Methods of endotracheal tube placement in patients undergoing pelviscopic surgery

Accidental endobronchial intubation is reported frequently during laparoscopic gynaecological surgery. We performed a prospective randomised study to compare three different methods of endotracheal tube placement in terms of susceptibility of accidental endobronchial intubation in patients undergoing laparoscopic gynaecologic surgery. The endotracheal tube was positioned by one of three methods: it was secured by palpating at the suprasternal notch while holding the pilot balloon (Group(Cuff)); by placing the 21 cm mark at the upper incisors (Group(21cm)); or by placing a guide mark, which was made on the surface of the tube 2 cm above the proximal end of the cuff at the level of the vocal cords (Group(VC)). The distance from the tip of endotracheal tube to the carina was measured with the patient in a neutral position (D(TC0)) and after the formation of pneumoperitoneum in the Trendelenburg position (D(TC1)). Eighty-eight patients were enrolled. Pneumoperitoneum and Trendelenburg position caused inward movement of the endotracheal tube toward the carina in 99%. In each group, the mean value of D(TC1) was significantly shorter than D(TC0) (Group(Cuff) 3.0 +/- 1.1 vs. 1.7 +/- 1.0, Group(21cm) 2.5 +/- 0.8 vs. 1.1 +/- 0.9, Group(VC) 3.5 +/- 0.7 vs. 2.3 +/- 0.8, D(TC0) vs. D(TC1) respectively) (all P < 0.01). Accidental endobronchial intubation occurred in 14%, with the lowest frequency in Group(VC) (2.6 %, P < 0.01) and the highest in Group(21cm), although this was not significantly (P = 0.09) different from Group(Cuff) (26.7% vs. 10.0%). The incidence of endobronchial intubation was lowest in Group(VC) but endobrochial intubation could not be avoided using any of these methods.