Purpose <p>Intraperitoneal onlay mesh (IPOM) repair without defect closure and IPOM with primary fascial closure (IPOM-Plus) are established techniques for laparoscopic ventral hernia repair. In contrast, evidence for IPOM with peritoneal bridging is limited and mainly comes from single-group studies. This randomized controlled trial compared these three methods regarding early postoperative outcomes in moderate midline ventral hernias.</p> Methods <p>This study was a single-center, prospective, randomized trial involving 120 adult patients with midline ventral hernias, with horizontal defect widths ranging from 3 to 6&#xa0;cm (4.6 ± 1.2&#xa0;cm). Participants were evenly divided into IPOM, IPOM-Plus, or IPOM-Pb groups. A single surgeon performed all procedures, using the same mesh, fixation, and perioperative protocols. Primary outcomes were postoperative seroma formation, pain scores at 48&#xa0;h and on postoperative days 5 and 10, and short-term recurrence at six months. Secondary outcomes included operative time, conversion to open surgery, and length of hospital stay.</p> Results <p>Early postoperative seroma was significantly more frequent in the IPOM-Pb group at 48&#xa0;h and postoperative day 5 compared with IPOM-Plus (12.5% vs. 2.5%; risk difference 10%, 95% CI 0.1–19.9; <i>p</i> = 0.025). Pain scores at all assessed time points were similar across groups. One hernia recurrence occurred in the IPOM group at six months. Operative time was significantly longer for IPOM-Pb compared with IPOM and IPOM-Plus (<i>p</i> &lt; 0.001). Conversion rates and hospital stay length did not show significant differences.</p> Conclusions <p>IPOM-Pb had higher early seroma rates and longer operative times without clear short-term benefits, supporting IPOM Plus as a balanced and reliable standard technique for laparoscopic repair of moderate midline ventral hernias.</p> Trial registration <p>CTRI No. CTRI/2023/08/056745</p>