European Journal of Cardiovascular Medicine

Laparoscopic cholecystectomy is commonly performed surgical procedure. Laparoscopic cholecystectomy has become gold standard for surgical management of cholelithiasis because of its advantage of minimal invasiveness, reduced bleeding, less postoperative pain, faster recovery as compared to open surgery. ^(1-3)

Inspite of all these benefits, laparoscopic approach comes with lot of challenges for anaesthesiologists. Creation of pneumoperitoneum and use of reverse Trendelenburg position produces marked physiological changes in cardiovascular and respiratory system. Increased intraabdominal pressure reduces venous return, alters preload and afterload and can result in significant hemodynamic perturbations.

The two most important strategies for maintenance of anaesthesia in laparoscopic cholecystectomy are total intravenous anaesthesia and combines intravenous and inhalation anaesthesia. Propofol based TIVA when delivered via target-controlled infusion (TCI) systems—has garnered attention for minimizing PONV, enhancing hemodynamic control, and facilitating faster emergence from anaesthesia, especially in outpatient and elderly populations ^(4,5,6)

 However, TIVA is costlier than inhalational anaesthesia, need for infusion pumps and BIS monitoring along with limited experience of anaesthetist to use it.

In contrast, Sevoflurane and isoflurane are widely used because of ease of administration and established safety. However, these agents may increase sympathetic stimulation during surgical stress and is associated with higher incidence of PONV. ^(7,8)

Aims and objectives

1. To compare the haemodynamic parameters in TIVA and inhalation agent for maintenance of anaesthesia in laparoscopic cholecystectomy.
2. To observe the incidence of PONV

This is a prospective randomised comparative study that was carried out on ASA GRADE I AND II, patient of either sex, aged 18 -60 yrs, undergoing elective laparoscopic cholecystectomy in GMC Baramulla after obtaining approval from institutional ethical committee and written informed consent from all participants.  A total of 80 patients scheduled for laparoscopic cholecystectomy were screened and recruited for the study based on predefined inclusion and exclusion criteria. Patients were randomly divided into two groups as per intervention by two different anaesthesia techniques. Group P consisted of 40 patients who received propofol infusion for maintenance of anaesthesia and group S who received sevoflurane for maintenance of anaesthesia. Sample size calculation was done on basis of pilot studies done for analysis of effect of TIVA and inhalational anaesthesia for various haemodynamic parameters. keeping power (1 – beta error) at 80 % and confidence level (1- alpha error) at 95%, the minimum sample size required was 36 patients, therefore we included 40 patients in each group The patient and observer of this study were blinded of the group allocation of the patient. Complete double-blinding was not feasible because the anaesthesiologist responsible for intraoperative management needed to know the maintenance agent to titrate therapy safely. To minimise bias patients were blinded to group allocation and postoperative assessments (PONV, recovery times, aldrete score) which was conducted by a clinician who was not involved in intraoperative care and was unaware of the assigned anaesthetic. Haemodynamic and BIS data were recorded directly from monitor outputs and entered into case record form by a data coordinator blinded to allocation. Randomization codes were held separately and were not revealed to outcome assessors until after analysis.

All basic investigations and Pre-anaesthetic checkup were done. All the patients were advised to be nil by mouth for at least 8 hours for heavy solid meal,6 hours for semisolid or juices and 2 hours for plain water prior to time of surgery. On arrival in pre-operative line area, the patient’s vital parameters were recorded and considered as baseline parameters. Group allocation was done as per randomization protocol. In the operation theatre iv line was established and multipara monitor were connected (ECG, NIBP, SPO2 ETCO2 and BIS.) Vitals were monitored at the start of induction, intubation, 15 min, 30 min and 45 min after pneumoperitoneum insufflation, desufflation of pneumoperitoneum and extubation in addition to preset monitoring cycles every 3 min. Injection glycopyrrolate 0.1 mg iv was given, injection fentanyl in dose of 2mcg /kg were administered, while the patient was preoxygenated by 100% oxygen through Bains circuit. After 3 min of pre oxygenation was completed injection propofol 2mg/kg was used as intravenous inducing agent in both groups. Following check ventilation by bag and mask ventilation, muscle relaxation was achieved by 0.5mg/kg atracurium and endotracheal intubation was done.

For maintenance of anaesthesia in Group P, patients were given propofol infusion at a rate of 100- 300mcg/kg/min and in groups S, patients were maintained on sevoflurane inhalation in a concentration of 1.7 % in Inspired air. BIS monitoring was done in both groups to achieve a target of 40 to 60^{. (9)} Haemodynamic parameters were recorded at pre- defined intervals along with regular monitoring at every 3 min. At the end of surgery, injection Ondansetron 0.1mg/kg was given intravenously, time of extubation, eye opening, orientation (by modified Aldrete score) and mobility (recovery profile) were assessed. PONV was observed and recorded immediately after extubation, during early postoperative period (0-4 hours).

Normally, distributed continuous variables were compared using unpaired t test, whereas the Mann- Whitney U -test was used for those variables that were not normally distributed. SSPS 21.0 software was used for statistical analysis and P<0.05 was taken as statistically significant. 

Inclusion criteria:

1. Patient undergoing laparoscopic cholecystectomy
2. ASA I and II patients
3. Age between 18-60 years.
4. Willing to give written informed consent

Exclusion criteria:

1. ASA III and IV patients
2. Uncontrolled hypertension
3. Refusal to participate.
4. Pregnancy and lactating mothers
5. Known allergy to study drugs
6. Difficult airways

TABLE 1: Comparison of age, gender and ASA distribution in studied cases

Table 2: Anthropometric parameters in studied cases

The study was conducted in a prospective randomised way in 80 patients scheduled for laparoscopic cholecystectomy. The patients were divided into two groups, group P and group S with 40 patients each. Group P received propofol infusion for maintenance of anaesthesia and Group S received inhalation agent sevoflurane for maintenance of anaesthesia. Demographic and anthropometric data were tabulated, and test of statistical significance were performed for inter group comparison. The analysis of age and gender distribution showed that the mean age in Group p was 38.41 ± 10.31 years and in group S was 38.95 ± 9.85 years. There was no significant difference in age distribution between the groups. (P = 0.8113).out of 40 patients 21 patients were male and 19 were females, in group S, 26 patients were male and 14 were female. There was no significant difference in gender distribution between the groups (P = 0.3638). distribution of ASA grade I and II patient in both groups was similar without any statistically significant difference (p=0.6219) (Table 1)

The mean weight and distribution range of subjects of both groups was comparable with no statistically significant difference. (P =0.4550) Mean weight in group P was 65.52 ± 9.71 and in group S was 64 ± 8.40. distribution range in group p was 49 -90 kg and in group S was 49 – 85 kg. similarly, in both the groups mean height and distribution range was comparable with no statistically significant difference. (P =0.3079) Mean height in group P was 164.95 ± 10.160 and in group S was 167.275 ± 10.102. distribution range in group p was 190-149 cm and in group S was 187– 149 cm. The mean BMI distribution range of subjects of both groups was comparable with no statistically significant difference (P =0.4550). Mean BMI in group P was 23.91 ± 2.08 and in group S was 22.895 ± 1.709. (Table 2)

On comparison of mean HR between two groups, we found baseline HR in group P was 86 ± 11.01 and in group S was 84 ± 10.16, which was without any statistically significant difference. At induction the HR in group P and group S was 79 ± 9.98 and 80 ± 9.27 respectively which was without any statistically significant difference. At 5 min after pneumoperitoneum insufflation group P was having   mean HR of 82 ± 8.06 and group S had HR of 90 ± 10.11 representing a rise of   4 (bpm) and 6(bpm) respectively. In both groups the heart rate reached its peak at 5 min after pneumoperitoneum insufflation and on inter group comparison the rise in HR was higher in group S and the difference was statistically significant. At 15 min, 30 min and 45 min after pneumoperitoneum insufflation HR in group p were 84 ± 7.98, 82 ± 11.23, 83 ± 8.75 respectively whereas in group S HR at 15 min, 30 min and 45 min after pneumoperitoneum insufflation was 92 ± 11.16,   92 ± 13.87, 89 ± 12.01 respectively. on comparison between the two groups the difference was significantly statistically. On desufflation of pneumoperitoneum the HR in group P was 80 ± 11.01 and in group S was 82 ± 13.98 and the difference was statistically insignificant. At extubation the HR in group P and group S was 80 ± 7.22 and 87 ± 13.49 respectively and difference was statistically significant.

On comparison of Systolic and Diastolic blood pressure between two groups, we found baseline SBP/ DBP in group P was 121 ± 11.02/69 ± 8.78 and in group S was 118 ± 12.09/71 ± 9.62, which was without any statistically significant difference. At induction the SBP and DBP in group P and group S was 111 ± 12.22/67 ±7.64 and 112 ± 10.11/ 68 ± 8.18 respectively which was without any statistically significant difference. At 5 min after pneumoperitoneum insufflation group P was having SBP and DBP of 116 ± 7.46/72 ± 6.36 and group S had SBP and DBP   of 124 ± 9.77/77 ± 7.99 representing a rise of   5/5(mmHg) and 9/5(mmHg) respectively. In both groups the SBP and DBP reached its peak at 5 min after pneumoperitoneum insufflation and on inter group comparison the rise in SBP and DBP was higher in group S than in group P and the difference was statistically significant. At 15 min, 30 min and 45 min after pneumoperitoneum insufflation SBP and DBP   in group p were 119 ± 7.87/72 ±5.87, 117 ± 6.95/73 ± 8.32, 118 ±7.04/73 ± 5.05 respectively whereas in group S, SBP and DBP  at 15 min, 30 min and 45 min after pneumoperitoneum insufflations was 125 ± 8.09/75 ±5.97, 122 ± 11.32/79 ±6.09, 123 ± 12.64/80 ± 6.09 respectively. on comparison between the two groups the difference was significantly statistically. On desuffalation of pneumoperitoneum the SBP and DBP in group P was 115 ± 5.43/ 71 ± 8.32and in group S was 119 ± 6.89 / 75 ± 6.02 and the difference was statistically significant. At extubation the SBP and DBP in group P and group S was 119 ± 4.99/73 ±5.05 and 125 ± 12.70/81±4.27 respectively and difference was statistically significant.

On comparison of mean arterial pressure between two groups, we found baseline mean arterial pressure in group P was 86. 3 ± 5.99 and in group S was 86.7 ± 6.22, which was without any statistically significant difference. At induction the mean arterial pressure in group P and group S was 81.7 ± 6.02 and 82.7 ± 6.78 respectively which was without any statistically significant difference. At 5 min after pneumoperitoneum insufflation group P was having mean arterial pressure of 86.7 ± 7.46 and group S had mean arterial pressure of 92.7 ± 8.77 representing a rise of   5 (mmHg) and 10(mmHg) respectively. In both groups the mean arterial pressure reached its peak at 5 min after pneumoperitoneum insufflation and on inter group comparison the rise in mean arterial pressure was higher in group S than in group P and the difference was statistically significant. At 15 min, 30 min and 45 min after pneumoperitoneum insufflation mean arterial pressure   in group p were 87.7 ± 6.07, 87.7 ± 8.97, 90 ± 8.65 respectively whereas in group S, SBP and DBP at 15 min, 30 min and 45 min after pneumoperitoneum insufflation was 91.7 ± 6.09, 93.3 ± 7.46, 94.3 ± 7.74 respectively. on comparison between the two groups the difference was significantly statistically. On disaffiliation of pneumoperitoneum the mean arterial pressure in group P was 85.7 ± 5.02 and in group S was 89.7 ± 7.92 and the difference was statistically insignificant. At extubation the mean arterial pressure in group P and group S was 88.3 ± 8.76 and 95.7 ± 9.89 and difference was statistically significant.

In the present study, the incidence of postoperative nausea and vomiting was significantly lower in group P compared to group S. In Group P, only 3 out of 40 patients (7.5%) experienced PONV, whereas in Group S, 16 out of 40 patients (40%) reported PONV.  The difference between the two groups was found to be statistically significant. (P=0012)

TABLE 3: comparison of heart rate in group P and group S

TABLE 4: comparison of systolic blood pressure in group P and group S

TABLE 4: comparison of Diastolic blood pressure in group P and group S

TABLE 6: comparison of mean arterial pressure in group P and group S

TABLE 7: Incidence of post operative nausea and vomiting.

This randomized, prospective study demonstrated that propofol-based TIVA provides superior intraoperative haemodynamic stability and a markedly lower incidence of postoperative nausea and vomiting (PONV) compared with sevoflurane in patients undergoing laparoscopic cholecystectomy. Both groups exhibited haemodynamic alterations after pneumoperitoneum, but the magnitude of rise in heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure was significantly greater in the sevoflurane group, consistent with earlier observations (10,11). The PONV incidence was also substantially lower in the propofol group, echoing consistent findings across diverse surgical populations (12,13,6).

Several randomized trials corroborate our results. Çaparlar et al. compared propofol–remifentanil TIVA with sevoflurane in outpatient laparoscopic cholecystectomy and found greater haemodynamic stability and less PONV in the propofol group (10). Janardhana et al. also reported reduced haemodynamic fluctuations and lower PONV with TIVA compared to inhalational anaesthesia (14) Bansal et al. demonstrated that propofol alone conferred the lowest PONV rates, while combination regimens showed intermediate benefit (6). These align closely with our observations.

Meta-analyses reinforce propofol’s antiemetic efficacy. Qin et al. pooled randomized controlled trials and confirmed that TIVA with propofol significantly reduced PONV, although haemodynamic results varied depending on co-administered opioids and anaesthetic protocols(13). Sneyd et al. earlier demonstrated in a meta-analysis that propofol itself has intrinsic antiemetic properties (15). Our finding of 7.5% PONV in the propofol group versus 40% with sevoflurane underscores this pharmacological advantage.

Not all studies agree on haemodynamic superiority. Some report comparable haemodynamic outcomes when sevoflurane is titrated using BIS or combined with potent opioids such as remifentanil (16). Dhande et al. found that during induction, propofol caused greater reductions in MAP than sevoflurane, suggesting that timing (induction vs. maintenance) critically influences results (17). Moreover, certain trials noted faster recovery and extubation with sevoflurane, despite its higher PONV risk (11). Thus, anaesthetic choice must weigh haemodynamic stability, recovery profiles, and postoperative comfort.

Mechanistically, propofol’s central sympatholytic effects blunt catecholamine surges, attenuating tachycardia and hypertension during pneumoperitoneum (18) .Sevoflurane, conversely, may enhance sympathetic responses under surgical stress, leading to more pronounced increases in HR and MAP (19). Propofol’s direct antiemetic action, mediated via interaction with chemoreceptor trigger zones and 5-HT₃ pathways, accounts for consistent reductions in PONV (8,15). Volatile agents, by contrast, are independently associated with increased PONV risk (20).Our findings complement studies in high-risk groups too. Yao et al. reported in elderly patients undergoing laparoscopic surgery that propofol provided better haemodynamic stability, improved postoperative cognition, and lower PONV compared with sevoflurane(21). Aijima et al. in a large cohort also demonstrated reduced haemodynamic perturbations and PONV with TIVA(22). Real-world confirmation from such studies strengthens the generalisability of our findings. Nevertheless, variability across trials suggests context matters. Pneumoperitoneum pressure, surgical duration, patient demographics, and antiemetic prophylaxis can modulate outcomes. In our trial, BIS guidance, standardized opioid dosing, and uniform antiemetic use likely accentuated the differences between groups. This design parallels protocols in which clear benefits of TIVA have been consistently demonstrated (6,11). Clinically, the implications are significant. Propofol-based TIVA appears preferable in patients at high risk of PONV (e.g. females, non-smokers, those with prior history) or those with cardiovascular comorbidities where haemodynamic perturbations could be deleterious (8,20). Sevoflurane may still be reasonable in lower-risk individuals or where resource limitations (infusion pumps, BIS monitors) constrain TIVA use (16). The trade-off between faster recovery with sevoflurane and lower PONV and haemodynamic stability with propofol must be considered on a patient-by-patient basis.

Comparative Evidence Table

Our study adds to this literature by providing evidence in a BIS-guided, standardized-opioid context, where differences between agents are more clearly observed. The marked difference in PONV (7.5% versus 40%) is particularly striking, reinforcing systematic evidence that propofol’s antiemetic effect is robust and clinically meaningful. The haemodynamic stability we observed further suggests that propofol should be considered in patients where cardiovascular perturbations carry added risk, although sevoflurane may remain a reasonable alternative in low-risk cases when resource limitations preclude the use of TIVA.

Overall, our findings complement the growing consensus that propofol-based TIVA improves perioperative outcomes, especially in high-PONV-risk patients or those vulnerable to haemodynamic fluctuations. At the same time, differences across trials highlight that optimal anaesthetic choice should be individualized, considering patient risk profile, surgical characteristics, and resource availability.

LIMITATION

The study included only ASA I and II patients whereas ASA III / IV patients with significant co-morbidities, were excluded. These high risk patients are more susceptible to result of haemodynamic perturbation. Moreover, study was conducting in patients requiring anaesthesia for an average of one hour, so effect on longer procedures couldn’t be evaluated.

Blinding limitation: the anaesthesiologist administering the intervention could not be blinded for safety and practical reason; this may introduce performance bias. To mitigate this, we blinded the patients and postoperative outcome assessors and used automated monitor recording for intraoperative haemodynamic variables. These steps reduce but do not completely eliminate the potential for bias

We conclude, that Propofol based TIVA has better intraoperative haemodynamic stability advantages over Sevoflurane in terms of intraoperative hemodynamic stability and reduced postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy.  These advantages could translate into better patient outcomes., improved patient satisfaction, and reduced healthcare costs.

1. Braschi C, Liu JK, Moazzez A, Petrie BA. Is laparoscopic surgery safe for elderly patients with diverticulitis? A national database study. Langenbeck's Arch Surg. 2022;407:3599–606. doi:10.1007/s00423-022-02695-2.
2. Xiang D, Xing H, Zhu Y. A predictive nomogram model for postoperative delirium in elderly patients following laparoscopic surgery for gynecologic cancers. Support Care Cancer. 2022;31:24. doi:10.1007/s00520-022-07517-1.
3. Ma Y, Zang X, Qi Y, Ju B, Ni G. The curative effect of laparoscopic hysterectomy combined with pelvic floor suspension in patients with uterine prolapse and its effect on the levels of IGF-1 and TNF-alpha. J Basic Clin Pharm Toxicol. 2020;127:84–5.
4. Varsha AV, Unnikrishnan KP, Saravana Babu MS, Raman SP, Koshy T. Comparison of Propofol-Based Total Intravenous Anesthesia versus Volatile Anesthesia with Sevoflurane for Postoperative Delirium in Adult Coronary Artery Bypass Grafting Surgery: A Prospective Randomized Single-Blinded Study. J Cardiothorac Vasc Anesth. 2024;38(9):1932–40.
5. Cho SA, Ahn SM, Kwon W, Sung TY. Comparison of remimazolam and desflurane in emergence agitation after general anesthesia for nasal surgery: a prospective randomized controlled study. Korean J Anesthesiol. 2024;77(4):432–40.
6. Bansal T, Singhal S, Kundu K. Prospective randomized double-blind study to evaluate propofol and combination of propofol and sevoflurane as maintenance agents in reducing postoperative nausea and vomiting in female patients undergoing laparoscopic surgery. Med Gas Res. 2022;12:137–40. doi:10.4103/2045-9912.337994.
7. Hendrix JM, Kramer J. Anesthesia Inhalation Agents and Their Cardiovascular Effects. [Updated 2025 Mar 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541090/
8. Apfel CC, Stoecklein K, Lipfert P. PONV: a problem of inhalational anaesthesia? Best Pract Res Clin Anaesthesiol. 2005;19(3):485–500. doi:10.1016/j.bpa.2005.03.001.
9. Wang E, Wang L, Ye C, Luo N, Zhang Y, Zhong Y, et al. Effect of electroencephalography spectral edge frequency (SEF) and patient state index (PSI)-guided propofol-remifentanil anesthesia on delirium after laparoscopic surgery: the eMODIPOD randomized controlled trial. J Neurosurg Anesthesiol. 2022;34:183–92. doi:10.1097/ANA.0000000000000823.
10. Çaparlar CÖ, Çolak T, Çolak Ş, Dikmen B. Fast-track anesthesia: remifentanil-propofol total intravenous anesthesia vs sevoflurane for outpatient laparoscopic cholecystectomy. J Clin Anesth. 2017;39:95–100. doi:10.1016/j.jclinane.2017.03.001.
11. Khare A, Mathur V, Jain K, Sethi SK, Garg D, Vishnoi R. A prospective randomized study for comparison of haemodynamic changes and recovery characteristics with propofol and sevoflurane anaesthesia during laparoscopic cholecystectomies. Int J Res Med Sci. 2016;4(8):3019–25. doi:10.18203/2320-6012.ijrms20164187.
12. Turan A, Yildirim V, Kiziltunc E, et al. Comparison of propofol and sevoflurane anaesthesia in terms of postoperative nausea-vomiting complication in cardiac surgery patients under ERAS protocol: a prospective randomized study. Turk J Anaesthesiol Reanim. 2024;52(3). doi:10.5152/TJAR.2024.241622.
13. Qin P, Ding Y, Wu C, et al. Propofol versus inhalational anesthesia: a systematic review and meta-analysis of randomized controlled trials. PLoS One. 2016;11(6):e0158139. doi:10.1371/journal.pone.0158139.
14. Janardhana J, et al. RCT comparing TIVA vs inhalational in laparoscopic cholecystectomy. J Clin Diagn Res. 2018;12(4):UC01–UC05.
15. Sneyd JR, Carr A, Byrom WD, Bilski AJ. A meta-analysis of propofol antiemetic efficacy in adults. Eur J Anaesthesiol. 1998;15(4):433–45. doi:10.1046/j.1365-2346.1998.00233.x.
16. Wolf A, Weir P, Segar P, et al. Combined intravenous and inhalation anesthesia: benefits and risks. BMC Anesthesiol. 2021;21:225. doi:10.1186/s12871-021-01467-9.
17. Dhande DV, Mohan GV, Bhatia PK, et al. Hemodynamic stability, patient acceptance and cost of intravenous propofol and inhalational sevoflurane for induction of anaesthesia: a prospective, randomized comparative study. J Clin Diagn Res. 2020;14(5):UC01–UC05. doi:10.7860/JCDR/2020/44129.13733.
18. Larsen R, Rathgeber J, Bagdahn A, et al. Effects of propofol on haemodynamics and myocardial oxygen balance. Br J Anaesth. 1988;61(6):677–83. doi:10.1093/bja/61.6.677.
19. Watcha MF, White PF. Postoperative nausea and vomiting: its etiology, treatment, and prevention. Anesthesiology. 1992;77(1):162–84. doi:10.1097/00000542-199207000-00023.
20. Kim M, Lee JH, Lee KY, et al. The risk of postoperative nausea and vomiting between surgical patients receiving propofol and sevoflurane anesthesia: a matched study. Anesth Analg. 2016;123(5):1130–6. doi:10.1213/ANE.0000000000001564.
21. Yao Y, Deng Y, Wang L, et al. Propofol versus sevoflurane anesthesia in geriatric laparoscopic surgery: impact on hemodynamics and cognitive outcomes. Front Med (Lausanne). 2024;11:1178992. doi:10.3389/fmed.2024.1178992.
22. Aijima R, Yoshida H, Tanaka K, et al. Hemodynamic stability and postoperative nausea/vomiting in total intravenous anesthesia compared with volatile anesthesia: a retrospective cohort study. BMC Anesthesiol. 2024;24:55. doi:10.1186/s12871-024-
23. Saha SC, Seraji SI. A Comparative Study of Propofol and Sevoflurane for General Anesthesia in Laparoscopic Appendectomy. Sch J App Med Sci. 2023;11(4):753–7.