In cases of massive ventral hernias in which the herniated viscera cannot be returned to the abdominal cavity with standard repair techniques, progressive preoperative pneumoperitoneum (PPP) results in significant expansion of the abdominal cavity to accommodate the reintroduction of the herniated contents. This procedure involves progressive insufflation of the abdominal cavity over time, thus lengthening the abdominal musculature and elevating the diaphragm to increase abdominal cavity volume. Herein, we discuss the concept and definitions of loss of domain, the indications, techniques, and outcomes of PPP, and the limitations of our current understanding of the physiology of ventral hernias with loss of domain.