INTRODUCTION
Most of gynaecological procedures can be performed laparoscopically. It reduces hospital stay of the patient, also improves the cosmetic results and patient satisfaction.1 Ambulatory anaesthesia fastens the patient’s outcome, recovery. Resuming early to day to day life chores gives cost effectiveness to this type of procedures. Anaesthesia plays utmost important role to the outcome and recovery of the patients undergoing these day care surgeries. We can use general anaesthesia, regional anaesthesia, monitored anaesthesia care for different type of surgeries as and when required. General anaesthesia is most commonly used because it is safe and familiar to most of anaesthesiologist. The use of inhalational agents such as desflurane, sevoflurane made the postoperative recovery easy for the patients. These volatile anaesthetic agents have low solubility, gives faster emergence early postoperative recovery as compared with older ones.
Sevoflurane and Desflurane are not ideal anaesthetic agents but are fulfilling most of the criteria. Both these agents have lower solubilities permits more precise control over the delivery of anaesthesia and more rapid recovery from anaesthesia. At higher concentrations desflurane can cause airway irritability, sevoflurane may not. As for this reason sevoflurane is used in induction of paediatric anaesthesia.2 In this study, we have used both the agents randomly on patients undergoing laparoscopic gynaecological surgeries. The effect of these agents on haemodynamic parameters, intraoperatively, postoperatively have been studied. As post-operative recovery is important for the success of ambulatory anaesthesia. It has been studied in both the agents and accordingly the best inhalational anaesthetic agent is decided.

MATERIAL AND METHODS
This prospective, randomized, interventional, single blind study was conducted on patients undergoing laparoscopic gynaecological surgeries over a period of two years. Permission and approval was taken from ethics committee of the institution. Written inform consent prior to one day of surgery was taken. The patients were explained on the day prior to surgery that she is the part of study and the type of anaesthesia to be administered. A patient information sheet provided to her and relatives in the language she and relatives understands.
Inclusion criteria
• Age: 18 years to 60 years 

• Female patients
• ASA I and II
• Surgery duration less than 2hrs.
Exclusion criteria
• Pregnant patients, breast feeding patients.
• Patients with significant cardiopulmonary diseases, hepatic and renal dysfunction, endocrine and neurological disturbances or psychiatric disorders.
• Patients with history of drug abuse or drug allergy
• Patient’s refusal to consent. 

Sample size
For desflurane (Group D), sample size was calculated by using the formula-
N={S.D./S. E}2 where, Z=95% =1.96. Sample size N= P(100-P)/(S.E.)2
Formulae for sample size
Comparison of means (two group) 
(alpha = 0.05, Beta = 0.2, power 80%)
-Between Group comparison (unpaired)
n =16 x (S.D./M1-M2)2 -within group comparison (paired) n = 8 x (S.D./M1-M2)2.
As per above formula sample size for each group is 19. However, 19 sample size was not enough for most statistical analysis, and since resources like patient quantity, investigative tools, time for research exist in sufficient quantity, it was planned to enroll minimum of 30 cases for each group (total 60) for present study. 

Methodology
A total 60 female patients between 18 to 60 years of age with ASA I or II grade and scheduled for elective laparoscopic gynaecological surgery under general anesthesia were included in this study.
These 60 Patients were randomly allocated into two groups of each with the help of a computer-generated table of random numbers.

• Group S (n=30): received inhalational agent sevoflurane induction and maintenance anaesthesia.
• Group D (n=30): received inhalational desflurane induction and maintenance anaesthesia.

Statistical analysis
Data obtained was compiled on a MS Office Excel Sheet (v 2010, Microsoft Redmond Campus, Redmond, Washington, United States). Data was subjected to statistical analysis using Statistical package for social sciences (SPSS v 21.0, IBM). Descriptive statistics like frequencies and percentage for categorical data, Mean and SD for numerical data has been depicted. Normality of numerical data was checked using Shapiro-Wilk test and was found that the data followed a normal curve; hence parametric tests have been used for comparisons. Inter group comparison (2 groups) was done using t-test. Comparison of frequencies of categories of variables with groups was done using Chi-square test.
For all the statistical tests, p<0.05 was statistically significant, keeping α error at 5% and β error at 20%, thus giving a power to the study as 80%.

RESULTS

In our study mean age of group D was 29.6±6.3 and group S was 30±6.19. ASA status, in group D was 1.07±0.254 and in group S was 1.03±0.138. The mean weight of group D was 61.37±5.62 and group S was 61.4±4.87. The mean height in group D was 157.73±6.08 cm and group S was 159.2±5.47 cm. Table no.1 shows the comparison between age, weight, height, and ASA grading. The difference between group D and group S was statistically non-significant (p>0.05).

 

Table 1: Distribution of patient characteristics

After intubation and after skin incision heart rate of both the groups have increased up to ±20% of the baseline value. The heart rate in both groups were comparable. There was no statistical significance found by applying student t-test. (p>0.05) for all the time intervals mentioned above. After creating pneumoperitoneum, the heart rate in both groups were comparable for all time intervals. There was no statistical significance found by applying student t-test. (p>0.05) for all the time intervals mentioned above.

Table 2: Mean heart rate at various intervals

After intubation and after skin incision SBP and DBP of both the groups have increased up to ± 20% of the baseline value. The SBP and DBP in both groups were2 comparable. There was no statistical significance found by applying student t-test. (p>0.05) for all the time intervals. (Table 3).

 

Table 3: Mean systolic and diastolic blood pressure (mmHg) at various intervals

Time (min)	Systolic BP		p value	Diastolic BP			p value
	Desflurane Group D (n=30)	Sevoflurane Group S (n=30)		Desflurane Group D (n=30)	Sevoflurane Group S (n=30)
Baseline	120.40±6.089	118.00±11.033	0.301	72.37±5.359	69.57±8.443	0.6529
After pre-medication	117.93±5.765	116.07±10.511	0.198	70.07±5.179	67.30±8.209	0.0619
1 min after induction	115.83±5.372	114.00±10.171	0.193	71.70±5.324	69.23±7.877	0.0803
1 min after intubation	124.40±5.23	123.67±9.488	0.356	74.33±5.466	72.33±7.877	0.117
After skin incision	130.13±3.636	127.53±7.942	0.542	76.97±5.816	74.60±7.823	0.0944
After pneumoperitoneum
0	126.63±3.134	124.23±7.911	0.0639	74.93±6.085	72.57±7.994	0.1010
15	124.03±3.200	121.60±7.907	0.0618	73.37±5.647	70.53±8.224	0.0953
30	122.00±3.184	119.57±7.775	0.0590	71.00±5.601	68.53±8.500	0.0634
45	119.97±3.347	117.67±7.857	0.0728	68.73±5.582	66.53±8838	0.1268
60	117.90±3.477	115.67±7.410	0.0702	66.77±5.562	65.13±9.008	0.2000
75	115.83±3.373	113.67±7.0041	0.0701	65.43±6.350	63.27±8.581	0.1318
90	113.77±4.091	111.77±6.645	0.0729	63.73±6.378	61.47±8.173	0.1180
After deflation	122.73±5.669	122.93±6.659	0.901	76.17±4.316	73.97±6.128	0.113
After extubation	121.07±5.753	120.90±6.717	0.4590	73.70±4.3561	71.90±6.0648	0.0959

In present study, response to painful stimulus calculated for both the groups. It was achieved in the group D in (2.50 ± 0.799) minutes and in group S in around (3.89 ±0.930) minutes. (p=0.000). The difference was statistically highly significant. It indicates that response to painful stimulus was achieved earlier in patients who received desflurane as compared to patients who received sevoflurane. For spontaneous eye-opening patients who received desflurane took (3.19±0.794) minutes and who received sevoflurane took (4.94±0.74) minutes. The difference was statistically significant between two groups (p=0.000). Obeying commands in group D was achieved within (2.78±0.67) minutes and in group S was achieved within (4.28±0.633) minutes. Limb lift in group D achieved within (5.04±0.834) minutes and group S achieved in (7.73±1.08) minutes. The difference was statistically significant between two groups (p<0.0001).

Table 4: Inter group Comparison of others and modified alderate score

Drowsiness were found out in 1 patient in group D and 1 in group S. There were 10 patients presented with PONV who received desflurane and 14 patients who received sevoflurane. Sore throat was present in 3 patients receiving desflurane and in 1 patient receiving sevoflurane. All these parameters were statistically analysed by using chi-square test in which result came nonsignificant for all the parameters p>0.05.

 DISCUSSION

In our study demographic parameters like age, body weight, height and ASA classification were noted and analysed statistically between two groups by using student ‘t’ test. The difference between group D and group S was statistically non-significant (p>0.05). Chudasama PA et al who studied the Comparison of haemodynamic parameters and recovery characteristics between sevoflurane and desflurane in patients undergoing day-care surgical procedure. All demographic parameters are comparable in their study.³ White PF et al studied desflurane versus sevoflurane for maintenance of outpatient anesthesia and the effect on early versus late recovery and perioperative coughing. The two study groups had comparable demographic characteristics.⁴ Our findings were consistent with above study. The MAP in both groups were comparable for all time intervals. There was no statistical significance found by applying student t-test. (p>0.05) for all the time intervals. Jindal et al suggested that desflurane and sevoflurane both provide similar haemodynamic conditions during maintenance period.⁵ Patel et al suggested that sevoflurane and desflurane both provide similar intraoperative haemodynamic condition during maintenance period.⁶ Nathanson et al found that intraoperative haemodynamic parameters are same with both the groups.⁷ Gergin et al concluded that desflurane, like sevoflurane, maintains haemodynamic stability during intraoperative period.⁸ Our findings were consistent with all above studies. Intraoperative parameters studied by Chudasama PA et al depicts that desflurane gives more hemodynamic stable picture in day care surgeries. In our study the findings regarding intraoperative hemodynamic parameters were inconsistent with this study.³ In our study we found out that achievement of modified Alderate score was earlier in desflurane group. In Jindal et al study time to achieve modified alderate score in group D was (10.8 ± 3.77) minutes and in group S was (16.2 ± 3.87) minutes. Our result is consistent with above study.⁵ Patel et al study stated that the response to painful stimuli, spontaneous eye opening and limb lift has been earlier achieved in desflurane than sevoflurane.⁹ Our findings were also consistent with above study. Jadhav et al studied recovery parameters in both the agents in 80 patients. In their study time to eye opening was achieved earlier in desflurane than sevoflurane. And overall early postoperative recovery is achieved earlier with desflurane than sevoflurane. They used Fast track criteria for discharge from PACU.¹⁰ Kotwani et al found out that recovery is achieved earlier in desflurane compared to sevoflurane. They used steward criteria for discharged from PACU. Our findings were consistent with this literature.⁶ Study by Nathanson et al suggested that there in early recovery period desflurane has a faster recovery profile than sevoflurane. But overall recovery and readiness to home discharge is same for both the agents. Our study result was consistent with early recovery parameter.⁷ Postoperative complications were statistically analysed by using chi-square test in which result came nonsignificant for all the parameters p>0.05. Study by Nathanson et al suggested that postoperative side effects were similar in both the groups.⁷ Study by Jadhav et al also suggested that there was no significant difference in postoperative complications in both the groups.¹⁰ Study by Jindal et al suggested that there was no difference between complications between study drug groups.⁵ Our results were consistent with above studies.

CONCLUSION

Desflurane and sevoflurane does not differ in intraoperative and postoperative hemodynamic parameters, and postoperative adverse effects, however early recovery is achieved with desflurane. Desflurane is better choice in ambulatory laparoscopic gynaecological surgeries.

 

REFERENCES