Is nasotracheal intubation a better choice over orotracheal intubation in prolonged laparoscopic abdominal surgeries? A prospective observational study

Laparoscopic surgeries performed under general anesthesia have gained significant popularity due to their minimally invasive nature and associated benefits, such as reduced postoperative pain, shorter hospital stays, and faster recovery times .However, the prolonged duration of these surgeries, particularly with the Trendelenburg position may pose challenges in terms of airway management . For example, risks of high airway pressure due to pneumoperitoneum, Trendelenburg position, and endobronchial migration of endotracheal tube may impose a threat in maintaining proper ventilation. Airway edema due to prolonged Trendelenburg position can result in difficult extubation in the form of delayed extubation or reintubation after extubation . During general anesthesia, effective airway management is crucial to ensure adequate oxygenation and ventilation. Orotracheal and nasotracheal intubation are the two commonly used methods for securing the airway in surgical procedures. Orotracheal intubation involves inserting an endotracheal tube through the mouth, while nasotracheal intubation involves the insertion of the tube through the nose. Each method has its advantages and potential drawbacks. Orotracheal intubation provides a more direct and easier route for tube insertion .But, as per our Institutional practice experience - it is more prone to kinking & migration. Due to the relative inaccessibility of the tube position after draping, the steep Trendelenburg position, and the presence of other confounding factors creating high airway pressure (position, pneumoperitoneum), inexperienced anesthesiologists often fail to detect it.  Nasotracheal intubation offers better patient comfort, is easier to secure, moves less if secured properly, and has a lesser risk of trauma to lips and tongue .In our Institution, besides orotracheal intubation (in which we frequently encounter disadvantages like intraoperative tube kinking and endobronchial migration) we routinely perform Nasotracheal intubation also to get the believed benefit associated with it (better tube securement, less chance of tube kinking, in case of delayed extubation due to airway edema - better tolerance of endotracheal tube in the postoperative period by the patients, etc.). But there is very limited data available documenting the evidence comparing the performance and outcomes of these two methods specifically in prolonged laparoscopic abdominal surgeries. Aim of the Study: To compare the performance of orotracheal and nasotracheal intubation specifically in the context of prolonged laparoscopic abdominal surgeries under general anesthesia. Objective:

**Primary Objective:**To compare the number of episodes of kinking or bending of the endotracheal tube in the intraoperative period.

Secondary Objectives: 1. To compare the proportion of patients requiring tube repositioning during surgery. 2. To evaluate the incidence of airway-related trauma in both the orotracheal and nasotracheal tube groups. 3. To compare the number of patients extubated in the operating room, recovery, and ICU between the two groups. 4. To compare the proportion of patients requiring reintubation within one hour of extubation between the orotracheal and nasotracheal tube groups. 5. To compare the end of surgery to extubation time between the two groups. 6. In cases of delayed extubation (extubation at recovery/ ICU), to compare the requirement of fentanyl and neuromuscular blocking agents in the first 12 hours after the end of surgery between the orotracheal and nasotracheal tube groups.