In 1983, the Classic Laryngeal Mask Airway (CLMA) marked the introduction of Supraglottic Airway Devices (SADs) to the field of anesthesiology [1]. It has been shown that their usage in laparoscopic surgery (LS) is feasible even if it is not standard [2]. As a result of the introduction of second-generation SADs, which have an esophageal vent, aspiration risk has decreased and airway sealing has improved [3]. The usefulness of SADs with drain tubes for securing airways during laparoscopic procedures has been demonstrated in studies by Lu et al. [4]. This study is to examine the literature about the application of SADs in laparoscopic surgery, with a particular emphasis on the Baska LMA, LMA-Supreme, Intersurgical i-gel, and Proseal Laryngeal Mask Airway (PLMA).

 During laparoscopic surgery, it is essential to use a ventilatory approach that ensures adequate oxygenation and ventilation, especially in cases when there is increased airway pressure, resistance, and poor airway compliance. This is usually accomplished by Volume Controlled Ventilation (VCV), in which, after the formation of pneumoperitoneum, the respiratory rate is raised to increase minute ventilation by around 20%. Another method is Pressure Controlled Ventilation (PCV), which has advantages including lower peak airway pressures, faster tidal volume attainment, and higher flow rates.

It is essential to maintain the peak inspiratory pressure of a supraglottic airway device (SAD) below the oropharyngeal leak pressure. Research, like that conducted by Jeon et al., has demonstrated that PCV causes patients having laparoscopic gynecological operations using a ProSeal LMA (PLMA) to have lower peak airway pressures and PaCO2 values. Similarly, obese patients having gastric banding with a PLMA was able to obtain appropriate gas exchange with PCV at an I ratio of 1:1 by Carron et al [5,6] without experiencing hemodynamic instability.

Reduced exposure to anesthetic gases, cheaper expenses, and the preservation of heat and humidity are all linked to low fresh gas flow (FGF) rates. During laparoscopic surgery, both minimal flow (FGF <0.5 l/min) and low flow (FGF < 1 l/min) have been utilized successfully with controlled breathing in properly positioned LMAs; nevertheless, using a SAD may result in higher gas loss than using an endotracheal tube. An essential metric is the Leak Fraction (LF), which is calculated as a percentage by dividing the inspired tidal volume by the variation in tidal volumes between inspired and expired. Generally speaking, an LF of more than 15% is substantial, and numerous studies have documented LF employing SADs during laparoscopic surgery.

A comprehensive search was conducted across various search engines, including PubMed, Medline, Google Scholar, the World Health Organization website, and government websites, to find all relevant resources on the subject from the year 2005-2024. Pertinent policy papers, technical publication series, case-control studies, cohort studies, systemic reviews, and meta-analyses. There were 60 studies found in all. The lack of a full version of the article led to the exclusion of nineteen studies. 41 publications in total were chosen and examined depending on how well they met the goals of the current review. The search was conducted using the following keywords: Laparoscopy, Proseal, Igel, Baska, and LMA supreme.

Ease of Insertion

Supraglottic airway devices (SADs) can be installed in a few different ways, including the conventional finger-guided method, the introducer-guided approach, and the gastric tube-guided technique. The bougie-guided operation for Pro Seal LMA (PLMA) has shown the highest success rate when compared to alternative insertion procedures, with 100% success [7]. All four SAD devices were successfully inserted after three tries [8,9].

How easy and successful an SAD installation is depends on several factors, including as the cuff's size and design, the insertion technique, and the criteria selected to determine the insertion time. Among other things, the device needs to be implanted, linked to the breathing circuit, have enough ventilation, or have a proper capnograph reading.

The OLP varies depending on how it is measured. Nonetheless, it has been demonstrated that there is a correlation between the four approaches—auctatory or capnographic leak detection, manometric stabilization, and auscultatory procedure [10]. With a cuff inflation pressure of 60 cm H2O, the OLP in all three devices—PLMA, SLMA, and i-gel—is comparable and ranges from 25 to 30 cm H2O, while for Baska LMA, it is closer to 30 to 40 cm H2O[9,11, 38]. Other experiments have also demonstrated higher sealing pressures with Baska masks over PLMA.

The alimentary and respiratory tracts are kept apart by a drain tube found in supraglottic airway devices (SADs) of the second and third generations. The simplicity of inserting a gastric tube is influenced by the size and location of this drain tube. In comparison to the i-gel, the ProSeal LMA (PLMA) and Supreme LMA (SLMA) both include wider bore drain tubes, which provide a more effective esophageal seal and are therefore supposedly better at preventing aspiration. The i-gel's drain tube is narrower, but because the esophagus and drain tube are directly aligned, the manufacturer claims that this still results in an adequate esophageal closure. In actuality, the SLMA and i-gel make it easier to place stomach tubes than the PLMA does, even if the success rates for insertion are comparable for all three devices [12, 13].

By providing a continuous conduit for the diversion of stomach contents away from the airway and lowering the danger of aspiration, the Baska LMA's unique integrated drain tube improves patient safety. This drain tube is positioned to successfully divide the alimentary and respiratory systems, making it simpler to empty the stomach and secretions. These design features enhance the safety and efficacy of the Baska LMA in airway management during anesthesia, especially when paired with the self-sealing cuff that modifies during positive pressurebreathing [11].

Establishing pneumoperitoneum and properly situating the patient is essential for optimizing intra-abdominal visualization and surgical access during laparoscopic procedures. When a patient has normal respiratory compliance and airway pressure (Paw < 20 cm H?O), utilizing a laryngeal mask airway (LMA) has been shown to be safe [14]. However, in the course of laparoscopic surgery, these factors change. For pelvic surgeries, the reverse Trendelenburg position is frequently employed, however, it can worsen cardiovascular symptoms, whereas the Trendelenburg (head-down) position usually presents more breathing difficulties. Increased airway pressures (Paw and Pmean), decreased functional residual capacity (FRC), ventilation-perfusion mismatch, lower thoracic-pulmonary compliance (30–50%), and intraoperative basal atelectasis due to diaphragm elevation are all consequences of pneumoperitoneum and placement. [15-20]

Several factors influence how well supraglottic airway devices (SADs) protect airways. Studies reveal that whereas SADs can lower the tone of the lower esophageal sphincter (LES), they have no discernible effect on pharyngo-esophageal reflux. During laparoscopic surgery, the increased intra-abdominal pressure (IAP) might cause reflux and raise the risk of regurgitation or pulmonary aspiration. On the other hand, some research indicates that elevated IAP might cause the LES to adapt, preserving the pressure gradient across the gastro-esophageal junction and lowering the chance of regurgitation. Furthermore, the head-down position utilized during pelvic laparoscopic procedures might aid in preventing fluids regurgitated into the airway.

ProSeal LMA (PLMA) has been shown by Evans et al. [21,22] to be a successful method for isolating the respiratory and gastrointestinal systems in patients who are paralyzed or not. Research conducted on cadavers has demonstrated that the ProSeal LMA effectively prevents aspiration and regurgitation by keeping the pharynx and larynx apart. Three pulmonary aspiration cases—none of which happened during laparoscopic surgery—were found in a retrospective investigation by Bernardini et al. [19] of 65,712 procedures performed under general anesthesia with positive pressure ventilation, including 35,360 surgeries including LMA. There may be a connection between the decreased usage of LMA in emergency procedures and the low aspiration incidence in the LMA group. However, a much larger patient sample would be required in order to correctly examine the difference in aspiration risk between endotracheal tubes (ETT) and LMA.

 Aspiration of esophageal contents has been reported in case reports involving both the PLMA and i-gel. These incidents have been linked to problems such as improper patient selection, air leaks causing stomach inflation, and device malpositioning [20, 21]. According to research by Parul et al., compared to LMA-S and Igel, the aspiration risk in Baska is significantly lower [9].

A common surgery that is carried done as an outpatient is laparoscopic cholecystectomy [22]. The pneumoperitoneum is created during this procedure, and the patient is positioned with a lateral tilt in a reverse Trendelenburg posture. When carbon dioxide is introduced for pneumoperitoneum, Peak Airway Pressure (Paw) usually increases by 5 to 7 cm H?O. However, there is no substantial difference in airway pressure between the supine and reverse Trendelenburg positions [23]

A frequent procedure performed as an outpatient is laparoscopic cholecystectomy [22]. During this technique, the pneumoperitoneum is established, and the patient is positioned in a reverse Trendelenburg posture, tilted laterally. Peak Airway Pressure (Paw) typically rises by 5 to 7 cm H2O when carbon dioxide is added for pneumoperitoneum treatment. The airway pressure in the supine and reverse Trendelenburg postures does not, however, differ much.[23]

Maltby et al. noted that gastric inflation happened even when the stomach tube was kept under constant suction for the duration of the procedure; they ascribed this observation to variations in viewing angles rather than true distension. In other research, the stomach tube has been connected to a collection bag or inserted and removed following suction, among other techniques, to control gastric inflation. In these instances, the procedure was not hampered by stomach inflation.

The traditional and gold-standard anesthetic methods for laparoscopic cholecystectomy still involve endotracheal intubation and controlled ventilation. However, after extensive experience with gynecologic laparoscopy and sterilization procedures, LMAs have been explored for use in non-obese, well-fasted patients without GERD or high aspiration risk.

 But Lu et al. [4] concluded that laparoscopic cholecystectomy is not a good fit for the Classic LMA (CLMA). Despite the fact that the CLMA produced sufficient ventilation before to pneumoperitoneum, it was linked to a significant rate of inadequate and unsuccessful ventilation after abdominal insufflation to 15 mm Hg. Following pneumoperitoneum, the peak airway pressure in both groups was identical (24 cm H?O for PLMA and 22 cm H?O for CLMA); however, in the CLMA group, it was higher than the oropharyngeal leak pressure (OLP) of 19 cm H?O, which led to inadequate ventilation. While PLMA and CLMA performed similarly throughout different laparoscopic procedures, Natalini et al. observed that in certain patients, the cuff pressure was raised over 60 cm H2O in order to enable ventilation through the SAD.

It is generally known that during laparoscopic surgery, intra-abdominal pressure rises by an average of 15 mmHg. Consequently, there is an approximate 50% rise in PAP and a 25% decrease in lung compliance. Compared to conventional surgeries with lower PAPs, laparoscopic surgeries result in more adverse ventilatory circumstances. Accordingly, it could be necessary to look into how SADs work during laparoscopic procedures with greater PAPs, which result in the aforementioned drawbacks. Finally, for laparoscopic surgery, SAD with a greater OLP value than PAP can be advised [24-28].

Initially, the Laryngeal Mask Airway (LMA) was the favored airway equipment for laparoscopic procedures, and this was used in gynecological laparoscopy.

Tubal ligation, diagnostic laparoscopy, hysterectomy, myomectomy, and oophorectomy are common gynecological laparoscopic operations. The patient must normally have their legs in lithotomy and be in a Trendelenburg posture at a tilt of around 15° for these procedures. Gynecological laparoscopy has made use of the ProSeal LMA (PLMA), Supreme LMA (SLMA), and i-gel supraglottic airway devices (SADs).

The fact that gynecological surgeries are elective and usually quick procedures, the regulated placement and pneumoperitoneum, and the advantages SADs provide for ambulatory surgery are all reasons why they are beneficial in this setting. For the Classic Laryngeal Mask Airway (CLMA) to be used in laparoscopic surgery, Brimmacombe and Brain developed a "rule of 15" that calls for a Trendelenburg tilt of ≤15°, an intra-abdominal pressure of ≤15 cm H2O, and peritoneal insufflation lasting ≤15 minutes.

It is now recognized that the first two criteria still apply, but that a SAD's appropriateness for laparoscopic surgery is typically assessed in the first fifteen minutes [29]. It should remain effective for the duration of the procedure if enough breathing is maintained throughout this period, along with muscle relaxation, appropriate anesthetic depth, and no SAD dislodgement [29].

In nine randomized trials, different airway devices used in laparoscopic gynecological surgery were compared with the PLMA. Four investigations using the endotracheal tube, one each with the SLMA, i-gel, Laryngeal Tube Suction, and Cobra Perilaryngeal Airway, and one comparing the PLMA, SLMA, and i-gel include these comparisons [27, 28, 29]. Comparable results were observed between the PLMA and the ETT, as well as between the SLMA and i-gel. There was no clinically meaningful difference in the oropharyngeal leak pressure (OLP) or leak volume. Hohlrieder et al. reported using the PLMA to minimize the need for analgesics, score lower on pain scales, and experience less nausea; a comparable study by Griffiths et al. revealed no significant differences. Similar ventilatory efficacy was also shown in comparisons between the SLMA and i-gel [27, 28].

It's crucial to remember that all of the study subjects in these investigations were female, thus the conclusions might not apply to men with comparable positions for pelvic surgery. The majority of research also did not include obese women. Nevertheless, despite the small study sizes, those that included obese patients did not report any problems utilizing SADs, therefore no firm conclusions can be made regarding the efficacy or safety of SADs in this patient population [29].

A ventilatory technique that can sustain sufficient ventilation and oxygenation in the face of increased airway resistance, pressure, and decreased airway compliance is essential during laparoscopic surgery. This is accomplished by using Volume Controlled Ventilation, in which the formation of pneumoperitoneum is followed by a rise in respiratory rate that increases minute ventilation by around 20%. Conversely, pressure-controlled ventilation has advantages such as reduced peak airway pressure, faster tidal volume accomplishment, and higher flow rates [30]. It is crucial to make sure that the oropharyngeal leak pressure is not exceeded by the peak inspiratory pressure when utilizing a supraglottic airway device (SAD). Jeon et al., for example, discovered that PCV decreased peak airway pressures and PaCO2 levels in patients having laparoscopic gynecological procedures using the ProSeal LMA [30-35]

In a research by Carron et al., hemodynamic instability was avoided when obese patients undergoing gastric banding were ventilated using a PLMA and PCV with an I ratio of 1:1 was used to provide appropriate gas exchange [36,37].

Benefits from using low fresh gas flow rates during anesthesia include lower exposure to anesthetic gases, financial savings, and preservation of humidity and heat. Both low-flow (fresh gas flow < 1 L/min) and minimal-flow (FGF < 0.5 L/min) approaches have been effectively employed with controlled ventilation during laparoscopic surgery when an LMA is appropriately positioned, even though SADs may result in higher gas loss than endotracheal tubes [29]. Leak Fraction (LF) during SAD use in laparoscopic surgery has been documented in a number of studies [38-41]. If the LF is greater than 15%, it is deemed significant. The LF is computed as the inspired tidal volume divided by the expired tidal volume and given as a percentage.

The two main characteristics that would characterize the use of SAD in laparoscopic procedures are safety and efficacy. Although numerous studies have shown efficacy, there is no guarantee against pulmonary aspiration.

It must be recognized that choosing the appropriate patient cohort and keeping pneumoperitoneum and placement within reasonable bounds are critical to the effectiveness of SAD usage in laparoscopic procedures. A skilled user's insertion, precise positioning determined by clinical techniques or fiber-optic bronchoscopy, application of neuromuscular blockade, and regulated ventilation are all essential for the effective use of SAD in laparoscopic surgery. Before attempting their use in other laparoscopic surgeries, it is advised that first-time users develop a respectable level of proficiency in short-term, straightforward laparoscopic procedures such as tubal ligation or diagnostic gynecological laparoscopy.

Since Laparoscopic surgeries produce increased abdominal pressure for better working space, the airway devices used should have a better seal. According to studies, the SAD that has a larger oropharyngeal leak pressure is more useful and offers effective aspiration prevention.

Nil.

Conflicts Of Interest

There are no conflicts of interest.

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