Objective To investigate the effect of opioid‑sparing anesthesia on emergence agitation (EA) in children undergoing laparoscopic hernia repair. Methods A single‑center randomized controlled trial was conducted. A total of 82 children, American Society of Anesthesiologists (ASA) Ⅰ or Ⅱ, aged 6 to 36 months, who underwent elective laparoscopic hernia repair were selected. According to the random number table method, they were divided into two groups (n=41): a conventional group (group C) and an opioid‑sparing group (group DS). Both groups underwent anesthesia induction with sevoflurane. Group C received sufentanil (0.3 μg/kg), and group DS received esketamine (1 mg/kg) combined with dexmedetomidine (0.5 μg/kg). Within 30 min after laryngeal mask removal, the incidence of EA was assessed with the Pediatric Anesthesia Emergence Delirium (PAED) scale every 5 min, and the highest PAED score was recorded. The mean arterial pressure (MAP) and heart rate were recorded at admission to the operating room (T0), before insertion of laryngeal mask (T1), 5 min after insertion of laryngeal mask (T2), 5 min after incision (T3), and at the end of operation (T4). Pain was assessed by the Face, Legs, Activity, Cry, Consolability (FLACC) scale every 5 min for 30 min after extubation, and the highest FLACC score was recorded. The use of rescue analgesia, the duration of operation, emergence time, the length of post‑anesthesia care unit (PACU) stay, and the incidences of adverse reactions, such as nausea and vomiting, hypoxemia, and laryngeal spasms during the recovery period in the PACU were recorded. The use of remedial analgesia, operation time, recovery time, PACU residence time and the occurrence of adverse reactions such as nausea and vomiting, hypoxemia and laryngeal spasm during PACU resuscitation were recorded. Results Compared with group C, group DS showed decreases in the incidence of EA, the highest PAED score and the highest FLACC score (all P<0.05). There were no statistical differences in the rate of rescue analgesia, the duration of operation, time to extubation, the length of PACU stay and the incidence of adverse reactions between the two groups (all P>0.05). The difference of time effect of heart rate between two groups was statistically significant (P<0.05), but the difference of time and group interaction effect was not statistically significant (P>0.05). The difference of time effect of MAP between two groups was statistically significant (P<0.05), and the difference of time and group interaction effect was statistically significant (P<0.05). There was no statistical difference in heart rate and MAP between the two groups at each time point (all P>0.05). Conclusions The opioid‑sparing anesthesia strategy reduces the incidence of EA and postoperative pain score in children undergoing laparoscopic hernia repair, without increases in perioperative complications.