Abstract Background: Repair of incisional hernia with prosthetic mesh provides tension free closure of the abdominal wall with improved results. Different methods of fixation of mesh have been described with varying results. Mesh fixation to the fascia is the most important part of a hernia repair. Anterior rectus sheaths are tough aponeurotic structures and so are ideal for mesh fixation. This study reports the long-term results of placement of prosthetic mesh in pre-rectus position and fixation to anterior rectus sheaths along with linea alba by open technique, for incisional hernias occurring in the midline. The primary end point was hernia recurrence. Patients and Methods: A total of 126 consecutive patients with incisional hernias occurring in the midline were operated from July 2009 to October2020. After dissection of the plane between rectus muscles and anterior rectus sheath, a polypropylene mesh of suitable size was placed in front of the rectus muscles and fixed to the posterior surfaces of anterior rectus sheaths and the linea alba. In 2013, cases were reviewed and the study continued. The patients were followed on phone or by personal visits up to March 2021. Results: The average period of follow up was 60 months. There were five recurrences. Wound infection was noted in 16 patients with complete healing in all cases with antibiotics and dressings. There were 4 cases of seroma, 5 cases of skin edge necrosis and two cases of suture sinus. There was no mortality, mesh infection or extrusion. Conclusion: Open ‘pre-rectus’ technique for repair of midline incisional hernias is effective with a low recurrence rate.