Abstract Background Incisional hernias (IH) have been progressively recognized as independent entities in the hernia field. However, the same indications for deferred treatment of ventral hernias are generally applied to IH, regardless of the potentially different outcomes. This meta-analysis aims to compare the characteristics and outcomes of patients treated urgently for IH with those undergoing elective surgery. Method Medline and Scopus were systematically searched from 1990–2023. Original studies comparing patients treated for emergency vs. elective IH were included. Study screening was performed using ASReview®. Data were pooled using random-effects models. Results Seventeen studies assessing 88,743 patients were included. Emergency IH patients were significantly older (MD 4.51 years; 95%CI 2.38–6.64. I2: 62%), more frequently women (RR 0.76; 95%CI 0.61–0.94. I2: 73%), and had a higher prevalence of ASA score III-IV (RR 1.38; 95%CI 1.03–1.84. I2: 30%). Furthermore, emergency surgery was associated with a longer hospital stay (MD 4.61 days; 95%CI 3.78–5.45. I2: 0%), higher need for reoperation (RR 2.20; 95%CI 1.73–2.80. I2: 0%), and higher mortality (RR 10.06; 95%CI 3.82–26.52. I2: 45%) compared to elective procedures. No differences in hernia recurrence rates or mesh repair were identified. Conclusion Emergent IH repair was associated with worse postoperative outcomes and higher mortality than elective repair. Nevertheless, scarcity of data precluded the inclusion of additional factors (type of repair, hernia size) and stratified/meta-regression analysis by relevant variables (age, sex, surgical risk). Larger studies are needed to determine predictors and outcomes of emergent repair in IH and appropriately identify patients who may benefit from watchful waiting.