Background: Pulmonary recruitment maneuver (PRM) at the end of laparoscopic gynecologic surgery has been shown to reduce postoperative pain. This prospective, randomized, controlled clinical trial aimed to investigate postoperative pain (primary endpoint) and nausea when performing a ventilator-piloted PRM at the end of laparoscopic bariatric surgery. Settings: A secondary-level public hospital in Sweden. Methods: After giving written consent, patients undergoing elective laparoscopic bariatric surgery were randomized to receive routine exsufflation (control group) or a ventilator-piloted PRM to remove residual carbon dioxide from the abdomen at the end of surgery. Pain and nausea intensities were recorded at 4, 12, 24, 36, and 48 hours after surgery using a questionnaire with numeric rating scales. Postoperative consumption of analgesics and antiemetics was also evaluated. Results: There were 150 randomly assigned patients recruited, 79 to PRM intervention and 71 controls. Pain intensity was significantly lower in the PRM group than in the control group 24 hours postoperatively (numeric rating scale 2 [1-3] versus 3 [2-5]; P =.002). Pain during the first 24 hours did not increase in the PRM group as it did in the control group (P =.045). Opioid requirements were significantly lower in the PRM group than in the control group (5.0 mg [2-10] versus 9.0 mg [5-15]; P =.025). The PRM did not affect incidence or intensity of nausea and vomiting. Conclusions: A ventilator-piloted PRM reduced postoperative pain intensity and opioid requirement after laparoscopic bariatric surgery. The heterogeneity of the study population and the large number of hospital staff involved indicate good generalizability of the results. (Surg Obes Relat Dis 2018;14:386-392.) (C) 2018 American Society for Metabolic and Bariatric Surgery. This is an open access article under the CC BY-NC-ND license.