Pre-operative imaging is often helpful in determining an appropriate operative approach, but occasionally when in the OR, the operative plan needs to be altered. This video demonstrates a case of a 54 year old female with a body mass index of 41, who is currently non-ambulatory She presented with an incisional hernia as well as traumatic flank and diaphragmatic hernias. Her main symptoms consisted of dysphagia and early satiety. After discussion of the patient in our case conference, the original operative plan was to repair only the diaphragmatic hernia as this was likely to be responsible for her symptoms. Additionally, due to her functional status, she was determined to be a poor operative candidate if all three were addressed as these would require an open approach with potentially a large flank incision. Intra-operatively, our operative plan had to be changed due to the close proximity of the diaphragmatic and flank hernias. This video illustrates operative decision making when anatomy is unclear, adjuncts that can be utilized to delineate uncertain anatomy as well as technical factors required to ensure a positive operative outcome. We also demonstrate an alternative way to close a hernia when under undue tension and ways to fixate mesh in situations where transfascial sutures or tacs are unable to be utilized.