Background Opioid‐free anesthesia (OFA) has been proposed as a strategy to reduce opioid exposure and opioid‐related adverse events in laparoscopic surgery. However, evidence from randomized trials remains heterogeneous regarding pain control, postoperative nausea and vomiting (PONV), and opioid consumption. Methods We performed a systematic review and meta‐analysis of randomized controlled trials (RCTs) comparing OFA with opioid‐based anesthesia (OBA) in adult patients undergoing elective laparoscopic surgery. Primary outcomes included postoperative pain scores (0–10 scale), PONV, and 24‐h opioid consumption. Secondary outcomes included hemodynamic events, recovery quality, and hospital length of stay. Results Sixteen RCTs ( n = 1322) were included. OFA reduced PONV by approximately 40% (RR 0.60; 95% confidence interval CI 0.48–0.75) and modestly decreased postoperative opioid use by 6.4 mg morphine equivalents (95% CI −9.1 to −3.7). Pain scores during the first 24 h were similar between OFA and OBA (MD −0.3 on a 0–10 scale; 95% CI −0.7 to +0.1). Hemodynamic instability (bradycardia and hypotension) occurred more frequently with dexmedetomidine‐based regimens but was transient and clinically manageable. No differences were observed in recovery time or hospital length of stay. Conclusion OFA provides clinically meaningful reductions in PONV and opioid exposure without compromising postoperative analgesia. These findings support OFA as a safe and effective alternative to OBA in laparoscopic surgery and a potential component of enhanced recovery pathways.
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