Background <p>Although pain after laparoscopic total extraperitoneal (TEP) hernioplasty is lower compared with open techniques, effective pain control in the early postoperative period still remains clinically important. Although local anaesthetics are widely used, their limited duration of action often necessitates additional analgesics. This study was conducted to evaluate the effectiveness of the combination of dexamethasone and bupivacaine, applied locally to the surgical site, in reducing early postoperative pain and the need for analgesics.</p> Methods <p>In this prospective, randomized controlled study, 175 patients who underwent elective unilateral TEP hernioplasty were allocated to the intervention (<i>n</i> = 87) and control (<i>n</i> = 88) groups. In the intervention group, after mesh placement, a combination of 4 mL 0.5% bupivacaine (20&#xa0;mg) and 8&#xa0;mg dexamethasone was topically applied to the surgical area via standard laparoscopic irrigation. No local pharmacological application was performed in the control group. In both groups, pain levels were assessed at the 3rd, 6th, and 12th postoperative hours using the Visual Analog Scale (VAS), along with additional analgesic requirements and patient satisfaction levels. The results were statistically compared between the groups.</p> Results <p>VAS scores at the 3rd, 6th, and 12th hours were significantly lower in the intervention group receiving topical dexamethasone and bupivacaine compared to the control group (<i>p</i> &lt; 0.001). The change in VAS scores was also significantly greater in the intervention group compared to the control group (3rd–6th hour: <i>p</i> = 0.005; 6th–12th hour: <i>p</i> &lt; 0.001; 3rd–12th hour: <i>p</i> &lt; 0.001). The proportion of patients requiring additional analgesics was significantly lower in the intervention group than in the control group (85.1% vs. 95.5%) (<i>p</i> = 0.020). Patient satisfaction scores were also significantly higher in the intervention group (<i>p</i> = 0.001).</p> Conclusion <p>Local application of dexamethasone in combination with bupivacaine during TEP hernioplasty significantly reduces early postoperative pain and the need for additional analgesia while increasing patient satisfaction. This technique could be considered in laparoscopic hernia repair.</p> Trial registration <p>This trial was retrospectively registered at ClinicalTrials.gov on October 8, 2025 (registration number NCT07208253).</p>