Although minimally invasive surgery has significantly reduced the incidence of incisional hernia (IH) in colorectal procedures, the choice of specimen extraction site continues to pose a risk. This study explores how the location of extraction site influences the occurrence of IH in patients undergoing minimally invasive colorectal resections. We conducted a retrospective observational cohort study involving consecutive patients who underwent minimally invasive colorectal resection for colorectal cancer from 2013 to 2021. Patients with open surgery, previous hernia repair, reoperations during the study period or without imaging follow-up were excluded. The primary outcome measured was the CT-proven incidence of IH at the extraction site. A total of 191 patients were analyzed. Among them, 113 patients (59.2%) had a midline extraction site, while and 78 patients (40.8%) had an off-midline extraction. Midline extraction was preferably used during right and transverse colectomy (98% and 100% respectively), whereas off-midline were preferred in left hemicolectomy, sigmoidectomy, and anterior resection (55%, 88%, 95% respectively). Remarkably, the overall incidence of IH at the extraction site was 30.9% for midline extractions compared to 0% for off-midline extractions (p value < 0.001). The mean follow-up duration was of 3.3 ± 2.1 years. Multivariate logistic regression analysis revealed midline extraction as a significant risk factor for IH with a relative risk of 29.1 (95% CI 3.8-220.5, p value < 0.001). The findings highlight a substantial increase in the risk of IH associated with midline extraction sites. As such, it is crucial to advocate for fully minimally invasive colorectal resection using off-midline incision to enhance patient outcomes and reduce the risk of incisional hernias.