I cannot agree with Dr. Kotsis’ conclusion that the transthoracic approach should be preferred in any case of visceral herniation to the chest. As long as no further resection for perforation or ischemia due to strangulation is required, the hernia may be repaired via a thoracotomy. In our case, however, a perforation of the left hemicolon was demonstrated preoperatively, and it required a left hemicolectomy.1Even for a well-trained thoracic surgeon, it may be impossible to perform this operation transthoracically. It was also obvious from the review of the literature that, in the case of intrathoracic colonic perforation, a laparotomy was the preferred approach in almost 70% of cases and a combined procedure was preferable in the remaining cases.2 As long as no perforation of intra-abdominal organs into the chest is suspected, a transthoracic approach should be preferred since it allows a better exploration of the thoracic cavity. In the presence of a complicated herniation (ie, strangulation or perforation), a laparotomy will be required, which may be combined with a thoracotomy.