Purpose <p>Totally visceral sac separation (TVS) is a novel concept proposed for hernia repair, preserving the integrity of the posterior rectus sheath (PRS). The aim of this study was to compare the results of TVS with the extended view totally extraperitoneal (e-TEP) method for umbilical and epigastric hernias.</p> Methods <p>A retrospective comparison analysis was conducted including 45 e-TEP and 43 TVS procedures performed between June 2021 and June 2024. Baseline characteristics, surgical records, and postoperative information were collected and analyzed for both groups from the electronic medical records system.</p> Results <p>The baseline characteristics showed no significant differences. The TVS group had a significantly longer mean operative time (230 (36) minutes vs. 190 (84) minutes, <i>P</i>&lt;0.01) and used a smaller mesh area (120 (10) cm² vs. 130 (20) cm², <i>P</i>&lt;0.01). No significant differences were observed between the two groups in terms of quality of life scores, postoperative length of stay, and medical expenses. One patient in the e-TEP group experienced surgical site and mesh infection, requiring mesh removal and resulting in hernia recurrence.</p> Conclusion <p>Despite its complexity and longer operative time, the TVS approach offers potential advantages in long-term outcomes and complication management for umbilical and epigastric hernias. These findings contribute to the understanding and potential adoption of the TVS technique in hernia repair.</p>