A woman in her 60s with history of multiple back surgeries presented with left flank pain. Cross-sectional imaging identified a left flank hernia. A laparoscopic, totally extraperitoneal approach was chosen for repair. The patient was positioned in right lateral decubitus position with a bed break at the level of the anterior-superior iliac spine (ASIS) to increase working space between the iliac crest and costal margin. To access the retroperitoneum, cutdown was performed slightly above the ASIS and medial to the mid-axillary line through the external oblique, internal oblique, and transversus abdominis. A balloon dissector was inserted and insufflated, creating working space. A 5mm port was placed slightly medial to the initial port. Surrounding tissue was dissected from the hernia. Multiple defects were identified, measuring 9cm in total length and 2cm in width. A 12x15cm flat piece of polypropylene mesh was placed over the defects with good coverage. One of the challenges of flank hernia repair is mesh fixation, and a laparoscopic extraperitoneal approach allowed this hernia to be repaired without fixation. The mesh was held in flat position during desufflation. Operative time was 84 minutes. The patient was discharged on postoperative day 1. At 2-week and 3-month follow-up visits there was no evidence of hernia recurrence or other perioperative complications.