Background <p>The growing population of elderly has resulted in a&#xa0;rise in complex abdominal wall hernias, especially among older and more vulnerable individuals. This review aims to summarize the latest evidence regarding the timing, surgical techniques, and perioperative care associated with the repair of complex abdominal wall hernias in geriatric patients.</p> Methods <p>A&#xa0;narrative review of the literature was conducted using structured searches of major databases for publications in English from 2000 to July 2025. Studies addressing age, frailty, comorbidities, surgical technique, and perioperative outcomes in older patients were qualitatively synthesized.</p> Results <p>Multimorbidity and frailty emerged as key predictors of postoperative risk, particularly among patients with a&#xa0;Charlson Comorbidity Index of ≥ 3, which was associated with higher mortality. Sarcopenia and malnutrition also contributed significantly to adverse outcomes. Elective repair was consistently associated with lower mortality and complication rates compared with emergency surgery. When comorbidities and frailty were optimized, older patients demonstrated outcomes comparable to younger cohorts in propensity-matched analyses. Prehabilitation strategies, including nutritional optimization and risk-factor modification, were associated with improved perioperative outcomes. Permanent synthetic mesh was favored in clean cases, while biologic options were used selectively in contaminated fields. Minimally invasive approaches reduced wound morbidity but require further evaluation in populations with frailty.</p> Conclusion <p>Chronological age alone should not preclude ventral or incisional hernia repair. Instead, frailty, multimorbidity, and nutritional status are critical determinants of risk. Elective repair following patient optimization is associated with improved safety, while prehabilitation and multidisciplinary care play a&#xa0;central role in reducing complications in older patients.</p>