Purpose: Benign elective procedures give rise to heterogeneity in indication for surgery and surgical technique among specialized surgeons in a variety of surgical fields. The objective was to analyze the extent of agreement in surgical management among expert hernia surgeons when evaluating the same patient in a standardized setting. Methods: Five Danish hernia experts answered questions concerning indication for surgery and surgical technique for 25 video recorded real-life clinical cases. The experts evaluated the patients by answering a standardized questionnaire. Results: All surgeons were experienced in incisional hernia repair with a median of 253 repairs (range 164–450 repairs). Perfect overall agreement among all the experts in indication, operation type, component separation, mesh fixation and mesh position was found in only five cases (20%). Agreement in indication for surgery was present in 14 cases (56%). The most common reason for not performing surgery was due to comorbidities. Agreement in operation type (open vs. laparoscopic) was present in 10 cases (40%). Agreement in mesh fixation (absorbable tacks/non-absorbable tacks/suture/other) method was also present in 10 cases (40%). Agreement in mesh position (onlay, sublay or intraperitoneal) was found in 40% of cases. The highest overall agreement among the surgeons was observed with regard to whether patients needed component separation (yes/no), 21 cases, (84%). Conclusions: In a standardized setting, agreement in choice of treatment strategy for patients with incisional hernias was very low among experienced surgeons. A standardization of surgical decision making is desirable to develop new interventions and improve clinical outcomes.