Purpose: To compare a minimally invasive preperitoneal (MIP) single-layer mesh repair with the standard Lichtenstein hernia repair (LHR) for inguinal hernia in terms of operative characteristics, recovery, complications, recurrence and chronic pain. Method: Two hundred and twenty male patients diagnosed with primary inguinal hernia were randomized to either MIP or LHR methods. MIP repair consisted of a single-layer polypropylene mesh developed by our group placed preperitoneally using the Kugel technique. Patients were followed for a minimum of 2 years. Chronic pain was assessed by Sheffield’s pain score. Results: One hundred and one patients in MIP group and 105 patients in LHR group were included in the analysis. Most patients were diagnosed with indirect hernia (n = 79 for MIP, n = 81 for LHR). Surgery was slightly but significantly shorter for MIP (38.2 ± 7.4 vs. 40.3 ± 6.6, p = 0.031). Early complications such as cord edema, hematoma, scrotal edema, and wound infection were infrequent in both groups. Recurrence was detected in three patients in MIP and one patient in LHR. Chronic pain score was similar with both methods within the first year, but significantly lower for MIP at 24 months (0.66 ± 0.06 vs. 0.87 ± 0.07, p = 0.03). Conclusion: MIP single-layer mesh repair is as effective and safe as LHR, with the additional benefits of minimally invasive nature, less chronic pain at 2 years and low polypropylene load when compared with the original Kugel patch.