Journal of Anesthesia

https://doi.org/10.1007/s00540-020-02780-0

ORIGINAL ARTICLE

Comparison of the standard and triple airway maneuvering

techniques for i‑gel™ placement in patients undergoing elective
surgery: a randomized controlled study
İlkay Baran Akkuş1 · Fatma Kavak Akelma1 · Merve Emlek1 · Derya Özkan1 · Jülide Ergil1 · Reyhan Polat1

Received: 23 December 2019 / Accepted: 16 April 2020

© Japanese Society of Anesthesiologists 2020

Abstract
Purpose  The i-gel is a supraglottic airway device with non-inflatable cuff which can suffer insertion failure if its stand-
ard placement technique is implemented. The aim of this study was to compare the placement technique proposed by the
manufacturer of i-gel with the triple airway maneuver in terms of successful device insertion time and first-attempt success.
Methods  After ethics committee approval, 103 ASA I–III patients were randomly allocated to the standard or triple airway
maneuver groups. In the standard Group, the i-gel was inserted in the sniffing position while, in the triple group, it was
inserted using the triple airway maneuver consisting of head tilt, jaw thrust, and open mouth. The time taken for successful
insertion, first-attempt success rate, i-gel position, airway complications, and hemodynamic responses were assessed.
Results  Between the two groups patient characteristics were similar. Time for successful insertion was significantly shorter
in the triple group (20 ± 7 s) than with the standard technique (32 ± 11 s; p < 0.001). Successful insertion at the first attempt
was 78% and 92% for the standard and triple group, respectively (p = 0.092). The i-gel position, airway complications, and
hemodynamic responses were similar in both groups.
Conclusion  The triple airway maneuver required less i-gel insertion time as compared with the standard placement tech-
nique. First-attempt success rates were similar with both techniques, although the triple airway maneuver was superior to
the standard method as a rescue technique in failed insertions. We therefore recommend use of the triple airway maneuver
in i-gel insertion.

Keywords  I-gel · Triple airway maneuver · Insertion

Introduction decrease morbidity when compared with other supraglot-

The i-gel (Intersurgical Ltd., Wokingham, UK) is a second-
generation, single-use supraglottic airway device (SAD)
with non-inflatable cuff designed to achieve rapid and reli-
able airway control [1–3]. Besides airway maintenance, it is
also used as a conduit for fiberoptic intubation in patients
with difficult airways.
The placement of supraglottic airway devices can be
challenging, and the i-gel has been shown to increase first-
attempt success rates [4, 5], shorten insertion time, and
* İlkay Baran Akkuş
ilkayb@hotmail.com
1
Department of Anesthesiology and Reanimation, University
of Health Sciences, Diskapi Yildirim Beyazit Trainig
and Research Hospital, Sehit Ömer Halisdemir Str,
06110 Dıskapı‑ Altındag, Ankara, Turkey
tic airway devices [6–8]. Nevertheless, i-gel is not without
drawbacks. Given its slightly rigid structure prior to expo-
sure to body temperature and lack of a pilot balloon to lower
the cuff pressure, the placement of the i-gel using the stand-
ard method may, in some cases, pose difficulties. Complica-
tions associated with i-gel insertion have been previously
reported [9, 10].
In cases where the i-gel cannot be inserted with the
standard technique, manipulations such as the application
of gentle force to insert the device or rotate it in various
directions are sometimes used and this increases the number
of insertion attempts. These manipulations may also increase
the risk of oropharyngeal trauma which can decrease the
success rate of subsequent attempts [11]. Also, in certain
patients, insertion may prove difficult and the tongue can get
caught by the i-gel therefore the triple airway maneuver may

13
Vol.:(0123456789)

provide a larger space for the i-gel and prevent this interac-
tion with the tongue [10].
The triple airway maneuver is an alternative method that
combines the head tilt-chin lift, jaw thrust, and open mouth
maneuvers together to achieve airway patency. As anesthe-
siologists, we use this maneuver to shift the tongue forward
in our daily practice and we hypothesized that setting the
tongue aside could be a significant advantage during i-gel
insertion; in particular, the triple airway maneuver could
provide increased pharyngeal room for the i-gel with its non-
inflatable cuff. Our specific hypothesis was that implement-
ing the triple airway maneuver as the first-attempt method
would increase the success of i-gel placement, shorten the
time it took, and reduce complication rates. The primary aim
of the study was therefore to compare first insertion success
and clinical performance between i-gel insertion using the
standard and triple airway maneuver techniques.
Methods
This randomized controlled trial was conducted between
December 2018 and February 2019 after obtain-
ing the approval of the institutional ethics committee
(25.12.2017–44/12). All participants provided written
informed consent for participation in the trial. The study
was registered at ClinicalTrials.gov (NCT03542032).
American Society of Anesthesiologists (ASA) I–III
patients who were aged 18–75, weighed 50–90 kg, and were
scheduled for elective urological or orthopedic surgery with
an expected surgical duration of less than two hours were
considered for inclusion. Patients were excluded if they were
pregnant, at risk of aspiration, or had a mouth opening of
less than 2.5 cm, a body mass index greater than 35 kg/m2,
a lung disease, or a pathology of the neck or upper respira-
tory tract. The i-gel was inserted by the same anesthesiolo-
gist who was experienced in the management of supraglot-
tic airway devices (> 300 i-gel insertions). Patients were
randomized to the standard insertion (standard group) and
triple airway maneuver (triple group) groups using a com-
puter-generated random number table. Demographic vari-
ables—age, sex, body mass index (BMI), and ASA physical
status—were recorded. Airway anatomy was assessed with
the modified Mallampati score, thyromental distance, inter-
incisor distance, measurement of the neck circumference,
and the upper lip biting test.
All patients were required to fast for at least 6 hours
before surgery, and none of them received any premedi-
cation. We used routine monitoring consisting of pulse
oximetry, electrocardiography, end-tidal carbon diox-
ide ­( ETCO 2), and non-invasive blood pressure, as well
as Bispectral index monitoring (BIS, VistaTM Aspect
Medical Systems, New–ton, MA, USA). Baseline blood
13
Journal of Anesthesia
pressure and heart rate values were recorded. Patients were
preoxygenated with facemask ventilation an inspired oxy-
gen fraction ­(FiO2) 80% until an end-tidal oxygen satu-
ration 90% was obtained. Induction was performed with
propofol 2–2.5 mg/kg and fentanyl 1.5–2 µg/kg, and neuro-
muscular blockade was achieved with rocuronium 0.6 mg/
kg. Anesthesia was maintained using 1.5–2% sevoflurane
in 50% oxygen–air mixture and remifentanil at a dose of
0.02–0.2 µg/kg/min.
The i-gel was inserted when the BIS value was between
40 and 60. Additional propofol doses of 0.5–1.0 mg/kg were
infused during the second and third attempts when required
to keep the BIS value between 40 and 60. Size selection and
insertion of the i-gel device were according to the manu-
facturer’s recommendations [1]. Before insertion, the cuff
was lubricated using a water based lubricant. The i-gel was
inserted in the sniffing position with gently pressing the
chin down in the Standard Group, and by the head extended,
mouth open and chin lifted upward and forward in the Triple
Group. The lubricated i-gel was grasped along the integral
bite block. The i-gel cuff outlet was facing the chin of the
patient. The leading soft tip was introduced into the mouth
towards the hard palate, and the device was glided down-
wards and backwards along the hard palate until a definitive
resistance was felt [1, 12].
Two attempts were allowed before the technique was con-
sidered a failure. When the first attempt failed, the same
technique was applied with a different size i-gel. The deci-
sion to increase or decrease the size of the i-gel was made by
the attending anesthesiologist, based on clinical judgment.
When two attempts with the same technique failed the other
technique was used as a rescue technique with the initial
i-gel size. Finally, if all three attempts failed, tracheal intuba-
tion was performed.
Effective ventilation was defined as the presence of an
end-tidal carbon dioxide waveform and simultaneous chest
movement. Ineffective ventilation was defined as an absent
capnography trace, inadequate chest movement, peak airway
pressure greater than 30 ­cmH20 or a leak volume greater
than 25% of the set-inspired tidal volume. Insertion time
was defined as the time between picking up the i-gel and
obtaining effective ventilation. After obtaining an effective
airway, the device was connected to a circle breathing sys-
tem (Primus, Drager, Lubek, Germany). Leak pressure and
leak percentage were assessed right after the i-gel placement
and at 15 min after placement while the anesthesia circuit
was temporarily closed. Leak pressure was measured and
recorded following a fresh gas insufflation of 5 l/min and
recording continued until an audible leak was remarked or
until airway pressure plateaued. Airway pressure was not
allowed to exceed 40 cmH2O [13]. Leak volume was defined
as the difference between the set-inspired and expired tidal
volumes.
Journal of Anesthesia

Heart rate and mean arterial pressure were recorded at Selected

1, 3, and 5 min after the insertion of the i-gel. Any adverse 103

events such as desaturation (peripheral oxygen saturation

­(SpO2) < 92%), airway obstruction, coughing, gagging, Excluded
Eligible
laryngospasm and airway trauma (defined as blood staining 5

on i-gel at removal) were noted. Laryngeal positioning of

the i-gel was assessed by fiberoptic view (2.8 mm; Olympus, Included
Tokyo, Japan). The view via the airway channels was rated 98

as follows: Grade 1, only vocal cords visible; Grade 2, only

arytenoids visible; Grade 3, only epiglottis visible; Grade 4,
no laryngeal structures visible [6, 11]. Standart Triple
Sevoflurane and remifentanil were discontinued at the end 49 49

of the surgery and the airway device was removed following

successful mouth opening to verbal command. The interview Failed Failed
1st trial 1st trial
was conducted in the post-anesthesia ward by nurses who 11 4

were blind to study groups with regards to the presence or

absence of sore throat. Succeded Succeded
The primary aim of the study was to compare first time 38 45

insertion success rate and insertion time between the stand-

ard and triple airway maneuver techniques. Secondary out-
Failed 2nd trial Failed 2nd trial
come measures were the incidence of airway complications, 10 3
hemodynamic responses to insertion and grade of view on
fiberoptic inspection of the larynx. Succeded Succeded
1 1

Statistical analysis
Statistical analyses were performed using the IBM SPSS
for Windows Version 22.0. Normality of continuous data
was assessed using one sample Kolmogorov Smirnov test.
Numerical variables were summarized as mean ± standard
deviation and categorical variables as frequencies and per-
centages. Homogeneity of variances was tested by Levene
test. Two group comparisons were conducted using inde-
pendent samples t test for normally distributed data and
Mann Whitney U for skewed data. Categorical variables
were compared using the chi square or Fisher exact test.
Repeated measures ANOVA was performed to identify
between and within group differences. Pairwise compari-
sons were performed using the Bonferroni test. A P value
less than 0.05 was considered statistically significant. We
used the insertion time to calculate the sample size in the
pilot study (Group Standard n = 8, 26 ± 11 s; Group Triple
n = 8, 20 ± 7 s). The sample size came out to be 49 patients
in each group at a power of 95% and alpha error of 0.05.
Considering the possibility of drop outs from the study, we
decided to include 104 patients.
Results
A total of 103 patients were included in the study of these
four had a cervical pathology and two refused to partici-
pate. The study was completed with 98 patients (Fig. 1). The
3rd trial Failed 3rd trial Failed
Technique intubated Technique intubated
change 2 change 3
Succeded Succeded
0
8
Fig. 1  Study population flowchart
patients’ characteristics and airway characteristics of these
patients are summarized in Table 1. Groups were similar in
terms of age, gender, body mass index, ASA, Mallampati
score, neck circumference, mouth opening and thyromental
distance (p = 0.081).
Insertion time was significantly shorter in triple group
than in standard group (p < 0.001). The first attempt success
rate was similar between insertion methods [45/49 (92%) vs.
38/49 (78%); p = 0.092] (Table 2). The number of require-
ment for i-gel size change during the second attempt was
also similar between the groups (p = 1). The triple maneuver
was successful as a recue technique in the third attempt for
the eight of the ten failed patients in the standard group.
However, the standard technique was not successful as a
rescue technique in any of the failed cases in the triple group
in the third attempt (p = 0.035). Effective ventilation for the
remaining failed cases was established using endotracheal
intubation (Standard group n = 2; Triple group n = 3).
Patients who failed the standard method in the first two
attempts but who succeeded with the triple airway maneuver

13
 Journal of Anesthesia

Table 1  Characteristics of patients and procedures and airway char- were assessed for potential risk factors for difficult supra-
acteristics glottic airway device placement. Accordingly, eight patients
Group stand- Group triple (n = 49) had a neck circumference greater than 40 cm, five had a BMI
ard (n = 49) between 30 and 35 kg/m2 and three between 22 and 30 kg/
m2, one patient had a mouth opening less than 5.5 cm and
Age (years) 51 ± 16 47 ± 14
six patients were male.
Gender female n (%) 24 (49%) 24 (49%)
There was no difference leak percentages between the
BMI kg/m2 28 ± 4 29 ± 3
groups. (Table 2). However, within-group analysis revealed
Mallampati Score n (%)
that leak percentage was significantly reduced with time in
 1 15 (31%) 15 (31%)
both groups (p < 0.001). Patients were compared in terms
 2 24 (49%) 20 (41%)
of leakage pressure and leakage pressure was higher in the
 3 9 (18%) 13 (26%)
triple group in both time periods (p = 0,012, p = 0.027).
 4 1 (2%) 1 (2%)
Intra-group analyzes showed that leakage pressure increased
ASA n (%)
significantly over time in the standard group (p = 0.031).
 1 10 (20%) 18 (37%)
Fiberoptic findings were similar between the groups
 2 33 (67%) 29 (59%)
(Table 2).
 3 6 (12%) 2 (4%)
The incidence of postoperative sore throat did not dif-
Neck circumference (cm) 40 ± 4 40 ± 5
fer between the groups (Table 3). Five patients in standard
Inter-incisor distance (cm) 6 [4–7] 6 [5–7]
group but none of the patients in triple group had blood
Thyromental distance (cm) 6 [4–8] 6 [5–7]
staining on the device at removal (p = 0.056). No hypoxia,
BMI Body mass index, ASA american society of anesthesiologists sta- laryngospasm, or airway obstruction was observed dur-
tus ing the placement or removal of the i-gel. Hemodynamic
parameters remained similar between the groups (p = 0503,
Table 2  Characteristics of successful airway insertion p = 0948).
Group standard Group triple p value
(n = 49) (n = 49
Discussion
Insertion time (s) 32 ± 11 20 ± 7  < 0001a
Successful insertion rate,
We found that the triple airway maneuver decreases i-gel
n (%)
insertion time as compared with the standard technique. We
 First attempt 38(78%) 45(92%) 0092
also demonstrated that it could be used as an alternative
 Second attempt (different 1 1 1
size) with regards to similar first insertion success rates, airway
 Third attempt (rescue 8 0.035a complications, and hemodynamic response.
method) Various placement methods have been introduced to
Failed 2 3 increase insertion success rates for supraglottic airway
Leak pressure (­ cmH2O) devices. A survey of anesthesiologists regarding the inser-
 1 20 [10–40] 26 [10–40] 0012a tion of laryngeal mask airways (LMAs) revealed that only
 2 24 [10–40] 29 [10–40] 0027a 30–34% of respondents followed the manufacturer’s recom-
 p 0,031a 0180 mendations, and that 36–42% did not use the standard inser-
Leakage percentage (%) tion technique [14].Several studies have assessed alternative
 1 14 [6, 20] 14 [4, 20] 0333 methods in increasing first attempt success rates. Two such
 2 12 [1 20] 10 [1 18] 0391 studies demonstrated that the rotation technique provided a
 p  < 0001a  < 0001a higher first attempt success rate than the standard insertion
Brimacombe score n (%) [11, 15]. Poor dentition was raised as a relative contraindi-
 Grade 1 5 (11%) 6 (13%) 0785 cation for this method [16]. The effect of prewarming the
 Grade 2 11 (24%) 7 (16%) i-gel on insertion time, ventilation, and sealing pressure has
 Grade 3 9 (20%) 9 (20%) been assessed but failed to demonstrate any advantage [17].
 Grade 4 9 (20%) 23 (51%) In the present study, we choose to use the triple airway
a maneuver to enhance the placement of i-gel because, this
 Statistical significance
technique does not require preparation and all anesthesi-
ologists are familiar with this maneuver. The triple airway
maneuver has long been used for the placement of several
supraglottic airway devices [12, 18, 19]. Using the LMA

13
Journal of Anesthesia
Table 3  Comparison of
incidence of adverse events
between placement techniques
Sore throat
The presence of blood on the i-gel
Cough in placement
Cough while removing
Heart rate beat/mean
 Before insertion
 5 min after insertion
Mean arterial pressure, mmHg
 Before insertion
 5 min after insertion
Unique Airway, for example, Eglen et al. compared three
insertion techniques and found that first-attempt insertion
success rates were 88.3% for both the standard and triple
airway maneuver methods [19].
In the presenting study, the success rates of first attempt
placement were found to be similar in the standard and
triple airway maneuver groups, 78% vs. 92% respectively.
However we detected significantly increased success rates
with the triple maneuver when used as rescue method at the
third attempt. We consider that this difference in our results
compared to those of Eglen et al. is related to the fact that
the i-gel differs from the other supraglottic airway devices
as it does not have an inflatable cuff. During insertion of
the LMA a wider pharyngeal space may not offer as much
advantage as the i-gel because of the presence of a deflatable
cuff. A deflatable cuff provides that the supraglottic airway
device is softer and can change shape which in turn increases
the ease of insertion through narrow spaces.
First attempt insertion success rate with supraglottic air-
way device has been reported to vary between 62 and 97%
[13, 20–23]. In the presenting study results from both groups
were consistent with previous reports.
When an anesthesiologist fails to insert the i-gel using
the standard placement method, other manipulations are
often used, such as neck extension or flexion, chin lift, jaw
thrust, and pushing or pulling the device. Repeated insertion
attempts increase the risk of complications, including bleed-
ing and edema, and each failed attempt reduces the likely
success of subsequent efforts [11]. In the current study, the
triple airway maneuver was successful in eight patients for
whom the standard i-gel insertion method had twice failed.
The standard method, on the other hand, was not successful
in any of the patients for whom the triple airway maneu-
ver had failed. This observation demonstrates that the triple
airway maneuver is a successful rescue technique in failed
insertions.
Eventually, the insertion failure rate using the standard
and triple airway methods were 4% and 6%, respectively.
Group standard Group triple p value
(n = 49) (n = 49)
2 (4%) 1 (2%) 1000
5 (11%) 0056
5 (11%) 1 (2%) 0203
5 (11%) 1 (2%) 0203
75 ± 13 77 ± 11 0503
71 ± 13 71 ± 12 0948
83 ± 13 85 ± 12 0634
78 ± 12 76 ± 11 0571
These rates are comparable with previous studies reporting
0–4% insertion failure rates [24].
The i-gel insertion time in the presenting study may seem
longer that some of the previous reports [23, 25–28, 30]. We
consider that this difference is related to how we measured
insertion time. The i-gel could be placed after second and
third attempts with a different size or rescue maneuver in 9
patients in the standard group whereas this was the case only
in one patient in the triple group. We included the time taken
by the second and third attempts in the i-gel insertion time
and confirmed the placement with adequate chest move-
ment and end tidal CO2 tracing. This methodology may
have increased the mean i-gel insertion time in the standard
group. In fact, i-gel insertion time is variable in previous
studies. The mean time to achieve an effective airway using
i-gel has been reported to be between 7 and 34.7 s [11, 22,
23, 25–30]. In our study, we found the insertion time in the
standard group similar to Kim et al. which reported 34.7 s.
i-gel insertion time [29]. In the studies of Damodaran and
Lee, there is no data about the inclusion of the duration of
the 2rd and 3rd trials in insertion time in cases which i-gel
could not be placed in the first attempt [25, 26]. Further-
more, in another study of Kim et al. the authors reported
26.9 s i-gel insertion time with the standard method, this
time is close to ours, despite the authors did not include the
time required for the second and third attempts [11].
Owing to its unique thermoplastic elastomer structure,
the i-gel adapts to the supraglottic tissue by stretching with
body temperature over time [31], and this adaptability is
associated with a decrease in leakage percentage over time.
We observed this pattern in the current study. The leakage
pressure measured during i-gel insertion is usually between
10–40 ­cmH2O [13], and pressures below 5 cmH2O have
been deemed to represent unsuccessful placements [24]. In
our study, higher leakage pressures were measured in the
triple group than in the standard group, and this may actually
be an advantage in particular clinical situations where higher
leakage rates are required such as laparoscopic surgery.
13

The i-gel differs from many other supraglottic airway
devices in that it does not have an inflatable cuff [32]. Its
non-inflatable structure has many advantages, but it is not
without its limitations; device placement against the phar-
ynx may, for example, be restricted by the tongue [15],
and related complications such as tongue trauma, frenu-
lum hemorrhage and edema, and bilateral lingual nerve
damage have been reported in the literature [9, 10]. The
use of the triple airway maneuver may reduce the rate of
such complications as it shifts the tongue aside providing
direct access to the pharynx. In the current study, we did
not observe any serious complications related to the use of
this maneuver, although blood staining on the device was
observed at removal in five of the patients in the standard
group (none of the triple group).
Successful i-gel placement depends not only on inser-
tion technique but also on the administration of anesthesia
sufficiently deep to suppress airway reflexes and hemody-
namic responses [33]. We used the bispectral index (BIS)
to monitor and standardize the depth of anesthesia and
used muscle relaxants to facilitate placement. The triple
airway maneuver is generally considered to be a painful
procedure, but we did not identify any additional response
during its application in the triple group. Furthermore,
the maneuver did not cause any hemodynamic instabil-
ity because of the sufficient anesthesia, as documented
with BIS monitoring. We also did not observe any adverse
effects or complications such as desaturation, laryngo-
spasm, hiccups, or airway obstruction.
In a randomized study comparing the adverse effects
of i-gel with a standard laryngeal mask (La Premiere),
the incidence of sore throat was found to be 5.5% for i-gel
[30]. Similarly, we found a remarkably low rate of sore
throat in both groups.
The need for a second anesthesiologist during the tri-
ple airway maneuver may be regarded as a limitation of
the procedure. It should, however, be noted that current
practice in the induction and maintenance of general anes-
thesia already usually requires two anesthesiologists, and
we therefore do not consider this an important constraint.
A limitation of the current study is that the anesthesiolo-
gist, understandably, could not be blinded to the technique
used. Another fact that should be interpreted is that all
i-gel placements were done by a one experienced anesthe-
siologist, we choose this method to standardize our study
protocol; however, this methodology may limit the gener-
alizability of the results to lesser experienced operators.
In addition, the current results can neither be generalized
to emergency situations nor to patients with problematic
airways because only patients requiring elective surgery
were enrolled and we did not exclusively enroll patients
with airway difficulties.
13
Journal of Anesthesia
Conclusion
We demonstrated that the triple airway maneuver required
less i-gel insertion time as compared with the standard
insertion technique. We also found that the triple airway
maneuver and standard methods provided similar first
insertion success rates and yielded similar airway com-
plications. Finally, the triple maneuver was superior to
the standard method as a rescue technique in failed i-gel
insertions. We therefore recommend the use of the triple
airway maneuver in i-gel insertion.
References
1. I-gel User Guide. 7th edn. Wokingham, UK: Intersurgical Ltd;
2009. https​://www.inter​surgi​cal.com/produ​cts/airwa​y-manag​
ement​/i-gel-supra​glott​ic-airwa​y.
2. Michalek P, Hodgkinson P, Donaldson W. Fiberoptic intubation
through an i-gel supraglottic airway in two patients with pre-
dicted difficult airway and intellectual disability. Anesth Analg.
2008;106(5):1501–4.
3. Mendonca C, Tourville CC, Jefferson H, Nowicka A, Patteril M,
Athanassoglou V. Fibreoptic-guided tracheal intubation through
i-gel® and ­LMA® Protector TM supraglottic airway devices—a
randomised comparison. Anaesthesia. 2019;74(2):203–21.
4. Tan HS, Li SY, Yao WY, Yuan YJ, Sultana R, Han NR, Sia
ATH, Sng BL. Association of Mallampati scoring on air-
way outcomes in women undergoing general anesthesia with
Supreme™ laryngeal mask airway in cesarean section. BMC
Anesthesiol. 2019;19(1):122.
5. Katsiampoura AD, Killoran PV, Corso RM, Cai C, Hagberg CA,
Cattano D. Laryngeal mask placement in a teaching institution
analysis of difficult placements. F1000Res. 2015;4:102.
6. Gatward JJ, Cook TM, Seller C, Handel J, Simpson T, Vanek
V, Kelly F. Evaluation of the size 4 i-gel airway in one hundred
non-paralysed patients. Anaesthesia. 2008;63(10):1124–30.
7. An J, Nam SB, Lee JS, Lee J, Yoo H, Lee HM, Kim MS. Com-
parison of the i-gel and other supraglottic airways in adult
manikin studies: systematic review and meta-analysis. Medicine
(Baltimore). 2017;96(1):e5801.
8. Ekinci O, Abitagaoglu S, Turan G, Sivrikaya Z, Bosna G,
Özgultekin A. The comparison of ProSeal and i-gel laryngeal
mask airways in anesthetized adult patients under controlled
ventilation. Saudi Med J. 2015;36(4):432–6.
9. Renes SH, Zwart R, Scheffer GJ, Renes S. Lingual nerve injury
following the use of an i-gel laryngeal mask. Anaesthesia.
2011;66(3):226–7.
10. Michalek P, Donaldson WJ, Hinds JD. Tongue trauma asso-
ciated with the i-gel supraglottic airway. Anaesthesia.
2009;64(6):692–3.
11. Kim HC, Yoo DH, Kim HJ, Jeon YT, Hwang JW, Park HP. A
prospective randomised comparison of two insertion methods for
i-gel placement in anaesthetised paralysed patients standard vs
rotational technique. Anaesthesia. 2014;69(7):729–34.
12. Kuvaki B, Küçükgüçlü S, Iyilikçi L, Tuncali BE, Cinar O. The
Soft Seal disposable laryngeal mask airway in adults: compari-
son of two insertion techniques without intra-oral manipulation.
Anaesthesia. 2008;63(10):1131–4.
13. Achmet A, Türkmen A, Kaya M, Cantürk S, Turgut N, Altan A.
Comparison of supreme LMA, Proseal LMA and cobra PLA in
Journal of Anesthesia
adult patients undergoing minor surgery. Turk J Anaesthesiol
Reanim. 2013;41(3):70–4.
14. Dingley J, Asai T. Insertion methods of the laryngeal mask airway
a survey of current practice in wales. Anaesthesia. 1996;51:596–9.
15. Megha S, Mukul CK, Rakesh A, Swaraj G. Insertion of i-gel™
by the reversed technique improves the success rate and reduces
the time taken for its placement: a prospective, randomized,
controlled, interventional trial. J Anaesthesiol Clin Pharmacol.
2017;33(2):226–30.
16. Kumar P, Joshi A. Rotational or standard method of i-gel inser-
tion? Anaesthesia. 2015;70(3):364–5.
17. Reddy AM, Varghese N, Herekar B, Shenoy UK. Does prewarm-
ing of i-gel improve insertion and ventilation in anaesthetised and
paralysed patients? A prospective, randomised, control trial. Saudi
J Anaesth. 2019;13(3):215–21.
18. Aoyama K, Takenaka I, Sata T, Shigematsu A. The triple airway
manoeuvre for insertion of the laryngeal mask airway in paralyzed
patients. Can J Anaesth. 1995;42(11):1010–6.
19. Eglen M, Kuvaki B, Gönenç F, Ozbilgin S, Küçükgüçlü S, Polat E,
Pekel E. Comparison of three different insertion techniques with
LMA-Unique™ in adults: results of a randomized trial. Rev Bras
Anestesiol. 2017;67(5):521–6.
20. Tan MG, Chin ER, Kong CS, Chan YH, Ip-Yam PC. Comparison
of the re-usable LMA Classic and two single-use laryngeal masks
(LMA Unique and SoftSeal) in airway management by novice
personnel. Anaesth Intensive Care. 2005;33(6):739–43.
21. Brimacombe J, Keller C, Morris R, Mecklem D. A comparison
of the disposable versus the reusable laryngeal mask airway in
paralyzed adult patients. Anesth Analg. 1998;87(4):921–4.
22. Weber U, Oguz R, Potura LA, Kimberger O, Kober A, Tschernko
E. Comparison of the i-gel and the LMA-Unique laryngeal mask
airway in patients with mild to moderate obesity during elective
short-term surgery. Anaesthesia. 2011;66(6):481–7.
23. Brimacombe J, Keller C. Insertion of the LMA-Unique with and
without digital intraoral manipulation by inexperienced personnel
after manikin-only training. J Emerg Med. 2004;26:1–5.
24. Theiler L, Gutzmann M, Kleine-Brueggeney M, Urwyler N,
Kaempfen B, Greif R. i-gel™ supraglottic airway in clinical prac-
tice : a prospective observational multicentre study. Br J Anaesth.
2012;109(6):990–5.
25. Damodaran S, Sethi S, Malhotra SK, Samra T, Maitra S, Saini V.
Comparison of oropharyngeal leak pressure of air-Q™, i-gel™,
and Laryngeal Mask Airway Supreme™ in adult patients during
general anesthesia: a randomized controlled trial. Saudi J Anaesth.
2017;11(4):390–5.
26. Lee YC, Yoon KS, Park SY, Choi SR, Chung CJ. A comparison
of i-gel™ and Laryngeal Mask Airway Supreme™ during general
anesthesia in infants. Korean J Anesthesiol. 2018;71(1):37–42.
27. Kara D, Sarikas CM. Comparison of the baska and i-gel supra-
glottic airway devices: a randomized controlled study. Ann Saudi
Med. 2019;39(5):302–8.
28. Sachidananda R, Shaikh SI, Mitragotri MV, Joshi V, Ladhad DA,
Mallappa M, Bhat VK. Comparison between the Baska ­Mask®
and i-gel for minor surgical procedures under general anaesthesia.
Turk J Anaesthesiol Reanim. 2019;47(1):24–30.
29. Kim MH, Lee JH, Choi YS, Park S, Shin S. Comparison of the
laryngeal mask airway supreme and the i-gel in paralysed elderly
patients: a randomised controlled trial. Eur J Anaesthesiol.
2018;35(8):598–604.
30. Keijzer C, Buitelaar DR, Efthymiou KM, Srámek M, ten Cate J,
Ronday M, Stoppa T, Huitink JM, Schutte PF. A comparison of
postoperative throat and neck complaints after the use of the i-gel
and the la premiere disposable laryngeal mask: a double-blinded,
randomized, controlled trial. Anesth Analg. 2009;109(4):1092–5.
31. Jeon WJ, Cho SY, Baek SJ, Kim KH. Comparison of the Proseal
LMA and intersurgical i-gel during gynecological laparoscopy.
Korean J Anesthesiol. 2012;63:510–4.
32. Pournajafian A, Alimian M, Rokhtabnak F, Ghodraty M,
Mojri M. Success rate of airway devices insertion laryngeal
mask airway versus supraglottic gel device. Anesth Pain Med.
2015;5(2):e22068.
33. Kannaujia A, Srivastava U, Saraswat N, Mishra A, Kumar A,
Saxena S. A preliminary study of i-gel: a new supraglottic airway
device. Indian J Anaesth. 2009;53(1):526.
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
13