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It is inherently challenging to achieve successful surgical outcomes for ventral hernia repairs. For complex ventral hernias, attempts to reconstruct the abdomen in patients who are overweight, deconditioned, malnourished, chronically infected or inflamed, have previous hernia recurrence, or otherwise carry a number of serious comorbidities affecting their surgical fitness are a major undertaking requiring careful preparation and planning. As the rate of abdominal wall reconstructions rises, so does the complexity of these procedures. One could argue that the prehabilitation of these patients is equally, if not more, important than the surgical technique itself. To achieve desirable outcomes and avoid surgical-site occurrences (SSOs), the surgeon must familiarize him/herself with ways to optimize a patient preoperatively. Understanding and identifying the aforementioned modifiable risk factors for SSOs is crucial. It is also important to recognize the impact that acute changes in the microbiome perioperatively can have on the postoperative success. Familiarizing oneself with the available literature for these patients is imperative. This review presents discussion and guidance for understanding the challenges and best practices for providing hernia surgery and abdominal wall reconstruction and achieving durable outcomes, with minimal SSOs.