Introduction After the first report of laparoscopic incisional and ventral hernia repair (LIVHR) in 1993, several studies have proven its efficacy over open method. Among the technical issues, the technique of mesh fixation to the abdominal wall is still an area of debate. This prospective randomized study was done to compare two techniques of mesh fixation, i.e., tacker with four corner transfascial sutures versus transfascial sutures alone. Materials and methods 68 patients admitted for LIVHR repair (defect size less than 25 cm 2 ) were randomized in two groups: group I, tacker fixation (36 patients) and group II, suture fixation (32 patients). Various intraoperative variables and postoperative outcomes were recorded and analyzed. Results The patients in the two groups were well matched in terms of age, sex, body mass index (BMI), and hernia characteristics. Mean BMI was 29.0 kg/m 2 . Operative time was found to be significantly higher in group II (77.5 versus 52.6 min, p  = 0.000). Patients in group I were found to have significantly higher pain scores at 1 h, 6 h, 24 h, 1 week, 1 month, and 3 months postoperatively. At follow-up, incidence of seromas was higher in group II but the difference was not significant (7 versus 4, p  = 0.219). During long-term follow-up, patients in group II were satisfied cosmetically. Conclusion Suture fixation is a cost-effective alternative to tacker fixation, for small and medium-sized defects in anatomically accessible areas. However, suture fixation requires significantly longer operation time, but patients have statistically significantly less postoperative pain.