Children 20–30 kg | 20 | 10 |
3 | Children 30–50 kg | 30 | 14 |
4 | Adults 50–70 kg | 45 | 14 |
5 | Adults 70–100 kg | 45 | 14 |
Available supreme LMAs.
Some studies advocate an anatomical-related size selection method. The patient’s thyromental distance is measured by the palm side of patient’s hand. If it is four fingers wide (index, middle, ring and little fingers), they suggest size 4 SLMA; If it is three fingers wide (index, middle, ring fingers), they suggest size 3 SLMA [71].
The Guardian laryngeal mask airway™ (GLMA) (Teleflex®, USA) is a new disposable silicone SGA device. The cuff forms a seal with the glottis for ventilation, and with the hypopharynx for airway protection. The gastric drainage port helps to suction the stomach contents. Also, it has a port for suctioning material from the hypopharynx. The pilot balloon valve with pressure logo indicates visual intracuff pressure (Yellow <40 cmH2O, Green 40–60 cmH2O and Red >60 cmH2O) (Figure 10). A study suggests that it provides sealing pressures as high as 32 cm H2o [72, 73].
LMA guardian.
The LMA-Protector™ (Teleflex®, USA) is a novel SGA made of medical-grade silicone (Figure 11). In comparison to other devices made of polyvinylchloride, it is more flexible and less traumatic. Its fixed, anatomically curved shape is elliptical in cross section and aids easier insertion. It has two separate drain channels. At the machine end, they begin as the male and female suction ports. The channels then enter a chamber behind the cuff bowl. At the patient end, the chamber ends at the tip of the cuff. The device is flexible and stays in place if the patient’s head is mobilised. A built-in bite block reduces the potential for damage to, or obstruction of the airway tube in the event of biting. Additionally, the LMA-Protector™ is available with a pilot balloon or the integrated Cuff Pilot™. The Cuff Pilot™ enables constant visualisation of intracuff pressure inside the mask cuff that provides easier adjustment and is colour coded for inflation pressure [74].
LMA protector cuff pilot.
It is commercially available in size 3, 4 and 5. The manufacturer recommends using a size 4 device for normal adults. After insertion, the device is fixed in place and inflated to the recommended pressure. There should be a minimum of a 1 cm gap between the fixation tab and the patient’s upper lip. The cuff should be inflated with sufficient air to prevent a leak with positive pressure ventilation, but it must not exceed either a pressure of 60 cm H2O or the specific device cuff volume maxima. If no manometer is available, inflate with just enough air to achieve a seal sufficient to permit ventilation without leaks. It provides high first attempt and overall insertion success rate. It helps rapidly achieve effective ventilation with reliable airway seal. Additionally, it acts as a conduit for FOB guided intubation [75, 76].
The AuraGain™ (Ambu®, Denmark) is intended for use as an alternative to a face mask for achieving and maintaining control of the airway during routine and emergency anaesthetic procedures. The gastric channel of AuraGain™ may be used as a conduit for passing a gastric tube into the stomach for removal of air and gastric fluids.
It is intended for use as a conduit for an endotracheal tube in “can’t intubate – can’t ventilate” scenarios. It may also be used to establish a clear airway during resuscitation in profoundly unconscious patients with absent glossopharyngeal and laryngeal reflexes who may need artificial ventilation [77].
The parts of AuraGain are as follows (Figures 12 and 13):
Inflatable Mask
Inflation line with pilot balloon.
Airway tube with integrated bite block
Gastric channel
Ambu AuraGain.
FOB guided intubation.
The mask is designed to conform to the contours of the hypopharynx with its lumen facing the laryngeal opening. When correctly inserted, the distal tip of the cuff rests against the upper oesophageal sphincter. It is anatomically shaped with an integrated bite block.
The AuraGain™ comes in eight different sizes for use in patients of different weight (Table 5). This device is meant to be used only once. Studies suggest that AuraGain™ provides adequate sealing of the airway [78, 79, 80].
Mask size | Patient weight | Maximum cuff volume of air (ml) | Gastric tube size (French) | Largest ETT ID (mm) |
---|---|---|---|---|
1 | Neonates/infants up to 5 kg | 4 | 6 | 3.5 |
1.5 | Infants 5–10 kg | 7 | 8 | 4 |
2 | Infants/children 10–20 kg | 10 | 10 | 5 |
2.5 | Children 20–30 kg | 14 | 10 | 5.5 |
3 | Children 30–50 kg | 20 | 16 | 6.5 |
4 | Adults 50–70 kg | 30 | 16 | 7.5 |
5 | Adults 70–100 kg | 40 | 16 | 8 |
6 | Adults more than 100 kg | 50 | 16 | 8 |
Available Auragain LMAs.
The i-gel® (Intersurgical®, UK) is the innovative second generation supraglottic airway device from Intersurgical launched in 2007. Made from a medical grade thermoplastic elastomer, i-gel has been designed to create a non-inflatable, anatomical seal of the pharyngeal, laryngeal and perilaryngeal structures whilst avoiding compression trauma.
The igel has the following parts (Figure 14):
Soft non-inflatable cuff
Gastric channel
Epiglottic rest
Buccal cavity stabiliser
Airway tube
Gastric tube
Parts of i-gel.
A horizontal line (Adult sizes 3,4 and 5 only) at the middle of the integral bite-block represents the correct position of the teeth. The soft design of the i-gel is able to retain its shape to facilitate ease of insertion. In a known difficult or unexpectedly difficult intubation, for intubating the patient, by passing an ETT through the device under fibre optic guidance.
Size selection is done on a weight basis (Table 6). However, individual anatomical variations should always be considered. Patients with cylindrical necks or wide thyroid/cricoid cartilages may require a larger size i-gel than would normally be recommended on a weight basis [81, 82].
Mask size | Patient weight | Largest ETT ID (mm) | Gastric tube size (French) |
---|---|---|---|
1 | Neonates 2-5 kg | 3 | NA |
1.5 | Infants 5–12 kg | 4 | 10 |
2 | Infants/children 10–25 kg | 5 | 12 |
2.5 | Children 25–35 kg | 5 | 12 |
3 | Children, Small adult 30–60 kg | 6 | 12 |
4 | Adults 50–90 kg | 7 | 12 |
5 | Adults >90 kg | 8 | 14 |
Available i-gel LMAs.
The i-gel can be used in difficult or unanticipated difficult intubations. Owing to its ease of insertion, it can quickly establish and maintain a clear airway in a pre-hospital setting [83, 84]. In a study it was observed that hemodynamic parameters, ease of insertion and postoperative complications were comparable among the i-gel, pLMA and cLMA but airway sealing pressure was significantly higher with i-gel [85].
A modification of this device is the i-gel O2. It contains a supplementary oxygen port for passive oxygen administration. It may be utilised for cardiopulmonary resuscitation. The i-gel O2 Resus Pack is a resuscitation pack provided by the manufacturer. It contains the i-gel O2 LMA, an airway support strap to fix and secure the device in place, a suction tube (12 Fr) and a pack of lubricant. The Resus Pack is available in three adult sizes (3, 4 and 5). The presence of a colour coded hook ring on the LMA allows easy identification of the size during resuscitation.
The Combitube® (Covidien-Nellcor®, Pleaseton, USA) is a single use, double-lumen tube that combines the features of a conventional ETT with those of an oesophageal obturator airway.
The Combitube® has the following parts (Figure 15):
A large proximal balloon cuff seals the hypopharynx
A ventilating, proximal lumen terminates at side ports overlying the laryngeal inlet
A distal lumen and its smaller balloon cuff terminate in and seal the upper oesophagus (in >90% of insertions)
Combitube.
The device commonly enters the oesophagus on insertion. Ventilation is achieved through multiple proximal apertures situated above the distal cuff (Figure 16). Both the proximal and distal cuffs have to be inflated to prevent air from escaping through the oesophagus. If the tube enters the trachea, ventilation is achieved through the distal lumen.
Combitube in-situ.
Combitube® is commercially available in two sizes (Table 7). It has a major advantage over conventional ETT as it can be inserted without head and neck movement, which may be an important consideration in trauma patients [86]. Situations where ETT placement is not immediately possible, it is used for emergency airway control [87]. The Combitube® has been used effectively in cardiopulmonary resuscitation [88, 89]. It has been used successfully in difficult airway situations owing to severe facial burns, trauma, upper airway bleeding and vomiting where there was an inability to visualise the vocal cords [90, 91, 92].
Patient’s height | Combitube size |
---|---|
4 to 6 feet tall | 37 French |
5 feet and above | 41 French |
Available combitube.
The King Laryngeal Tube Suction-D™ (Ambu®, Denmark) is a disposable, double-lumen, supralaryngeal device for airway management introduced in 2005. A single pilot tube can be used to inflate both oropharyngeal and oesophageal soft silicon cuff. A ventilating outlet opens in front of the vocal cords. It is present between these cuffs. It is available in six sizes to fit patients from neonates to large adults.
Parts of the LTS-D (Figures 17 and 18):
Proximal cuff.
Distal cuff
Inflation line with pilot balloon
Ventilation holes
Drain tube
Parts of LTS-D.
LTS-D drain tube.
The Proximal cuff stabilises the device and seals the oropharynx. Distal cuff blocks entry of the oesophagus, reducing the possibility of gastric insufflation. Multiple distal ventilatory openings and bilateral ventilation eyelets facilitate air flow. The device has a curvature of 60 degrees. Sealing pressures of 30 cm H20 or more are achievable.
Size selection is done on a weight basis (Table 8). The slim profile allows easy insertion; thus, it can be considered for airway management in patients with restricted mouth opening. Since insertion is relatively easy and guarantees a clear airway in most patients on the first attempt extensive training is not necessary [93].
Size | Patient weight | Maximum cuff volume of air (ml) | Colour of Connector |
---|---|---|---|
0 | Neonates<6 kg | 15 | TRANSPARENT |
1 | Infants 6–15 kg | 40 | WHITE |
2 | Children 15–30 kg | 60 | GREEN |
3 | Small Adult 30–60 kg | 120 | YELLOW |
4 | Medium Adult50–90 kg | 130 | RED |
5 | Large Adults >90 kg | 150 | VIOLET |
Available LTS-D tubes.
It can be used during spontaneous or controlled ventilation. The LTS-D has been recommended as an emergency device to be used in cases of difficult intubation and cannot intubate, cannot ventilate situations while one is preparing to perform a surgical airway [94, 95, 96]. A modification of this device, the Intubating Laryngeal Tube Suction-D(iLTS-D™) is a novel device which may also be used as a conduit for intubation.
The Baska Mask® (Baska Versatile Laryngeal Mask Pty Ltd., Australia) has been designed by Australian anesthesists, Kanag and Meenakshi Baska. It obviates the need of an orogastric tube and replaces this with a sump and two drains. It brings together features of PLMA, SLMA, SLIPA and i-gel. The biggest advantage of Baska mask lies in the fact that cuff deflation or inflation is not required prior to insertion [97].
Parts of the Baska mask® (Figures 19 and 20):
Self-sealing variable pressure cuff
Insertion tab
Integrated bite block
Airway tube
Suction attachment
Sump area
Baska mask-anterior.
Baska mask-posterior.
It is made of medical grade silicone. It differs in several ways from the conventional LMA, including; a cuff-less self-sealing membranous bowl which inflates and deflates with each positive pressure inspiration and expiration respectively, an inbuilt “tab” that permits to increase its angulation for easy negotiation of the oropharyngeal curve during placement, a bite block. It has a dual high flow suction drainage system. The distal aperture at oesophageal end is aspirated using two vents running along the entire length of the stem. One tube is connected to high pressure suction whereas the other is left open.
Size selection is given below (Table 9). Zundert et al. in their study concluded that Baska mask® improves safety when used in both intermittent positive pressure ventilation (IPPV) and spontaneous breathing [98]. Another study found its safety profile comparable to i-gel [99].
Mask size | Patient | Colour coded connector |
---|---|---|
1 | Neonates | PURPLE |
1.5 | Infants 1–2 yrs | ORANGE |
2 | Children 2-5 yrs | DARK BLUE |
2.5 | Large child or small female | WHITE |
3 | Large female or small man | GREEN |
4 | Average adult man | YELLOW |
5 | Large man | RED |
Available Baska LMAs.
The Air-Q® Blocker™ ILA (Cookgas® LLC, Mercury Medical, USA) was introduced by Daniel Cook in 2005. It is a disposable, anatomically shaped device ideal for use in pre-hospital and critical care settings.
Parts of the Air-Q® Blocker™ ILA (Figure 21):
Inflatable cuff with elevation ramp
Built up mask heel
Airway tube
Integrated bite block
Blocker Channel
Thethered Colour Coded connector
Air-Q blocker.
The Air-Q® Blocker™ airway outlet is keyhole-shaped. The anatomical shape facilitates ease of insertion. The soft blocker channel accepts naso-gastric tube to suction stomach contents. Alternatively, a blocker tube may be inserted through the blocker channel and helps to suction the pharynx or suction and block the upper oesophagus. The tethered colour coded connector avoids misplacements. In a known difficult or unexpectedly difficult intubation, it may be used as a conduit for intubation. The elevation ramp directs ETT midline and upward toward the laryngeal inlet. The Air-Q Removal Stylet helps easily remove the Air-Q® Blocker™ after intubation without ETT dislodgement.
Size selection is done on a weight basis (Table 10). It is available in three sizes. Device placement is easy and offers less resistance. The major advantage of the device design is that conventional PVC endotracheal tube can be passed through it without the use of conventional laryngoscope. It is useful in delivery of anaesthesia, resuscitation, critical care and difficult airway management in and out of hospital. It has a self-pressurising cuff which inflates to adequate pressure during positive pressure ventilation. This prevents airway trauma and morbidity associated with excessive cuff inflation [100].
Mask size | Patient ideal body weight(kg) | Internal cuff volume (ml) | Cuff inflation volume (ml) | Largest ETT ID (mm) |
---|---|---|---|---|
2.5 | 30–50 | 12 | 2–3 | 6.5 |
3.5 | 50–70 | 18 | 3–4 | 7.5 |
4.5 | 70–100 | 25 | 4–5 | 8.5 |
Available air-Q blocker LMAs.
The LMA® Gastro™ Airway with Cuff Pilot™ Technology (Teleflex®, USA) is the first SGA designed to enable active management of the airway while facilitating direct endoscopic access via the integrated endoscope channel. It is a soft, disposable, anatomically shaped device made up of silicone.
Parts of the LMA® Gastro™ Airway (Figure 22):
Inflatable cuff
Gastric drain tube or Endoscope channel
Silicone airway tube
Integrated bite block
Adjustable holder and strap
Cuff pilot
Gastro LMA.
Being anatomically shaped, it conforms to the patients’s airway creating a better seal. Cuff Pilot™ Technology prevents cuff over inflation and reduces airway morbidity. The gastric channel provides as a conduit for passage of gastro-duodenoscope.
Size selection is done on a weight basis (Table 11). It is available in three sizes. Moderate to deep sedation if often required for endoscopic procedures. This can lead to hypoxemia and warrants the need of rescue airway. LMA® Gastro™ can be successfully employed as a primary airway technique for such procedures [101].
Mask size | Patient weight (kg) | Maximum intracuff pressure (cm H2O) | Maximum endoscope size (mm) |
---|---|---|---|
3 | 30–50 | 60 | 14 |
4 | 50–70 | 60 | 14 |
5 | 70–100 | 60 | 14 |
Available gastro LMAs.
The first clinically useful SGA was introduced more than 3 decades ago.
The clinical utility of various SGAs has significantly increased over this period. Different designs have specific advantages in different clinical scenarios. Insertion is easy to learn, and with adequate training nonphysicians are capable of securing an airway.
The use of SGAs for expanded indications has been described in many ways. The expanded spectrum of indications including airway instrumentation, surgeries in prone position, paediatric age group and use in critical care settings. The position of SGAs for rescue airway management is prominent in guidelines issued by various authorities. SGAs continue to be an important mode of rescue ventilation in patients in “can’t ventilate can’t intubate” scenarios. The ability to aspirate gastric contents renders them a safe alternative to the conventional ETTs. The ability to act as a conduit for intubation in elective and emergency patients is a valuable rescue technique.
Knowledge about the indications and contraindications of using an SGA is prudent for its appropriate use. SGAs with enough documented evidence of safety and efficacy should be used. Increasing recognition of an SGA’s applications should expand its role in airway management for the anesthesiologist.
The author declares no conflict of interest.
SGA | Supraglottic Airway |
LMA | Laryngeal Mask Airway |
ETT | Endotracheal Tube |
OT | Operation Theatre |
FOB | Fibreoptic Bronchoscopy |
CPR | Cardiopulmonary Resuscitation |
ID | Internal Diameter |
mmHg | millimetres of mercury |
L | Litre |
Min | Minute |
mm | millimetre |
cmH2O | centimetre of water |
Kg | kilogramme |
ml | millilitre |
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\n\nAll scientific Works are subject to Peer Review prior to publishing.
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\n\nThe Open Access publishing model followed by IntechOpen eliminates subscription charges and pay-per-view fees, thus enabling readers to access research at no cost to themselves. In order to sustain these operations, and keep our publications freely accessible, we levy an Open Access Publishing Fee on all manuscripts accepted for publication to help cover the costs of editorial work and the production of books.
\n\n\n\nDigital Archiving Policy
\n\nIntechOpen is dedicated to ensuring the long-term preservation and availability of the scholarly research it publishes.
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