Pregnancy in a rudimentary horn is an extremely rare but serious obstetric condition. It is associated with uterine rupture and increased maternal mortality. The standard treatment is excision of the pregnancy and rudimentary horn. Several case reports describe a successful laparoscopic approach for rudimentary horn pregnancies diagnosed in the first trimester. A midtrimester rudimentary horn pregnancy was managed with a hand-assisted laparoscopic technique. This patient sought prenatal care at 19 weeks without any symptoms. A routine ultrasound found an empty uterus and an abdominal pregnancy was suggested. She subsequently had a hand-assisted laparoscopic delivery of a 19-week fetus with excision of the left-sided noncommunicating rudimentary horn. Intraoperative and pathologic findings were both consistent with a noncommunicating uterine horn pregnancy with placenta increta. Midtrimester rudimentary horn pregnancy can be successfully managed via hand-assisted laparoscopy in a patient who is hemodynamically stable.