Anesthetic management of a morbidly obese patient undergoing laparoscopic right nephrectomy

: A 41-year-old man weighing 196 kg (body mass index of 62.5 kg m2) with renal cancer was scheduled for laparoscopic right nephrectomy. On the day before surgery, we confirmed the intraoperative patient position with the patient and medical staff to prevent neurological deficit during the intraoperative period. For postoperative analgesia and prevention of respiratory complications, an epidural catheter was inserted under radiography and ultrasound guidance. Difficult airway was anticipated, and we attempted awake intubation in the left lateral position with Airwayscope (AWS). The vocal cord was visualized with AWS; however, because of his small oral cavity, we could not place the Intlock of AWS to insert the tracheal tube appropriately. Using a flexible fiberoptic bronchoscope under AWS guidance, the trachea was intubated. During neumoperitoneum at 12 mmHg, mechanical ventilation was achieved without hypercapnia, hypoxia or elevated airway pressure, with rate of 12 min-1, FIO2 of 0.6, PIP of 25 cmH2O and PEEP of 8 cmH2O. The surgery was completed and his trachea was extubated in the operating room. He did not develop any perioperative complications and was discharged on the 10th day after the surgery.