Purpose <p>The purpose of this narrative review is to critically examine the paradox in ventral hernia repair (VHR): the widespread clinical adoption of prehabilitation despite limited high-level evidence supporting its universal benefit. We aim to deconstruct this evidence-practice gap and propose a risk-stratified framework to guide future practice and research.</p> Methods <p>A comprehensive analysis of contemporary literature on prehabilitation for VHR was conducted, focusing on interventions for obesity, nutrition, physical training and psychological preparation. The drivers of clinical practice beyond evidence were explored.</p> Results <p>Current evidence is contradictory. Observational studies suggest potential benefits from risk factor modification, yet randomized controlled trials have not consistently demonstrated improved long-term surgical outcomes. This discrepancy may arise from non-individualized interventions, inappropriate outcome measures, and the powerful influence of pathophysiological rationale and publication bias on clinical decision-making.</p> Conclusion <p>A paradigm shifts from universal to precision prehabilitation is needed. We propose a risk-stratified clinical decision framework to direct multimodal prehabilitation toward high-risk patients. Future research must prioritize RCTs in this cohort, employing personalized protocols and patient-centered outcomes.</p>