Abstract Introduction Incisional hernia (IH) is a common complication after abdominal surgeries, whether conventional open or laparoscopic. Despite many efforts to reduce the incidence of IH, there is still a lack of consensus concerning the best approach for its prevention and repair. This pilot study evaluates a technique integrating perforatorpreserving anterior component separation with onlay mesh reinforcement at the midline and lateral external oblique incisions, addressing persistent challenges in tension management, vascular preservation, and recurrence reduction post-abdominal surgery. Patients and methods This is a prospective pilot study conducted from January 2023 to January 2024 to evaluate the repair of large midline incisional hernias in 17 patients who underwent previous vertical midline incisions due to various indications. We used anterior component separation with perforator preservation along with onlay mesh reinforcement. Results All cases underwent only mesh fixation. There were no intraoperative complications reported. The reported postoperative complications were wound seroma (41.2%), superficial wound ischemia (5.9%), and wound seroma with superficial wound ischemia (5.9%), while no complications were encountered in the rest of the cases (47.1%). There were no reported cases with deep wound ischemia and/or wound dehiscence. Conclusion The anterior component separation technique with perforator preservation is a feasible and effective method for treating large incisional hernias with difficult midline closures. When paired with onlay mesh reinforcement for both the midline and lateral releasing incision, it provides satisfactory outcomes, low recurrence rates, and a manageable complication profile. The technique of the procedure should be tailored to each patient's specific condition.