Incisional hernia represents the most common wound complication after abdominal surgery. The repair of large incisional hernias requires an accurate knowledge of the interactions between the tissues of the abdominal wall, the prosthetic materials and the bowel. At the same time a careful attention must be placed on the physiopathology of abdominal hypertension. Repair of giant incisional hernias with heavy loss of substance may take to a sudden increase of intra-abdominal pressure and, sometimes, to Abdominal Compartment Syndrome (ACS). The aim of preventing recurrences very often requires the use of a prosthesis, which must be placed on a low-tension environment to avoid early failures and excessive increase of intra-abdominal pressure. It is also necessary to employ as much parietal tissues as possible to prevent visceral adhesions and lesions and to pay attention to an appropriate employment of prosthesis. Utilization of composite materials, absorbable prosthesis or of combinations of mesh and flaps looks promising in preventing endoabdominal hypertension without increasing the rate of recurrences, infections and adhesive complications.