Abstract Background Sandwich ventral hernia repair (SVHR) may reduce ventral hernia recurrence rates, although with an increased risk of surgical site occurrences (SSOs) and infections (SSIs). Previously, we found that a modified negative pressure wound therapy (HVAC) system reduced SSOs and SSIs following VHR. We aimed to describe our outcomes following SVHR paired with HVAC closure. Methods We conducted a four-year retrospective review of all complex SVHRs (biologic mesh underlay and synthetic mesh overlay) with HVAC closure performed at our institution by a single surgeon. All patients had fascial defects that could not be re-approximated primarily utilizing anterior component separation. Descriptive statistics were used to report the incidence of postoperative complications and hernia recurrence. Results Sixty patients (59.3±11.4 years, 58.3% male, 75% ASA class ≥3) with complex ventral hernias underwent sandwich repair with HVAC closure. Major post-operative morbidity (Dindo-Clavien class ≥3) occurred in 14 (23.3%) patients, but incidence of SSO (n=13, 21.7%) and SSI (n=4, 6.7%) was low compared to historical reports. Median follow-up time for all patients was 12 months (IQR 5.8-26.5 months). Hernia recurrence occurred in 8 patients (13.3%) after a median time of 20.6 months (IQR 16.4- 25.4 months). Conclusion Use of a dual layer sandwich repair for complex abdominal wall reconstruction is associated with low rates of hernia recurrence at one-year postoperatively. The addition of the HVAC closure system may reduce the risk of SSOs and SSIs previously reported with this technique, and deserves consideration in future prospective studies assessing optimization of VHR approaches.