Esketamine-Based Opioid-Free versus Opioid-Based Anesthesia for Recovery Quality After Laparoscopic Transabdominal Preperitoneal Repair: A Randomized Noninferiority Trial

Purpose: This study aimed to compare the quality of postoperative recovery between esketamine-based opioid-free anesthesia (OFA) and opioid-based anesthesia (OBA) in patients undergoing laparoscopic transabdominal preperitoneal (TAPP) repair. Patients and Methods: In this prospective, randomized, double-blind, noninferiority trial, 126 adults scheduled for elective laparoscopic TAPP repair were randomized to OFA (n = 63) or OBA (n = 63) group. The OFA group received esketamine (0.5 mg·kg − 1 induction, 0.4– 0.5 mg·kg − 1 ·h − 1 maintenance), while the OBA group received sufentanil (0.4 μg·kg − 1 induction) and remifentanil (0.1– 0.2 μg·kg − 1 ·min − 1 maintenance). The primary outcome was the 15-item Quality of Recovery (QoR-15) score at 24 hours postoperatively, with a noninferiority margin of − 8. Secondary outcomes included pain scores, rescue analgesia, sleep quality, safety outcomes. Results: The OFA group showed a higher QoR-15 score at 24 hours postoperatively than the OBA group (median difference: 2; median [IQR]: 129 [125 to 132] vs 127 [123 to 130]; 95% CI, 0 to 4; P =0.014). Pruritus incidence was lower ( P =0.027), vasopressor use was reduced (P = 0.012), and hypotensive episodes tended to be fewer ( P =0.106) in the OFA group. Pain scores on coughing at 24 and 48 hours postoperatively were also lower in the OFA group ( P =0.002 and P < 0.001, respectively). Conclusion: Esketamine-based OFA provided a noninferior quality of postoperative recovery compared with OBA in patients undergoing laparoscopic TAPP repair, offering a safer alternative to OFA regimens that minimizes opioid-related complications while maintaining perioperative comfort and supporting enhanced recovery. Keywords: esketamine, transabdominal preperitoneal, noninferiority trial, opioid-free anesthesia, postoperative recovery