The combination of panniculectomy with a ventral hernia repair may result in an increased rate of wound complications. In select patients, this approach may be optimal and potentially reduce the long-term risk of hernia recurrence. A 59-year-old morbidly obese woman presented with recurrent small bowel obstruction. She had a massive pannus, BMI 49.53 kg/m² a history of diabetes, and a 10-year history of chronically incarcerated ventral hernia. In preparation for surgery, the patient lost 28 pounds and failed nonoperative management. After appropriate preparation and consent, the procedure began with a panniculectomy by vertically suspending the patient's pannus with orthopedic hardware. Careful dissection was performed around the hernia sac, followed by adhesiolysis and dissection of the preperitoneal tissue plane. The peritoneum was then approximated over the omentum-covered viscera. The defect area was 225cm², and a 35x30cm mid-weight polypropylene mesh was positioned in the preperitoneal space. The mesh was secured using transfascial sutures, and the fascia was approximated without tension. The incision was closed, and a negative pressure vac dressing was applied. The patient recovered without any complications and was discharged home. In conclusion, the combination of panniculectomy with a PPVHR can be done safely and in certain patients is necessary. Technique, as demonstrated in this case will help optimize postoperative outcomes.