<p>Incisional hernia remains a common and challenging complication following abdominal surgery, with mesh repair representing the current standard of care to reduce recurrence. Among the various mesh placement techniques, the onlay and sublay approaches are most frequently employed; however, they differ in technical complexity, tissue dissection, and postoperative outcomes. Despite widespread use, consensus regarding the optimal technique—particularly in terms of short-term outcomes such as surgical site complications, postoperative pain, and hospital stay—remains inconclusive. This prospective comparative study aims to evaluate and compare the short-term clinical outcomes of onlay versus sublay mesh hernioplasty in patients undergoing elective repair of incisional hernia [1–3]. A prospective, randomized controlled comparative trial was carried out at a tertiary care center between August 2023 and August 2025. The study included 40 adult patients aged 18–60 years with confirmed incisional hernia who were medically fit for surgery. All patients underwent imaging to establish the diagnosis and those with defect larger than 8 cm were excluded from our study then all patients were randomly assigned in a 1:1 ratio to either onlay or sublay mesh hernioplasty. A standardized preoperative evaluation was applied, and all procedures were performed electively. Outcomes assessed over a 30-day follow-up period included postoperative pain, seroma formation, surgical-site infection, hematoma, early recurrence, operative time, and length of hospital stay. In this prospective randomized controlled trial, patients with incisional hernias measuring less than 8 cm were allocated to either onlay (n = 20) or sublay (n = 20) mesh repair. The onlay group showed a significantly shorter operative duration (1.90 ± 0.50 vs. 3.88 ± 0.79 h; p &lt; 0.001), lower intraoperative blood loss (196.50 ± 87.86 vs. 309.00 ± 99.15 cc; p = 0.001), and reduced length of hospital stay (4.25 ± 1.22 vs. 5.05 ± 1.05 days; p = 0.015). However, higher rates of seroma formation (35% vs. 15%; p = 0.273), surgical-site infection (15% vs. 5%; p = 0.605), and persistent abdominal discomfort at 30-day follow-up (30% vs. 15%; p = 0.451) were observed in the onlay group. In contrast, the sublay group had isolated cases of intra-abdominal infection (5%; p = 0.050), postoperative fever, and ileus. No early hernia recurrence was reported in either group. Onlay mesh hernioplasty showed greater operative efficiency, characterized by shorter surgical duration, less intraoperative blood loss, and a reduced length of hospital stay when compared with the sublay technique. However, it was associated with higher incidences of seroma formation, surgical-site infection, wound dehiscence, and persistent abdominal discomfort at 30-day follow-up. Consequently, These results indicate that the sublay approach tends to be associated with a more favorable wound-related complication profile.</p>