Purpose <p>For small primary umbilical hernias, suture-only repair remains common, yet there is limited comparative evidence guiding suture material selection. Our study compared the recurrence and complication rates of primary umbilical hernias using permanent or absorbable sutures.</p> Methods <p>We performed a retrospective cohort study using the Abdominal Core Health Quality Collaborative (ACHQC), a national, prospectively maintained hernia registry. Adults undergoing elective, open primary umbilical hernia repair without mesh between May 2014 and February 2024 with ≥ 1-year follow-up were included (<i>N</i> = 1,140). Patients were stratified by suture type: slowly absorbable (<i>n</i> = 500) versus permanent (<i>n</i> = 640). The primary endpoint was 1-year hernia recurrence; secondary endpoints included 30-day surgical site infection (SSI), surgical site occurrence (SSO), readmission, reoperation, and patient-reported outcomes (HerQLes and PROMIS). Multivariable logistic and linear regression models adjusted for suture configuration, BMI, COPD, ascites, smoking, and diabetes.</p> Results <p>One-year recurrence rates were similar between slowly absorbable and permanent suture repairs (6% vs. 5%; adjusted OR 1.14, 95% CI 0.66–1.96; <i>p</i> = 0.65). Suture configuration, including figure-of-eight closure, was not associated with recurrence. There were no differences in 30-day SSI, SSO, readmission, or reoperation between groups. Patient-reported quality-of-life outcomes (HerQLes and PROMIS pain scores) were comparable at both 30 days and 1 year.</p> Conclusions <p>In elective primary open umbilical hernia repair without mesh, suture material—slowly absorbable versus permanent—was not associated with differences in recurrence, wound morbidity, or patient-reported outcomes. These findings support surgeon discretion in suture selection and highlight the need for prospective randomized trials to define optimal closure strategies for small umbilical hernias.</p>