Introduction the role of surgery in managing massive midline abdominal wall defects has continued to rise, leading to higher demand for more effective techniques in order to limit recurrences. There is paucity of data on this subject in Southeast Nigeria. The aim of this study is to document the indications and challenges of treatment of complex, midline abdominal wall defects in our centre. Methods this was a cross-sectional study of adult patients with complex, midline abdominal wall defects managed with mesh implants over a five-year period. Results a total of 182 adult patients, predominantly females 160(87.9%), received mesh implants for complex abdominal wall defects. The common indications were incisional hernia 128(70.3%), abdominal wound dehiscence 16(8.8%) and divarication of recti 16(8.8%). About one-third 62(34.1%) of the patients required additional abdominoplasty procedure. Delay towards prompt surgical repair was noted in 168(92.3%) patients, notably due to financial constraints 32(17.6%) followed by comorbidities requiring serial assessments 24(13.2%). Superficial wound infection rate was 5.5% while deep (mesh) infection was noted in two (1.1%) patients. Recurrence and perioperative mortality rates were 1.1% and 1.6% respectively. Diabetes mellitus in obese female patients was an independent predictor of perioperative death (p=0.000). Conclusion the most common indication for abdominal wall reconstruction in our environment is incisional hernia. The use of prosthetic meshes to repair complex abdominal wall defects is largely safe and effective in our practice, but timely reconstruction is commonly hampered by multi-faceted economic, clinical and pathological barriers.