Anterior Transthoracic Approach

Axial drawings of the routes to a thoracic disc
Axial drawings of the routes to a thoracic disc. The anterior routes in panel b pass either through the pleural cavity (transpleural, red) or through the retropleural space (yellow) to reach the side of the vertebral body and disc. Image from Baram A, Cracchiolo G, Riva M, Capo G, Anselmi L, Brembilla C, Radice S, Tropeano MP, Anania C, Morenghi E, Fornari M, Pessina F. Comparative analysis of mini-open trans-thoracic transpleural and posterior approaches in thoracic disc herniation surgery, A 10-year retrospective review. Brain Spine. 2025, 5, 104244. CC BY 4.0.
Gray’s Anatomy illustration of the costovertebral joints
Costovertebral joints from the front. The transthoracic approach exposes the vertebral bodies, rib heads and segmental vessels. Image by Henry Vandyke Carter, Gray’s Anatomy (1918), Wikimedia Commons, public domain.
  • Unrivalled exposure to anterior portions of vertebral bodies T2 – T12
  • Operate in conjunction with Thoracic surgeon

Indications

  • Infections TB
  • Fusion
  • Tumour
  • Bone grafting
  • Correction of scoliosis
    • Dwyer instrumentation & rods
  • Correction of kyphosis

Position

  • Lateral
  • Stabilised with lateral supports
  • Patient’s arm placed above the head
  • Axillary roll & feel for radial pulse in dependent arm
  • Surgeon is behind the patient
  • Approach from RIGHT side to avoid aortic arch & aorta
  • NG tube to help identify oesophagus

Landmarks

  • Tip of scapula
  • Spines of thoracic vertebrae
  • Inframammary crease

Incision

  • L shaped incision over 7th or 8th rib
  • Start: 2 fingerbreadths below tip of scapula
    • curved forward towards inframammary crease
    • curved backward & upward midline between spine & medial border of scapula

Superficial Dissection

  • Divide latissimus dorsi in line with skin incision
  • Divide Serratus Anterior along the same line, down to the RIBS
  • scapula can now be elevated to expose the underlying ribs
  • Many vessels are encountered & are cauterised
  • Intercostal space or Rib resection
    • intercostal space / rib to be resected depends on the location of pathology
    • 5th intercostal space
      • T2 – T10
    • 6th intercostal space
      • T10 – 12
  • Cut down to rib with cutting diathermy
  • Cut the periosteum on the upper border of the rib
  • If resecting the rib
    • Resect the posterior ¾ of the rib as far posterior as necessary
  • Insert rib spreader to hold ribs apart

Deep Dissection

  • Ask Anaesthetist to DEFLATE the lung
    • Gently retract it anteriorly with moist lap pads to protect it
  • Identify the Oesophagus
  • Incise the pleura over the oesophagus so that it can be mobilised
    • Ligate / tie off intercostal vessels that are necessary
    • Retract & hold oesophagus medially with 2 penrose drains
  • vertebral bodies are now exposed
  • If need to reach T11 –T12
    • Part of diaphragm may need to be resected
    • Remove arcuate ligament from its origin on transverse process of L1

Dangers

  • Intercostal vessels
  • Lungs
    • Inflate lungs every 30 minutes to help prevent microatelectasis postop

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.