Background and Aims Inguinal hernia is a common surgical condition, with elderly individuals being the primary population undergoing inguinal hernia repair. However, there is currently no consensus on the choice of surgical approach for elderly inguinal hernia patients. Local anesthesia Lichtenstein repair is characterized by low difficulty, good outcomes, and faster postoperative recovery and is widely used in clinical practice. Laparoscopic tension-free inguinal hernia repair is increasingly accepted and recommended by surgeons due to its advantages such as a wide field of vision, and the ability to detect contralateral occult hernia and to simultaneously repair a bilateral hernia. This study was performed to analyze the clinical data of elderly patients undergoing local anesthesia open hernia repair or general anesthesia laparoscopic hernia repair, so as to provide guidance for clinical practice.Methods The clinical data of 130 elderly patients (>60 years old) who underwent inguinal hernia repair in Zhongda Hospital Affiliated with Southeast University from January 2019 to December 2021 were collected through telephone follow-up and medical record system and retrospectively analyzed. Among them, 67 cases underwent open Lichtenstein surgery (open surgery group), and 63 cases underwent laparoscopic hernia repair surgery (laparoscopic group). Baseline data and surgery-related variables were compared between the two groups.Results The analysis of baseline data showed that the average age of patients in the open surgery group was higher than that in the laparoscopic group (78.94 years vs. 71.83 years), and the proportion of cases with high anesthesia risk, the proportion of cases with different comorbidities, and the rate of bilateral hernia were all higher in the open group than those in the laparoscopic group (all P<0.05); the remaining baseline variables showed no statistically significant differences between the two groups (all P>0.05). Analysis of surgery-related variables showed that the length of postoperative hospital stay was shorter (1.51 d vs. 2.16 d), and the pain score on postoperative day 1 was lower in the laparoscopic group (2.70 vs. 3.58) than those in the open surgery group (both P<0.05); there were no statistically significant differences between the two groups in terms of postoperative complications (incision infection, hematoma, seroma, nerve sensory abnormalities, urinary retention), one-year recurrence rate, and long-term pain (>3 months) (all P>0.05).Conclusion In elderly patients, the hernia side, anesthesia risk classification, and preoperative comorbidities are factors that clinical physicians need to assess when choosing a surgical approach. After comprehensive preoperative assessment, laparoscopic surgery is a safe option.