Although repair of large incisional hernia is challenging, surgical techniques have evolved at a high pace in recent decades. In 1990, Oscar Ramirez described the open anterior component separation. This technique comprised division of the external oblique aponeurosis or muscle to achieve tension-free restoration of the linea alba during midline hernia repair. While this approach is highly effective, there are many reports of increased wound morbidity secondary to the required considerable subcutaneous dissection to reach the external oblique from the midline. Endoscopic anterior component separation as an adjunct to repair of large incisional hernia is a minimally invasive approach to this technique, as it reduces subcutaneous dissection and prevents division of the periumbilical perforators supplying the skin. This technique has become one of the many important tools for the abdominal wall surgeon. In the current chapter, we review the technique, from preoperative considerations to specific technical details, pitfalls, and potential limitations.