Objective To determine the safety and effectiveness of dexmedetomidine in monitored anesthesia care (MAC) combined with local anesthesia for hernia repair in the elderly patients. Methods Forty very old patients [(85.65±4.59) years old] suffering from unilateral inguinal hernia who received surgical treatment in our hospital from September 2012 to July 2014 were prospectively recruited in this study. They were randomly divided into MAC group (observation group) and the control group, with 20 cases in each group. The patients of the former group were given MAC and local anesthesia, while those from the latter only local anesthesia. The incidences of intraoperative adverse cardiac events and hypoxic events, local anesthetic dosage, and patient’s satisfaction with anesthesia in postoperative follow-up were studied and compared between the 2 groups. Results Mean arterial pressure (MAP), heart rate (HR), bispectral index (BIS), and observer’s assessment of alertness/sedation (OAA/S) score were gradually declined at all time points in 10 min after administration in the MAC group, which were statistically different with that in the control group at the same period (P＜0.05). In the MAC group, there were significant differences in MAP, HR, BIS values and OAA/S score between other time points and T1 (P＜0.05). Significant difference was found in the local anesthetic dosage between the 2 groups (P＜0.05). The patients of the MAC group had higher satisfaction with anesthesia care in the postoperative following-up than that of the control group (P＜0.05). Conclusion Dexmedetomidine in MAC combined with local anesthesia is safe and effective, and improves patient’s satisfaction and intraoperative comfort in hernia repair for the elderly patients.