From the Guidelines
For a 2-year-old male undergoing hypospadias repair, an endotracheal tube (ETT) is usually preferred over a laryngeal mask airway (LMA). The ETT provides a more secure airway during this procedure, which typically requires the patient to be in lithotomy position and may involve significant surgical time. Hypospadias repair often necessitates complete immobility, and an ETT offers better airway protection against aspiration, especially since the surgical field is close to the airway. Additionally, the procedure may involve sharing the airway space with surgeons, and an ETT helps maintain airway patency throughout the case. The ETT also allows for positive pressure ventilation with higher pressures if needed, which may be beneficial during longer procedures. While LMAs can be used for some pediatric surgeries, the nature of hypospadias repair (duration, position, proximity to airway) makes an ETT the standard choice for most pediatric anesthesiologists. The ETT would typically be sized appropriately for a 2-year-old (usually 4.0-4.5 mm internal diameter, uncuffed or cuffed depending on institutional preference) 1.
Some studies have compared the use of LMAs and ETTs in pediatric surgeries, with mixed results. A meta-analysis found a lower incidence of postoperative cough with supraglottic airway, but no difference in terms of respiratory complications between tracheal intubation and supraglottic airway in a population of children undergoing gastrointestinal endoscopy 1. However, a randomised controlled trial found a significant decrease in the number of perioperative respiratory adverse events in the "laryngeal mask" group, but this study was conducted in infants undergoing minor surgery, which may not be directly applicable to hypospadias repair in a 2-year-old 1.
Key considerations for airway management in this case include:
- The need for a secure airway during a potentially long and complex procedure
- The proximity of the surgical field to the airway, which increases the risk of aspiration
- The need for positive pressure ventilation with higher pressures if needed
- The importance of maintaining airway patency throughout the case. Given these considerations, an ETT is the preferred choice for airway management in a 2-year-old male undergoing hypospadias repair.
From the Research
Anesthesia Methods for Hypospadias Repair
- The choice between endotracheal tube (ETT) and laryngeal mask airway (LMA) for a 2-year-old male undergoing hypospadias repair depends on various factors, including the surgeon's preference and the patient's overall health.
- A study published in 2015 2 compared the efficacy of different anesthesia methods in children undergoing hypospadias surgery and found that the laryngeal mask airway under general anesthesia combined with epidural block was a better choice for children scheduled for hypospadias angioplasty.
- Another study published in 2023 3 compared the effects of laryngeal mask airway and endotracheal tube in general anesthesia in children and found that the laryngeal mask airway group had significantly lower heart rate variability, incidence of hypoxemia, and postoperative cough compared to the endotracheal intubation group.
- A study published in 2021 4 compared the insertion of endotracheal tube, laryngeal mask airway, and I-gel in children undergoing strabismus surgery and found that the I-gel had less impact on undesirable stress responses compared to LMA and ETT.
Considerations for Anesthesia Choice
- The American Academy of Pediatrics and other medical organizations do not provide specific guidelines for the choice of anesthesia method for hypospadias repair in children.
- The decision to use ETT or LMA should be based on the individual patient's needs and the surgeon's expertise.
- The studies mentioned above suggest that LMA may be a suitable option for children undergoing hypospadias repair, but more research is needed to determine the best anesthesia method for this specific procedure.
- It is essential to consider the potential risks and benefits of each anesthesia method and to discuss the options with the patient's family and the surgical team 5, 6.