Background: Large incisional hernias in high-risk patients, such as those undergoing immunosuppressive therapy, represent an extra surgical challenge due to elevated risks of infection and poor wound healing. This case report details the reconstruction of an abdominal wall defect in a high-risk patient using a high-cost yet robust and effective biologic mesh. Case presentation: A 38-year-old obese female with multiple comorbidities developed an LIH and an incarcerated left-sided inguinal hernia following a kidney transplantation. The surgical approach involved a two-layer mesh reconstruction, combining a biologic intraperitoneal mesh and an absorbable onlay mesh. To reduce the risk of infection and provide extra reinforcement, the hernia sac was preserved and sutured over the biologic mesh. Postoperative complications, including infection and seroma formation, were managed effectively with negative pressure wound therapy. The wound closed after seven months, with no recurrence observed during follow-up. Discussion: The biologic mesh, combined with the well-vascularized sac, demonstrated integration with vascularized tissue, minimizing infection risk, and providing natural reinforcement and enhanced healing. Advanced wound management, including negative pressure wound therapy, effectively resolved postoperative complications such as infection and seroma. Conclusion: This case demonstrates the use of a multilayer reconstruction approach that combines a biologic mesh and the reuse of the hernia sac, offering a viable option for managing complex hernias in high-risk, immunosuppressed patients. This technique minimizes infection risk and provides stable long-term outcomes, even in challenging clinical settings. Highlights:

This Critical Appraisal aims to explore the pharmacokinetics and pharmacodynamics of medications used in organ donors after euthanasia (ODE) and their impact on abdominal organ quality. With the legalization of ODE, the donor pool has expanded, but it has introduced complexities regarding organ quality. This study evaluates existing euthanasia protocols in the Netherlands, Belgium, Spain, and Canada, focusing on differences in the medication types and dosages. Additionally, a literature review assessed the potential hepatotoxic effects of high-dose medications like thiopental, propofol, and non-depolarizing neuromuscular blocking agents. High doses of non-depolarizing neuromuscular blocking agents, particularly rocuronium, are associated with hepatotoxic effects in vitro. Furthermore, thiopental doses exceeding 750 mg significantly increase the risk of liver dysfunction. Recent findings also indicate that high-dose propofol and lidocaine can slightly prolong the time to death, which is crucial for optimizing organ viability in ODE. This study highlights the need to optimize organ donation procedures after euthanasia. Further research is needed to achieve this balance, maintaining the integrity and ethical standards of the euthanasia process while enhancing the outcomes of organ donation.