Laparoscopic surgery has become the preferred approach for a wide range of abdominal procedures because of its minimally invasive nature, reduced tissue trauma, shorter hospital stay, and faster return to normal activities compared with open surgery [1]. Common laparoscopic procedures, including cholecystectomy, appendectomy, hernia repair, and gynecological interventions, are now routinely performed worldwide. Despite these advantages, postoperative pain, postoperative nausea and vomiting (PONV), and delayed recovery continue to represent significant challenges in the perioperative management of patients undergoing laparoscopic surgery [2]. Effective control of these postoperative complications is essential for improving patient satisfaction, reducing hospital stay, and facilitating early mobilization.

Traditionally, opioids have served as the cornerstone of perioperative analgesia because of their potent analgesic properties. Opioid-based anesthesia (OBA) typically involves the administration of agents such as fentanyl, morphine, remifentanil, or sufentanil during and after surgery to achieve adequate analgesia and hemodynamic stability [3]. Although opioids remain highly effective in controlling acute postoperative pain, their use is frequently associated with several undesirable adverse effects, including respiratory depression, excessive sedation, ileus, urinary retention, pruritus, opioid-induced hyperalgesia, and postoperative nausea and vomiting [4]. Moreover, increasing concerns regarding opioid dependence, misuse, and the global opioid crisis have prompted healthcare systems to reconsider conventional perioperative analgesic strategies [5].

Postoperative nausea and vomiting remains one of the most common and distressing complications following general anesthesia. The incidence of PONV following laparoscopic surgery has been reported to range from 30% to 70%, depending upon patient-related and procedure-related risk factors [6]. Laparoscopic procedures are particularly associated with an increased risk of PONV due to pneumoperitoneum, peritoneal stretching, use of volatile anesthetics, and perioperative opioid administration [7]. PONV not only adversely affects patient comfort and satisfaction but may also lead to dehydration, electrolyte imbalance, aspiration, prolonged post-anesthesia care unit (PACU) stay, unanticipated hospital admission, and increased healthcare costs [8]. Consequently, minimizing factors that contribute to PONV has become a major objective in modern perioperative care.

Enhanced Recovery After Surgery (ERAS) programs have emerged as evidence-based multidisciplinary pathways designed to optimize perioperative care and accelerate postoperative recovery. Since their introduction, ERAS protocols have consistently demonstrated reductions in postoperative complications, length of hospital stay, and healthcare expenditure across multiple surgical specialties [9]. A fundamental component of ERAS pathways is the reduction of perioperative opioid exposure through the implementation of multimodal analgesic techniques [10]. Contemporary ERAS guidelines advocate opioid-sparing or opioid-free approaches whenever feasible, emphasizing the use of multiple analgesic modalities acting through different mechanisms to achieve effective pain control while minimizing opioid-related adverse effects [10,11].

Multimodal analgesia (MMA) refers to the simultaneous use of two or more analgesic interventions with distinct mechanisms of action to enhance analgesic efficacy and reduce reliance on opioids [12]. Common components of multimodal analgesia include acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), local anesthetic infiltration, regional anesthesia techniques, N-methyl-D-aspartate receptor antagonists such as ketamine, alpha-2 adrenergic agonists, and gabapentinoids [13]. By targeting multiple pain pathways, multimodal analgesia provides superior pain control while reducing total opioid consumption and opioid-related side effects [12].

Recent evidence suggests that opioid-sparing and multimodal anesthetic strategies may significantly improve postoperative outcomes in laparoscopic surgery. Several randomized controlled trials and systematic reviews have demonstrated that multimodal analgesia is associated with reduced postoperative pain scores, lower incidence of PONV, earlier ambulation, shorter PACU stay, and enhanced patient satisfaction compared with conventional opioid-based regimens [11,14]. Furthermore, opioid-free and opioid-sparing anesthesia techniques have shown promising results in reducing postoperative complications without compromising analgesic efficacy [15]. In gynecological laparoscopic procedures, opioid-sparing anesthesia has been associated with a significant reduction in postoperative nausea and vomiting while maintaining comparable postoperative analgesia [14].

Despite growing international evidence supporting multimodal analgesia, its implementation in low- and middle-income countries remains inconsistent. In Pakistan, perioperative pain management practices continue to rely predominantly on opioids, particularly in public-sector tertiary care hospitals. Limited local evidence exists regarding the comparative effectiveness of multimodal analgesia versus conventional opioid-based anesthesia in patients undergoing laparoscopic surgery. Differences in patient demographics, institutional resources, clinical practices, and perioperative protocols necessitate locally generated evidence to guide anesthesia practice and facilitate the integration of ERAS principles into routine surgical care.

Ayub Teaching Hospital, Abbottabad, is one of the largest tertiary care teaching hospitals in Khyber Pakhtunkhwa and performs a substantial number of elective laparoscopic procedures annually. Evaluating the effectiveness of multimodal analgesia within this setting may provide valuable insights into its feasibility and clinical benefits in resource-constrained environments. Additionally, understanding its impact on postoperative recovery and PONV could support the development of institutional opioid-sparing protocols and enhance patient-centered perioperative care.

Therefore, the present study was designed to compare multimodal analgesia with conventional opioid-based anesthesia among patients undergoing elective laparoscopic surgery at Ayub Teaching Hospital, Abbottabad. The primary objective was to evaluate differences in postoperative recovery time and incidence of postoperative nausea and vomiting. Secondary objectives included comparison of postoperative pain scores, opioid consumption, and duration of PACU stay between the two anesthetic approaches.

This prospective comparative study was conducted in the Department of Anaesthesia, Ayub Teaching Hospital, Abbottabad, Pakistan, over a period of fifteen months from January 2025 to March 2026. Prior to commencement, ethical approval was obtained from the Institutional Ethical Review Committee of Ayub Teaching Hospital and Ayub Medical College, Abbottabad. Written informed consent was obtained from all participants after explaining the purpose, benefits, and potential risks of the study. The study was conducted in accordance with the principles of the Declaration of Helsinki concerning research involving human subjects. A total of 160 patients scheduled for elective laparoscopic surgery under general anesthesia were enrolled using a non-probability consecutive sampling technique. Adult patients aged between 18 and 65 years, belonging to the American Society of Anesthesiologists (ASA) physical status I and II, and undergoing elective laparoscopic procedures such as laparoscopic cholecystectomy, appendectomy, and hernia repair were included in the study. Patients with known allergy to study medications, chronic opioid use, history of substance abuse, severe hepatic or renal dysfunction, psychiatric illness, pregnancy, body mass index greater than 35 kg/m², history of severe postoperative nausea and vomiting or motion sickness, and patients requiring conversion to open surgery were excluded. Eligible participants were allocated into two equal groups comprising 80 patients each. Group M received multimodal analgesia, while Group O received conventional opioid-based anesthesia. In Group M, patients received intravenous paracetamol (1 g), intravenous ketorolac (30 mg) unless contraindicated, and local infiltration of port sites with 0.25% bupivacaine prior to skin closure. Intraoperative opioid administration was minimized and limited to rescue analgesia when clinically indicated. In contrast, patients in Group O received conventional opioid-based anesthesia consisting primarily of fentanyl administered at induction and additional doses intraoperatively according to standard institutional practice. All patients underwent standardized general anesthesia with intravenous induction using propofol (2 mg/kg), muscle relaxation with atracurium (0.5 mg/kg), and maintenance with sevoflurane in an oxygen-air mixture. Standard intraoperative monitoring including electrocardiography, pulse oximetry, non-invasive blood pressure measurement, end-tidal carbon dioxide, and temperature monitoring was employed in all cases. The primary outcome measures were postoperative recovery time and incidence of postoperative nausea and vomiting (PONV). Recovery time was defined as the duration from discontinuation of anesthetic agents to attainment of a Modified Aldrete Score of ≥9, indicating readiness for discharge from the post-anesthesia care unit (PACU). The occurrence of nausea or vomiting during the first 24 postoperative hours was recorded by trained anesthesia residents. Secondary outcome measures included postoperative pain intensity assessed using the Visual Analog Scale (VAS; 0–10) at 2, 6, and 24 hours after surgery, total postoperative opioid consumption during the first 24 hours, and duration of PACU stay. Rescue analgesia with intravenous tramadol was administered for VAS scores ≥4, while ondansetron 4 mg intravenously was administered as rescue antiemetic therapy when required. Data were collected using a structured proforma specifically designed for the study. Demographic variables including age, gender, body mass index, ASA status, and type of surgical procedure were documented. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 26.0. Continuous variables were presented as mean ± standard deviation, whereas categorical variables were expressed as frequencies and percentages. Independent sample t-test was used to compare continuous variables between the two groups, while Chi-square test was applied for categorical variables. A p-value of less than 0.05 was considered statistically significant.

A total of 160 patients undergoing elective laparoscopic surgery were enrolled in the study, with 80 patients allocated to the multimodal analgesia group (Group M) and 80 patients to the opioid-based anesthesia group (Group O). All enrolled participants completed the study and were included in the final analysis.

The baseline demographic and clinical characteristics of the study participants were comparable between both groups, with no statistically significant differences regarding age, gender distribution, body mass index (BMI), ASA physical status, or type of laparoscopic procedure performed (p>0.05) (Table 1).

Table 1: Baseline demographic and clinical characteristics of study participants (n=160)

Patients receiving multimodal analgesia demonstrated significantly faster postoperative recovery compared with patients receiving opioid-based anesthesia. The mean recovery time to achieve a Modified Aldrete Score ≥9 was significantly shorter in Group M (34.6 ± 8.2 minutes) compared with Group O (48.9 ± 10.7 minutes) (p<0.001). Similarly, the duration of PACU stay was significantly reduced among patients in Group M (56.4 ± 12.5 minutes) compared with Group O (71.8 ± 15.1 minutes) (p<0.001) (Table 2).

Table 2: Comparison of postoperative recovery parameters between study groups

The incidence of postoperative nausea and vomiting within the first 24 hours was significantly lower among patients managed with multimodal analgesia. In Group M, 15 patients (18.8%) experienced PONV compared with 33 patients (41.3%) in Group O (χ²=9.62, p=0.002) (Table 3).

Table 3: Comparison of postoperative nausea and vomiting (PONV) between groups

Postoperative pain assessment using the Visual Analog Scale (VAS) revealed significantly lower pain scores in the multimodal analgesia group at all measured postoperative intervals. At 2 hours postoperatively, the mean VAS score in Group M was 2.8 ± 1.1 compared with 4.2 ± 1.3 in Group O (p<0.001). Similar statistically significant differences were observed at 6 and 24 hours after surgery (Table 4).

Table 4: Comparison of postoperative pain scores (VAS) between groups

Overall, multimodal analgesia was associated with superior postoperative outcomes, including shorter recovery time, reduced PACU stay, lower incidence of postoperative nausea and vomiting, decreased postoperative opioid requirements, and improved pain control compared with conventional opioid-based anesthesia.

Incidence of postoperative nausea and vomiting

Comparison of PONV incidence between multimodal analgesia and opioid-based anesthesia groups.

Figure 1:  Incidence of postoperative nausea and vomiting (PONV) in study groups

The present study compared the effectiveness of multimodal analgesia (MMA) and conventional opioid-based anesthesia (OBA) in patients undergoing elective laparoscopic surgery at Ayub Teaching Hospital, Abbottabad. The findings demonstrated that patients managed with multimodal analgesia experienced significantly shorter recovery times, lower incidence of postoperative nausea and vomiting (PONV), reduced postoperative opioid consumption, decreased pain scores, and shorter post-anesthesia care unit (PACU) stays compared with those receiving conventional opioid-based anesthesia. These findings support the growing body of evidence favoring opioid-sparing anesthetic techniques within Enhanced Recovery After Surgery (ERAS) pathways. One of the principal findings of the current study was the significantly shorter recovery time observed in the multimodal analgesia group. Patients receiving MMA achieved a Modified Aldrete Score ≥9 considerably earlier than those managed with opioid-based anesthesia. Faster recovery following opioid-sparing techniques has been attributed to reduced residual sedation, decreased respiratory depression, and lower incidence of opioid-related adverse effects. A systematic review by Frauenknecht et al. reported that multimodal analgesic strategies substantially improved early postoperative recovery and facilitated earlier discharge readiness in various surgical populations [15]. Similarly, a recent randomized controlled trial conducted by Mulier et al. demonstrated that opioid-free anesthesia significantly accelerated postoperative functional recovery and reduced time spent in recovery units among patients undergoing laparoscopic procedures [16]. The present study also demonstrated a significantly lower incidence of postoperative nausea and vomiting among patients receiving multimodal analgesia. Approximately 18.8% of patients in the MMA group experienced PONV compared with 41.3% in the opioid-based group. This reduction may be explained by decreased perioperative opioid exposure, as opioids are well-established independent risk factors for PONV. Similar findings have been reported by Beloeil et al., who observed significantly lower rates of nausea and vomiting among patients managed with opioid-free anesthesia compared with conventional opioid-based techniques [17]. Furthermore, a multicenter randomized trial by Lavand'homme and Estebe found that opioid-sparing anesthetic regimens significantly reduced the incidence of PONV while maintaining adequate analgesia and hemodynamic stability [18]. Given that PONV remains one of the leading causes of delayed discharge and patient dissatisfaction following laparoscopic surgery, the reduction observed in the current study has important clinical implications. Postoperative pain scores were significantly lower at all measured time intervals among patients managed with multimodal analgesia. These findings are consistent with the theoretical basis of multimodal analgesia, which targets multiple nociceptive pathways simultaneously, thereby providing synergistic analgesic effects. A comprehensive meta-analysis by El-Boghdadly et al. concluded that multimodal analgesic approaches consistently provide superior postoperative pain control and reduce the requirement for rescue analgesics across a broad range of surgical procedures [19]. Similarly, Soffin and YaDeau emphasized that multimodal analgesia remains the cornerstone of contemporary perioperative pain management because of its ability to optimize analgesic efficacy while minimizing opioid exposure [20]. An important observation in the present study was the substantial reduction in postoperative opioid consumption among patients receiving multimodal analgesia. Total opioid requirements during the first postoperative day were reduced by almost half compared with conventional opioid-based anesthesia. This finding is particularly relevant in the context of increasing global concerns regarding opioid overuse and dependence. Persistent postoperative opioid use has emerged as a major public health issue, even after minor surgical procedures. Brummett et al. demonstrated that perioperative opioid exposure is independently associated with prolonged opioid use after surgery, highlighting the importance of minimizing unnecessary opioid administration whenever possible [21]. Consequently, implementation of multimodal analgesic protocols may contribute not only to improved perioperative outcomes but also to long-term reductions in opioid-related harm. The significantly shorter PACU stay observed among patients in the multimodal analgesia group further underscores the potential benefits of opioid-sparing anesthesia. Reduced PACU duration may translate into improved operating room efficiency, increased patient throughput, and lower healthcare costs. Previous studies have similarly reported shorter recovery room stays and earlier hospital discharge among patients managed with ERAS-based multimodal analgesic protocols [22]. In resource-constrained healthcare settings such as Pakistan, optimization of recovery pathways through multimodal analgesia may therefore offer substantial institutional and economic benefits. The findings of this study are particularly important in the Pakistani healthcare context, where conventional opioid-based analgesic practices continue to predominate in many tertiary care hospitals. Local evidence evaluating opioid-sparing anesthesia remains scarce. By demonstrating the effectiveness of multimodal analgesia in a high-volume tertiary care center, the present study provides valuable evidence supporting the incorporation of ERAS principles into routine perioperative practice. Adoption of standardized multimodal analgesic protocols could potentially improve postoperative outcomes, enhance patient satisfaction, and reduce opioid-related complications in surgical patients across the country [23]. Nevertheless, several limitations should be acknowledged. First, this study was conducted at a single tertiary care institution, which may limit the generalizability of the findings to other healthcare settings. Second, long-term postoperative outcomes, including chronic postsurgical pain and persistent opioid use, were not evaluated. Third, the study primarily included patients with ASA physical status I and II; therefore, the findings may not be directly applicable to high-risk surgical populations. Future multicenter studies involving larger sample sizes and longer follow-up periods are recommended to further validate these findings and assess long-term clinical outcomes associated with multimodal analgesic strategies [24,25]. Despite these limitations, the present study demonstrates that multimodal analgesia offers significant advantages over conventional opioid-based anesthesia in patients undergoing laparoscopic surgery. The observed improvements in recovery time, postoperative nausea and vomiting, pain control, and opioid consumption strongly support the routine implementation of multimodal analgesic approaches as part of ERAS protocols in contemporary perioperative practice.

The findings of the present study demonstrate that multimodal analgesia is superior to conventional opioid-based anesthesia in patients undergoing elective laparoscopic surgery. Patients managed with multimodal analgesia experienced significantly faster postoperative recovery, lower incidence of postoperative nausea and vomiting, reduced postoperative pain scores, decreased opioid consumption, and shorter post-anesthesia care unit stay. These results support the growing evidence favoring opioid-sparing anesthetic strategies as an integral component of Enhanced Recovery After Surgery (ERAS) protocols. The adoption of multimodal analgesic techniques in routine perioperative practice may enhance patient outcomes, improve recovery profiles, and minimize opioid-related adverse effects in laparoscopic surgical patients.

Recommendations

Based on the findings of this study, it is recommended that multimodal analgesia should be routinely incorporated into perioperative management protocols for patients undergoing laparoscopic surgery at tertiary care hospitals. Healthcare institutions should consider implementing standardized ERAS pathways emphasizing opioid-sparing anesthetic strategies to optimize postoperative recovery and reduce the incidence of opioid-related complications. Regular training programs should be conducted for anesthesiologists and perioperative staff to promote the effective use of multimodal analgesic techniques. Furthermore, multicenter studies with larger sample sizes and long-term follow-up are recommended to evaluate the sustained benefits of multimodal analgesia, including its impact on chronic postoperative pain, persistent opioid use, patient satisfaction, and healthcare costs.

Authors’ Contributions

Dr. Muhammad Naeem contributed to the conceptualization of the study, data collection, patient management, manuscript drafting, and interpretation of the results. Dr. Muhammad Taqi contributed to the study design, statistical analysis, interpretation of data, critical revision of the manuscript, and overall supervision of the research. Dr. Sareena Pathan contributed to the conceptualization and coordination of the study, literature review, manuscript preparation, supervision, and served as the corresponding author. All authors read and approved the final manuscript.

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