The initial management of intra-abdominal hypertension (IAH) is medical measures to reduce intra-abdominal pressure (IAP). These, in combination with percutaneous drainage of peritoneal free fluid, may serve to reduce IAH. If these measures fail, surgical decompression of the abdomen by laparotomy is necessary to control the IAP, search for and treat inciting factors, and reduce the hypertension. The abdomen is usually left open with temporary abdominal closure techniques. Surgical decompression of IAH associated with acute pancreatitis or secondary abdominal compartment syndrome has other surgical options besides a complete celiotomy. Attention to detail in surgical technique and postoperative care is essential for optimal outcome.