In this video presentation, we present a laparoscopic antegrade sleeve gastrectomy in a 67 year-old male with morbid obesity (BMI 45) and a complex ventral hernia with substantial loss of domain. This patient presented to our clinic with a large ventral hernia that extended down to his knees. Immediate abdominal wall reconstruction was thought to be at high risk of failure given his morbid obesity. The patient had failed multiple weight loss programs, and thus we considered surgical weight loss options for him. Pre-operative imaging showed that the majority of the patient’s stomach was contained within the hernia sac, along with the rest of his intra-peritoneal organs. We offered the patient a laparoscopic sleeve gastrectomy. This case is unique because the operation was performed predominantly within the hernia sac, rather than within the true abdomen. Post-operatively, the patient developed a mild acute kidney injury that resolved with fluid administration. He had no other complications and he was discharged from the hospital on post-operative day 4. At his 6 week follow up appointment, the patient had lost 34 lbs and his BMI had decreased from 45 to 39. Conclusion: Laparoscopic antegrade sleeve gastrectomy can be a feasible option for patients with complex ventral hernias that involve significant loss of domain and challenging anatomy.