Video-laryngoscopy photo
Tracheal Intubation with video-laryngoscopy
Old traditional mode of tracheal intubation
Ultrasound-guided canulation of the internal jagular vein
  • Video-laryngoscopy photo
  • Tracheal Intubation with video-laryngoscopy
  • Old traditional mode of tracheal intubation
  • Ultrasound-guided canulation of the internal jagular vein


The overall outcome of patients undergoing surgery (especially major surgery) depends also upon the quality of anesthesia administered, as well as the whole anesthesia care provided to patients before and after the operation. In addition to the obvious importance of thorough and complete preoperative evaluation, the close, continuous intraoperative cardiorespiratory monitoring, and the optimal postoperative pain management using continuous epidural or intravenous analgesics, the modern anesthesiologist applies techniques and methods which maximize the safety and efficacy of anesthesia and of the operation on general. Our surgery-anesthesia team applies the following techniques as a routine:

1. Fiberoptic intubation. Instead of the old technique (however still utilized widely worldwide) of using a bulky, metallic instrument in order to extend the lower jaw of the patient and be able to place the “endotracheal tube” in the right place within the trachea (or, “breathing pipe”), our team uses the fiberoptic endoscope, which is a very thin, flexible “telescope”. Using the fiberoptic endoscope, the anesthesiologist does not need to forcefully extend the lower jaw, so he/she can create the space to see the bottom of the throat where the endotracheal tube should be placed. Instead, the fiberoptic endoscope slides easily in the mouth and into the throat, the vocal cords are readily and fully visualized by the anesthesiologist, without any force being applied to them, and then the endotracheal tube slides on top of the fiberoptic endoscope in the right place. This procedure, performed by the experienced anesthesiologist, is quicker, safer, prevents postoperative throat pain and hoarse voice. It is important to emphasize that this technique is applied to all our patients undergoing general anesthesia; not only to those with “difficult intubation”.

2. Ultrasound guidance. Often, in major operations, a “central line” should be placed for optimal monitoring and fluid administration. This a specialized intravenous line positioned in a rather large vein (usually in the neck, or high up in the chest area, called the internal jugular, or the subclavian vein). These large veins are very close to large arteries heading up to the head or the arm. In addition, these veins, because of their thin wall and the amount of blood flowing through them, are amenable to injury, in which case significant bleeding may occur. Also, because of their very close proximity to the lung, a lung injury may ensue. Traditionally, these central lines were placed according to the experience of the anesthesiologist. Contrary to this approach, our anesthesia experts place such central lines always under ultrasound guidance. Ultrasonography shows the precise position of the vein deep in the neck, shows where the artery and the lung are, and shows exactly and absolutely accurately the position of the needle in relation to all these major structures. This way, the central line is easily placed with maximal safety in the correct vessel without multiple “blind” attempts based on the “anesthesiologist’s experience”.

3. Multimodal anesthesia. In major operations our team usually performs combined anesthesia. This is general anesthesia combined with regional directed at the area of the operation. The advantage of multimodal anesthesia is that it allows for much lower levels of general anesthetics because the regional anesthesia maximizes the analgesic effect at the area of the operation. Because of the lower doses of general anesthetics administered, patients wake up easier, faster and more “clear minded”. In addition, postoperative pain is almost nil because of the accumulated analgesic effect of the combined modalities. The regional component of multimodality anesthesia is performed through regional nerve blocks (corresponding to the precise area of the operation), and/or epidural anesthesia.