Abdominal compartment syndrome is a lethal complication of severe acute pancreatitis that is associated with high morbidity and mortality. When the intra-abdominal pressure is mildly elevated, conservative methods such as neuromuscular blockade, nasogastric decompression, sedation and a correction of positive cumulative fluid balance should be used first. This should be followed by semi-conservative methods, such as percutaneous catheter drainage, to obviate the need for surgery. If these modalities fail, surgical intervention via embryonal natural orifice transluminal endoscopic surgery or abdominal re-approximation anchor system with ABThera open abdomen negative pressure therapy system is highly recommended within four days of disease onset. Primary fascial closure should be attempted, but a planned ventral hernia approach using components separation technique should be used for type I defects and a tensor fascia lata flap should be used for type II defects when primary approximation of fascia is not possible or when previous repair has failed.