Objective To evaluate the efficacy and safety of open-type tension-free inguinal hernia repair (Millikan) and laparoscopic totally extraperitoneal prosthetic(TEP) in elderly patients with inguinal hernia. Methods A total of 298 elderly patients with inguinal hernia admitted in our hospital from September 2013 to August 2016 were randomly divided into two groups: group A (n=148) treated with group B (n=150) treated with TEP. Different surgical procedures and postoperative recovery were observed. The complications of the two groups were counted. The differences in gastrointestinal motility indexes were compared between the groups. All patients were followed up for 2 years. And the disease recurrence was recorded. Results The patients in group B had less bleeding, less postoperative pain, shorter time to get out of bed, and the shorter time of anal exhaust, postoperative feeding, bowel sound recovery, and less postoperative complications compared with group A (P<0.05). The operation time of group A was shorter than that of group B (P< 0.05). There was no difference in recurrence rate between the two groups (P>0.05). Conclusions In elderly patients with inguinal hernia, the treatment with Millikan and TEP can effectively improve symptoms and avoid recurrence of hernia. Patients with TEP have fewer postoperative complications, faster gastrointestinal motility recovery, and less intraoperative blood loss.