Onlay mesh placement significantly lowers the risk of reoperation for recurrence and bowel obstruction after ventral hernia repair.

• Retromuscular mesh placement and IPOM both showed higher reoperation risks: HR 1.63 and HR 1.38, respectively, compared to onlay.
• The risk of bowel obstruction was also elevated, with HRs of 2.01 for retromuscular and 3.47 for IPOM.

Surgeons should consider onlay or preperitoneal approaches to minimize complications in primary ventral hernia repairs.