Background: Ventral hernias represent a significant surgical challenge, affecting a considerable portion of the global population. This study aims to compare the surgical outcomes of onlay and underlay mesh placement techniques for ventral hernia repair, focusing on operative time, postoperative complications, pain scores, and long-term recurrence rates.Materials and Methods: This comparative study was conducted at a tertiary care hospital and included 140 patients diagnosed with ventral hernias. Patients were equally divided into two groups: onlay repair (n = 70) and underlay repair (n = 70). Both groups underwent standardized surgical procedures, and postoperative parameters such as complications, pain scores, hospital stay, and recurrence rates were recorded. Statistical analysis was performed using SPSS software (version 21.0), with a p-value < 0.05 considered statistically significant.Results: The mean operative time was significantly longer in the underlay repair group (92.3 ± 14.1 minutes) compared to the onlay repair group (85.6 ± 12.4 minutes; p = 0.03). However, hospital stay duration (4.2 ± 1.1 vs. 3.9 ± 1.0 days, p = 0.15) and return to normal activities (12.5 ± 2.8 vs. 11.7 ± 2.5 days, p = 0.21) were comparable between groups. The incidence of seroma was higher in the onlay group (14.29%) than in the underlay group (7.14%), though not statistically significant (p = 0.19). Wound infections, hematoma formation, and recurrence rates were similar in both groups. Postoperative pain scores showed slightly lower values in the underlay group, but differences were not statistically significant. Long-term outcomes at six months revealed comparable recurrence and mesh infection rates, with slightly lower chronic pain incidence in the underlay group.Conclusion: Both onlay and underlay mesh repair techniques for ventral hernias yield similar outcomes regarding postoperative complications, pain scores, and recurrence rates. The underlay repair requires a longer operative time but demonstrates a trend toward lower seroma formation and chronic pain. Given these findings, the choice of technique should be tailored based on patient-specific factors and surgeon expertise, as both methods are effective and safe.