Purpose Incisional hernia (IH) is one of the most frequent postoperative complications. Of all patients undergoing IH repair, a vast amount have a hernia which can be defined as a large incisional hernia (LIH). The aim of this study is to identify the preferred technique for LIH repair. Methods A systematic review of the literature was performed and studies describing patients with IH with a diameter of 10 cm or a surface of 100 cm 2 or more were included. Recurrence hazards per year were calculated for all techniques using a generalized linear model. Results Fifty-five articles were included, containing 3,945 LIH repairs. Mesh reinforced techniques displayed better recurrence rates and hazards than techniques without mesh reinforcement. Of all the mesh techniques, sublay repair, sandwich technique with sublay mesh and aponeuroplasty with intraperitoneal mesh displayed the best results (recurrence rates of <3.6 %, recurrence hazard <0.5 % per year). Wound complications were frequent and most often seen after complex LIH repair. Conclusions The use of mesh during LIH repair displayed the best recurrence rates and hazards. If possible mesh in sublay position should be used in cases of LIH repair.