Purpose The aim of this study was to compare the preperitoneal versus the preaponeurotic mesh positioning in open paraumbilical hernia repair. Methods During the period from January 2011 until July 2012, 60 adult patients were randomly assigned to two equal groups. The patients in group A were treated by preperitoneal mesh repair and those in group B underwent preaponeurotic mesh repair. Both groups were assessed and compared. Results There were no significant differences between the two groups in the demographics, hernia characteristics, risk factors, type of anesthesia, American Society of Anesthesiologists score or the mean follow-up period. The length of the operation was significantly shorter in group B than in group A ( P value = 0.01). There were no significant differences in the early postoperative complications except for the development of a seroma, which developed only in group B ( P value = 0. 044). The postoperative pain was significantly lower in group A than in group B ( P value = 0.01). The time of return to normal daily activities was significantly shorter in group A than in group B ( P value = 0.001). Conclusion The preperitoneal mesh placement during the repair of paraumbilical hernias is superior to the preaponeurotic placement, because it is associated with fewer complications, less pain and a shorter time of return to normal daily activities.