Background <p>Mesh fixation, one of the controversial issues of laparoscopic surgery, has not been investigated in the enhanced view-totally extraperitoneal (eTEP) technique. This study aimed to compare mesh fixation (FX) and non-fixation (NFX) in difficult cases in the eTEP technique.</p> Methods <p>A total of 61 consecutive patients diagnosed with inguinal hernias who underwent the eTEP procedure were randomized for the study. The groups were FX and NFX. The primary outcome was mesh displacement; secondary outcomes were recurrence, return to normal life, pain, and postoperative findings. </p> Results <p>Mesh displacement, recurrence, mean operative time, length of stay, pneumoperitoneum, and postoperative complications were similar. VAS scores were higher in the FX group (<i>p</i> = 0.017, <i>p</i> &lt; 0.001, <i>p</i> &lt; 0.001, respectively). Return to normal life was more days in the FX group (<i>p</i> = 0.02). The mesh displacement at 6&#xa0;months was higher than at 1&#xa0;month in both groups (<i>p</i> &lt; 0.001).</p> Conclusions <p>There is no increased risk of mesh displacement and recurrence in difficult cases, such as scrotal and recurrent hernias, without mesh fixation. With the eTEP technique, mesh fixation can be safely avoided for less pain and a faster return to normal life.</p> <p>Trial registration: Clinicaltrials number: NCT06417359.</p>