Acute mesenteric ischemia is an emergency with a high mortality. The incidence is age-dependent and increases with pre-existing cardiovascular risk factors. Because of the low tolerance to ischemia, especially of the intestines, progressive intestinal necrosis with transmigratory peritonitis and multiorgan failure occurs in the natural course of the disease. Therefore, mesenteric ischemia should always be considered in patients with acute abdomen. The disease typically progresses in three clinical phases, whereby improvement of symptoms initially occurs, which is why the diagnosis is difficult. Computed tomography angiography (CTA) is considered the gold standard for confirming the diagnosis. Depending on the etiology, such as embolism, arterial thrombosis, or nonocclusive mesenteric ischemia, treatment can be carried out as an open surgical or endovascular procedure. Establishment of a diagnostic and treatment algorithm improves the prognosis. After successful revascularization, resection of bowel and organ sections may become necessary. In this case, the rules of damage control surgery apply, which may necessitate a planned relaparotomy (second look).