Comparative clinical efficacy of IPOM and TES in treating midline ventral hernias: a multicenter retrospective cohort study.

To systematically compare the clinical outcomes of intraperitoneal onlay mesh (IPOM) repair versus total endoscopic sublay (TES) repair for midline ventral hernias, and to provide evidence for surgical decision-making. A multicenter retrospective cohort study enrolled 398 patients (IPOM = 238, TES = 160) from three tertiary hospitals (2021-2026). Baseline, perioperative, and prognostic data were compared. Baseline characteristics were similar. IPOM had greater intraoperative blood loss (20.0 vs. 10.0 mL, P < 0.001) but lower peritoneal tear (2.5% vs. 13.8%, P < 0.001) and vascular injury (1.7% vs. 6.2%, P = 0.015). Postoperatively, IPOM showed less seroma (0% vs. 6.9%, P < 0.001) but more intestinal obstruction (9.2% vs. 1.9%, P = 0.003). Total costs were higher in IPOM (¥23,800 vs. ¥16,990, P < 0.001). Chronic pain was 0% in both. TES provided better acute pain control (24‑h VAS: 1.0 vs. 4.0, P < 0.001), better 12‑month quality of life (EuraHS‑QoL: 2.0 vs. 4.0, P < 0.001), and shorter hospital stay (4.0 vs. 4.0 days, P < 0.001; median equal but significant due to distribution). Recurrence at 12 months was not significantly different (3.4% vs. 6.9%, P = 0.107). IPOM and TES offer distinct complementary advantages. IPOM had a numerically lower recurrence rate, whereas TES favored faster recovery and lower costs. Choice should be individualized.