Background and Aims The ventral hernia repair surgery is one of the most common surgical procedures, with approximately two million cases of ventral hernia patients undergoing surgical treatment worldwide each year. Compared to open surgery, laparoscopic ventral hernia repair offers significant advantages. However, there is currently no large-scale clinical research confirming the advantages, disadvantages, and therapeutic effects of two laparoscopic techniques: intraperitoneal onlay mesh (IPOM) and extraperitoneal sublay repair (ESR) for repairing ventral hernias. Therefore, this study was conducted to compare the short- and long-term efficacy of ESR and IPOM in the treatment of ventral hernias, so as to provide evidence-based references for clinical practice.Methods The clinical data of 157 patients who underwent laparoscopic ventral hernia repair in 11 medical institutions in Hunan Province from January 1, 2017 to December 31, 2022 were retrospectively analyzed. Among them, 124 cases underwent ESR (ESR group) and 33 cases underwent IPOM (IPOM group). A comparative analysis was performed on the clinical characteristics, surgical methods, and short- and long-term postoperative outcomes of the two groups of patients.Results There were no cases of conversion to open surgery or perioperative deaths in the entire cohort. There were no statistically significant differences in age, gender, BMI, or hernia type between the two groups (all P>0.05). There were no statistically significant differences in hernia defect diameter, operative time, intraoperative blood loss, or hernia ring closure rate between the two groups (all P>0.05). In terms of mesh fixation methods, self-fixation and suture fixation were mainly used in the ESR group (91.1%), while helical tack fixation was mainly used in the IPOM group (69.7%), and the difference was statistically significant (P<0.05). The postoperative pain score in the ESR group was significantly lower than that in the IPOM group (2.37±0.82 vs. 2.76±1.00, P<0.05), and the hospitalization cost was significantly lower in the ESR group compared to the IPOM group (21 001 yuan vs. 38 437 yuan, P<0.05). There were no statistically significant differences in postoperative hospital stay and short-term complication rates between the two groups (all P>0.05). With a median follow-up of 10.3 months, there were no cases of recurrence in the ESR group, while the IPOM group had 2 cases of recurrence (6.1%), and the difference was statistically significant (P<0.05).Conclusion ESR is one of the main techniques for laparoscopic abdominal ventral repair in the Hunan region. Due to differences in fixation methods and mesh selection, ESR has advantages over IPOM, including milder postoperative pain, lower costs, and lower recurrence rates. Furthermore, it does not significantly increase operative time or the incidence of short-term postoperative complications.