PURPOSE: Remimazolam toluene sulfonic acid is a short-acting benzodiazepine primarily studied for intravenous anesthesia. To date, few studies have focused on the effects of the combination of remimazolam and inhalation anesthesia or its impact on postoperative recovery. Our study aims to investigate the influence of remimazolam combined with sevoflurane for general anesthesia maintenance on postoperative recovery quality in elderly patients undergoing laparoscopic abdominal surgery. METHODS: A total of 109 patients, aged 60 to 80 years old, scheduled for laparoscopic gallbladder or hernia surgery were randomly divided into two groups: remimazolam group (Group R) and remimazolam-sevoflurane combination group (Group S). Group R had remimazolam for anesthesia maintenance, while Group S received remimazolam and sevoflurane. Both groups followed the same induction protocol, with bispectral index (BIS) maintained between 40 and 60 during surgery. The primary outcome was assessed with the Quality of Recovery (QoR)-15 score. The secondary outcomes included loss of consciousness (LoC), perioperative hemodynamic variables, extubation time, and the incidence of postoperative adverse events. During the study, 7 patients were lost to follow-up, and finally, 102 patients were included in the statistical analysis. The data will be analyzed in a modified full analysis set. RESULTS: Group S had higher QoR-15 and physical comfort scores on postoperative day (POD) 1 and POD3 compared to Group R (135.0[8.0] vs. 132.0[11.0], P = 0.004
143.0[6.0] vs. 141.0[7.0], P = 0.007). Despite using less remifentanil (P = 0.021), Group S had a significantly longer extubation time (P = 0.048). There were no significant differences in induction time, perioperative hemodynamic variables, or postoperative adverse events between the groups. CONCLUSION: Combining remimazolam with sevoflurane improves postoperative recovery quality in elderly patients undergoing laparoscopic abdominal surgery. This approach ensures optimal anesthesia depth and sedation while minimizing adverse events and complications. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2200065332. Date of registration: 02/11/2022.