Approach to Posterior Lateral Thorax for Excision of Ribs

Skin incision for a muscle sparing posterolateral thoracotomy, marked as a dotted line curving below the tip of the scapula with the patient — Skin incision for a muscle sparing posterolateral thoracotomy, marked as a dotted line curving below the tip of the scapula with the patient in the lateral position. Image from Issoufou I, Sani R, Amadou D, Alio K, Adamou-Nouhou K, Lakranbi M, Sani R, Ouadnouni Y, Abarchi H, Smahi M. Which Role for Muscle-Sparing Posterolateral Thoracotomy in the Treatment of Spontaneous Pneumothorax?. Surg J (N Y). 2023, 9(4), e149-e155. CC BY 4.0.

Gray’s Anatomy illustration of the costotransverse joint — Costotransverse joint seen from above, showing how each rib attaches to its vertebra and transverse process. Image by Henry Vandyke Carter, Gray’s Anatomy (1918), Wikimedia Commons, public domain.

Position

prone on operating table
position bolsters longitudinally on either side of patient from ASIS to shoulders
- chest expansion

Landmarks

ribs

Incision

midline longitudinal incision centred over most prominent apical rib
Start
End

Internervous Plane

Trapezius
- Spinal accessory nerve
Latissimus dorsi
- Thoracodorsal nerve

Superficial Dissection

Continue incision down to fascia
Using retractors to retract skin & fascia laterally at least 12 cm from midline

Deep Dissection

Identify lateral border of trapezius & retract it medially
Identify the thoracolumbar fascia & latissimus dorsi
- Incise medial border & retract laterally
Split iliocostalis muscles longitudinally over each involved rib that is being removed
Incise periosteum in line with each rib
- Strip the intercostal muscles subperiosteally to expose the rib
Ask anaesthetist to stop the patient’s breathing the lung before excising ribs

Dangers

Neurovascular bundle
- Lower edge of each rib
Pneumothorax
- Treatment: chest tube
Haemothorax
- Chest tube

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