Abdominal wall reconstruction has evolved significantly over the last decade. Enhanced-view totally extraperitoneal (eTEP) approaches have expanded the options that now exist for complex defects that previously were challenging to adequately address via minimally invasive techniques [1]. For defects involving the flank and lumbar regions in particular, traditional intraperitoneal strategies, be it minimally invasive or open, have notable challenges and are associated with a high burden of complex recurrences. Placement of an intraperitoneal mesh may be associated with visceral adhesions, mesh erosions, and in some circumstances, a fistula. Beyond the common concerns attributed to intraperitoneal mesh, flank and lumbar hernias present further issues related to sufficient circumferential fixation, which is challenging as the mesh margins will often be in close proximity to neurovascular structures and bony landmarks (e.g., anterior superior iliac spine or costal margin). As such, experience has led many abdominal wall specialists to focus on extraperitoneal mesh placement, reducing the need for circumferential fixation or anchoring of the mesh to bony prominences. Open approaches for repair are well-described and associated with adequate long-term outcomes. However, open approaches have significant wound morbidity, in particular for patients with concurrent midline hernias. In these scenarios, traditional retromuscular repairs with transversus abdominis release may require both a midline incision as well as a counter-incision over the flank defect. As the surgeon experience with eTEP-approach has evolved, so too has our ability to tackle these complex defects through limited via minimally invasive approaches. Through this approach, a surgeon may address hernias that exist along the entire abdominal wall, from lateral margins defined by the psoas muscles and from the central tendon of the diaphragm to the myopectineal orifice. In this chapter, we will review our decision-making related to flank and lumbar hernias and highlight scenarios in which the eTEP approach may be advantageous.