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Year : 2012  |  Volume : 1  |  Issue : 1  |  Page : 33-35

Accidental displacement of endotracheal tube into esophagus complicating laparoscopic surgery

1 Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Punjab, India
2 Department of General Surgery, Gian Sagar Medical College and Hospital, Banur, Punjab, India

Date of Web Publication21-May-2012

Correspondence Address:
Sukhminder Jit Singh Bajwa
Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab
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Source of Support: None, Conflict of Interest: None

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How to cite this article:
Bajwa SS, Singh A, Abbey R. Accidental displacement of endotracheal tube into esophagus complicating laparoscopic surgery. Int J Health Allied Sci 2012;1:33-5

How to cite this URL:
Bajwa SS, Singh A, Abbey R. Accidental displacement of endotracheal tube into esophagus complicating laparoscopic surgery. Int J Health Allied Sci [serial online] 2012 [cited 2022 Jun 26];1:33-5. Available from: https://www.ijhas.in/text.asp?2012/1/1/33/96421


Gastric distension during mask ventilation is quite common during administration of general anesthesia especially during difficult ventilation. Such complications are however unavoidable majority of times and can be safely dealt with insertion of Ryle's tube before the commencement of surgical procedure. These complications acquire significant dimensions during laparoscopic procedures as gastric and gut distension can lead to difficulty in Verres needle insertion and carrying out surgical dissection. The inflated stomach and gut not only becomes vulnerable to injury during peritoneal cavity access, but can also interfere in the normal visualization of the organs to be operated, especially the gall bladder during laparoscopic cholecystectomy. [1],[2],[3] We are describing a case of a 45-year-old American Society of Anesthesiologist (ASA)-I female who was operated for laparoscopic cholecystectomy for the symptomatic cholelithiasis and in whom we faced such a complication. Administration of general anesthesia, mask ventilation, and intubation was uneventful. Air entry was checked twice bilaterally by the senior anesthesiologist with stethoscope and found to be equal in the apical, axillary, and basal region, and the endotracheal tube (ETT) was fixed with Dynaplast bandage at 20 cm mark. The attending anesthesiologist started preparing for the attachment of closed circuit; heat and moisture exchanger filter as well as the capnography. It was only during the preparation of skin with Betadine that we realized that she had developed abdominal distension. Immediately, laryngoscopy was done and ETT was taken out and after 1 min of bag mask ventilation, reintubation was done with 7.5 mm size cuffed ETT. The parameters on the monitor did not show any change during this entire episode. Later on, it was revealed by the nurse technician that during the fixing of the ETT, some portion of the tube came out and she just pushed it inside and applied the bandage. Even the nurse technician either took it casually or was afraid to tell what had happened and tried to push the tube herself which probably got lodged in the oesophagus. The entire episode lasted for 2-3 min before the airway was secured again successfully. Thereafter, insertion of Ryle's tube deflated the stomach but could not deflate the inflated gut as we were unable to negotiate the pyloric sphincter [Figure 1],[Figure 2] and [Figure 3]. We were about to postpone the surgical procedure; however, with immense co-operation from the surgeon and an assurance of safety from him, trocars were inserted safely and procedure was carried out though with much difficulty. Patient was extubated successfully and the recovery period was uneventful.
Figure 1: Monitor showing the distended gut caused by accidental esophageal intubation

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Figure 2: Successful clipping of the vessels during the gall bladder dissection complicated by the distended gut

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Figure 3: Difficult gall bladder dissection due to distended gut

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The present incident throws light not only on the surgical difficulties induced by complications of anesthesia procedure, but also on the human nature and attitude toward such incidents. The fear of accident reporting or the lack of awareness on the part of nurse technicians about the consequences of such incident can happen in any setting in our day to day practice. The problem with such complications is the lack of reporting which compound the situations and leads to repetition of similar incidents. Reporting of such incidents is as vital as reporting of rare incidents as this can add to the basic safety measures to be adopted while dealing with similar life-threatening situations. The anesthesiologist, however, vigil may be during the surgical procedures, does require good support from the assistants to carry out smooth and safe anesthesia. The distended stomach and gut not only makes the surgical procedure difficult, but can also cause gastric perforation, difficult ventilation, and makes the abdominal tissues prone to develop injuries during peritoneal access. [4],[5],[6],[7] In such cases, there is a big dilemma whether to postpone the surgery and to cause the economic and psychological setback to the patient and relatives or to resort to other alternatives such as rectal tubes to deflate the gut in case of difficult Ryle's tube insertion. We were however fortunate that the surgeon was vastly experienced in carrying out such procedures in difficult circumstances. The injuries during such procedures can have legal implications as well. [8] The anesthesiologist himself or herself will be held responsible for such events even if they have been caused by the support staff. These are not uncommon incidents but the significant aspect is the accurate reporting so that in future even these possibilities should be kept in mind for any of the eventuality occurring inside the operation theatre. Anesthesiologists are also human and can make mistakes but they have to take care of even forced errors also and this shows the pressures of modern anesthesia in the background of medico-legal implications. The errors induced by the support staff are imposed on the anesthesiologist no matter how much they are vigil during the surgical procedure. The care provided by the anesthesiologist may be labeled as substandard in these circumstances although he may be striving to provide zero error and the best care as per his abilities. The incident also throws light on administrative aspect, and that the anesthesiologist of modern times should be ready to shoulder these responsibilities and to manage the operation theatre staff like a captain of a ship. The take home message is that usually in proactive services, the managers and their helper should look for possible cause of such near misses and take appropriate measures to manage them.

  References Top

1.Munro MG. Laparoscopic access: Complications, technologies and techniques. Curr Opin Obstet Gynecol 2002;14:365-74.  Back to cited text no. 1
2.Molloy D, Kalloo PD, Cooper M, Nguyen TV. Laparoscopic entry: A literature review and analysis of techniques and complications of primary port entry. Aust NZJ Obstet Gynaecol 2002;42:246-54.  Back to cited text no. 2
3.Brill AJ, Cohen BM. Fundamentals of peritoneal access. J Am Assoc Gynecol Laparosc 2003;10:287-97.  Back to cited text no. 3
4.Merlin T, Hiller J, Maddern G, Jamieson GG, Brown AR, Kolbe A. Systematic review of the safety and effectiveness of methods used to establish pneumoperitoneum in laparoscopic surgery. Br J Surg 2003;90:668-70.  Back to cited text no. 4
5.Berg MD, Idris AH, Berg RA. Severe ventilatory compromise due to gastric distention during pediatric cardiopulmonary resuscitation. Resuscitation 1998;36:71-3.  Back to cited text no. 5
6.Smally AJ, Ross MJ, Huot CP. Gastric rupture following bag-valve-mask ventilation. J Emerg Med 2002;22:27-9.  Back to cited text no. 6
7.Maltby JR, Beriault MT, Watson NC, Fick GH. Gastric distension and ventilation during laparoscopic cholecystectomy: LMA-Classic vs. tracheal intubation. Can J Anaesth 2000;47:622-26.  Back to cited text no. 7
8.Corson SL, Chandler JG, Way LW. Survey of laparoscopic entry injuries provoking litigation. J Am Assoc Gynecol Laparosc 2001;8:341-7.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3]


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