Background <p>Repair of large complex abdominal hernias has evolved over time. Most recently, the component separation technique (CST) with mesh placement has gained popularity. However, there is no consensus regarding the type of mesh repair that is preferred. This study presents the senior author’s technique for a dual-stage approach with a combination of CS with underlay placement of biologic mesh, which aids in source control, mitigating recurrence risks, enhances wound healing, and is able to provide durable reinforcement.</p> Case presentation <p>A 73-year-old female presented with complaints of nausea, vomiting, and abdominal pain. Computed tomography (CT) scan of the abdomen and pelvis revealed a large abdominal wall hernia with an 8&#xa0;cm defect and the presence of dilated bowel. The patient underwent a dual-stage approach including initial surgical intervention with a robotic convert to open exploratory laparotomy, small bowel resection, and placement of AbThera negative pressure dressing. Then, the patient was taken back two days later with placement of underlay biologic XenMatrix (Bard Davol Inc, Warwick, RI) mesh and unilateral component separation to allow for the abdomen to be closed with placement of a wound vacuum.</p> Conclusion <p>Therefore, in carefully selected patients, including those with active concerns for infection or contamination, a decreased recurrence rate, postoperative complication rate, and improved quality of life may be seen with a combination CST and underlay placement of biologic mesh. Our patient has no reported recurrence at 12-moth follow-up, remains ambulatory, and independent in her activities of daily living (ADLs).</p>