Lateral Decubitus (Left Side Up) | Rib Resection | Diaphragm Takedown | Artery of Adamkiewicz at Risk
- Lateral decubitus, usually left side up - the left side is preferred because the descending aorta is easier to mobilise and tolerates segmental ligation far better than the thin-walled IVC, and the liver is avoided.
- Resect the rib one to two levels above the target vertebra because the rib slopes obliquely downward from posterior to anterior - for the T12-L1 junction the 10th or 11th rib is typical.
- There is no true internervous plane - this is a transthoracic and retroperitoneal exposure that splits the abdominal wall musculature in the line of its fibres and crosses the rib bed, the diaphragm and the psoas.
- Take the diaphragm down circumferentially along its costal attachment, leaving a 2 cm peripheral cuff (with its pleural and peritoneal coverings) for a sound watertight repair.
- Ligate segmental vessels at the vertebral mid-body, away from the intervertebral foramen, to protect the artery of Adamkiewicz (T9-L2, most often on the left) - injury causes anterior cord infarction.
When & Why
What it exposes. The anterior thoracoabdominal approach gives direct, daylight anterolateral exposure of the T10-L2 vertebral bodies, the disc spaces and the anterior thecal sac across the diaphragm. It joins a transthoracic route (through a resected rib) with a retroperitoneal route, the two connected by taking down the diaphragm. It is the workhorse exposure for thoracolumbar corpectomy, anterior cord decompression, deformity correction, tumour resection and infection. Why this approach is chosen. The thoracolumbar junction is the most commonly injured region of the spine - it sits at the transition from the rigid thoracic kyphosis (stabilised by the rib cage) to the mobile lumbar lordosis, concentrating mechanical stress, which explains the high incidence of burst fractures here. Retropulsed middle-column bone compresses the cord and conus from directly anterior, and a posterior approach alone cannot safely retrieve bone lying against the anterior thecal sac. Anterior column reconstruction (strut graft, expandable cage or plate) is also biomechanically superior for restoring load sharing and sagittal alignment. Primary indications:
- Thoracolumbar burst fractures with significant canal compromise from retropulsed bone, where anterior decompression is required
- Vertebral body tumour requiring en bloc or intralesional marginal resection and anterior column reconstruction
- Pyogenic infection or tuberculous spondylodiscitis (Pott disease) needing radical debridement and strut support (the classic Hodgson indication)
- Thoracolumbar deformity (kyphosis, scoliosis) requiring anterior release, discectomy and fusion
- Pseudarthrosis or non-union of the anterior column after posterior surgery
- Biopsy of an accessible anterior lesion when image-guided biopsy is non-diagnostic Contraindications (mostly relative):
- Severe cardiorespiratory compromise preventing one-lung ventilation or lateral decubitus (consider a posterior approach)
- Prior abdominothoracic surgery with dense scarring across the planned route
- Inability to tolerate the diaphragm being taken down in a patient with borderline respiratory reserve
- Active empyema or pleural disease on the approach side, or skin compromise over the incision Alternative approaches:
- Posterior pedicle-screw decompression and fusion - for fractures manageable by indirect reduction and posterior stabilisation alone
- Costotransversectomy / lateral extracavitary approach - a more posterior route to the body that avoids formal thoracotomy and diaphragm division
- Video-assisted thoracoscopic surgery (VATS) combined with a small retroperitoneal incision - the minimally invasive alternative for selected corpectomies
- Lateral transpsoas (XLIF/DLIF) approach - for lower thoracic and lumbar levels reached through the retroperitoneal corridor without diaphragm takedown
- Anterior retroperitoneal (flank) approach - for L2 and below without entering the chest
| Approach | Levels | Diaphragm taken down | Best for |
|---|---|---|---|
| Thoracoabdominal | T10-L2 | Yes | Corpectomy, tumour, deformity, infection |
| Thoracotomy | T5-T10 | No | Mid and upper thoracic body |
| Thoraco-retroperitoneal (flank) | T12-L3 | Partial or no | Lower junction and upper lumbar |
| Anterior retroperitoneal | L2-S1 | No | Lower lumbar and lumbosacral |
| Costotransversectomy / LECA | T10-L2 | No | When formal thoracotomy is undesirable |
- Confirm and mark the side of approach against the imaging and surgical plan
- Double-lumen endobronchial tube or bronchial blocker for selective lung ventilation
- Large-bore intravenous access, arterial line, urinary catheter; cell salvage available, group-and-save cross-matched
- Neuromonitoring (somatosensory and motor evoked potentials) where cord decompression is planned
- C-arm or intraoperative fluoroscopy for AP and lateral imaging
For the thoracolumbar junction the standard approach is from the left. The descending aorta on the left is thick-walled, can be safely mobilised, and tolerates segmental ligation far better than the thin-walled, tear-prone inferior vena cava on the right. The large right lobe of the liver also blocks access from the right. A right-sided approach is reserved for pathology that is predominantly right-sided, such as a tumour extending across the midline.
Surface landmarks: the inferior angle of the scapula (lies over the seventh intercostal space / eighth rib at rest), the costal margin (lower limit of the thoracic cage and the line of diaphragmatic attachment), the iliac crest (lower boundary of the flank and retroperitoneal window), and the erector spinae / paraspinous mass (posterior limit of the incision). The target rib is confirmed by counting ribs on the preoperative chest radiograph and cross-referenced with intraoperative fluoroscopy. Incision planning: a curvilinear incision along the selected rib (typically the 9th, 10th or 11th rib), beginning at the posterior axillary line and extending obliquely toward, and often just beyond, the costal margin; for lower pathology it continues into the flank toward the lateral border of the rectus sheath. The rib is selected to be one to two levels above the target vertebra because the rib slopes downward from posterior to anterior, so a higher rib overlies a lower vertebra.
The Exposure
The route is transthoracic and retroperitoneal. There is no true internervous plane: the incision splits the abdominal wall musculature (external oblique, internal oblique and transversus abdominis) in the line of its fibres, crosses the resected rib bed, the diaphragm and the psoas to reach the spine. Muscles are split rather than detached, so denervation is limited. Work down from the skin along the selected rib, enter the chest, take the diaphragm down circumferentially, develop the retroperitoneal plane, then ligate the segmental vessels at the mid-body to expose the vertebral body.
Intra-operative photograph or axial cross-section of the anterior thoracoabdominal approach in lateral decubitus: a curvilinear incision over the resected 10th rib, the chest opened with the lung retracted superiorly, the diaphragm divided circumferentially with a 2 cm peripheral cuff, and the retroperitoneal plane developed to expose the T12-L1 vertebral body with the aorta mobilised and segmental vessels ligated at the mid-body.
Context: A verified image is being sourced for this exposure.
Exposure sequence
- With the patient lateral, left side up, confirm the target level on imaging and fluoroscopy and mark the rib one to two levels above the target vertebra (the 10th rib for the T12-L1 junction).
- Make a long curvilinear incision along the line of the rib, from the posterior axillary line obliquely forward to, and just beyond, the costal margin.
- For lower pathology continue the incision into the flank toward the lateral border of the rectus sheath.
- Divide skin and subcutaneous tissue in line with the incision.
- Deepen through latissimus dorsi and serratus anterior (or external oblique) in the line of their fibres, coagulating perforators as they are encountered.
- Reach the surface of the selected rib.
- Incise the periosteum over the rib along its long axis and develop the subperiosteal plane with a periosteal elevator and a Doyen raspatory.
- Stay strictly on bone: the intercostal neurovascular bundle lies in the costal groove on the inferior border of the rib and must be protected.
- Keep the elevator on the superior border to avoid plunging.
- Divide the rib posteriorly and anteriorly with rib shears and remove a generous segment.
- Save the resected rib for use as autograft or a strut.
- The exposed rib bed is now the gateway to the chest.
- Carefully incise the parietal pleura in the bed of the resected rib to enter the pleural cavity.
- The deflated lung (via the double-lumen tube) is gently retracted superiorly.
- Divide the inferior pulmonary ligament under direct vision to mobilise the lower lobe and improve exposure of the lower thoracic spine.
- Incise the diaphragm circumferentially along its costal attachment, leaving a peripheral cuff of about 2 cm of muscle (with its pleural and peritoneal coverings) attached to the chest wall for later repair.
- Begin at the rib bed and carry the incision around the periphery.
- A circumferential peripheral incision preserves the centrally-entering phrenic nerve branches and makes a watertight, strong repair straightforward.
- Deep to the divided diaphragm, bluntly develop the retroperitoneal plane.
- Sweep the peritoneum (containing the abdominal contents, the ureter and, on the left, the spleen and splenic flexure) medially and anteriorly off the retroperitoneal fat and the psoas.
- Keep the peritoneum intact as a single envelope - do not buttonhole it or allow abdominal contents to herniate into the field.
- The psoas major lies over the lateral aspect of the lumbar vertebral bodies; the genitofemoral nerve runs on its surface and should be preserved.
- The great vessels (aorta on the left, IVC on the right) lie anterior to the bodies.
- The sympathetic trunk runs on the lateral body wall deep to the psoas.
- Confirm the level with a marker on a vertebral body and an intraoperative radiograph.
- Identify the segmental vessels crossing the waist of the vertebra; ligate and divide each at the mid-body, well away from the intervertebral foramen.
- Gently mobilise the aorta (or IVC) anteriorly off the anterior longitudinal ligament to expose the vertebral body and disc spaces across the midline.
- Incise the annulus of the disc above and below the target body and remove the disc material back to the posterior annulus.
- Excise the vertebral body piecemeal from the side of the approach across toward the opposite pedicle, working anterior to posterior.
- Remove retropulsed middle-column bone from the anterior aspect of the thecal sac to decompress the cord and conus; preserve the posterior longitudinal ligament unless pathology dictates its removal.
- Size and place an anterior strut (tricortical iliac crest autograft, femoral ring allograft, or a mesh or expandable cage filled with autograft) spanning the defect into prepared end-plate recesses.
- Apply anterior instrumentation (a lateral plate, or a rod-and-screw construct) across the levels to stabilise the construct and restore sagittal alignment.
- Confirm position and alignment with fluoroscopy.
The artery of Adamkiewicz is the dominant feeder of the anterior spinal artery and enters the canal through an intervertebral foramen between T9 and L2, most often on the left - exactly the territory of this approach. Ligate each segmental vessel at the mid-body of the vertebra, well away from the foramen where the medullary feeder enters; ligating close to the foramen risks interrupting this vessel and causing devastating anterior cord infarction. Use somatosensory and motor evoked-potential monitoring, and where the side of entry is uncertain, clip (rather than diathermy) the vessel on the suspected side and watch the potentials before definitive division.
If asked for the internervous plane, the correct and honest answer is that there is none. The thoracoabdominal approach is a transthoracic and retroperitoneal exposure that splits the abdominal wall musculature (external oblique, internal oblique, transversus abdominis) in the line of its fibres and crosses the rib bed, the diaphragm and the psoas to reach the spine. Stating this directly, rather than inventing a plane, is exactly what the examiner wants.
Dangers & Extensions
Structures at risk, by layer
| Layer | Structure at risk | Protection |
|---|---|---|
| Rib resection | Intercostal nerve and vessels (costal groove) | Strict subperiosteal dissection; keep on the superior rib border |
| Chest entry | Lung, inferior pulmonary ligament | One-lung ventilation, gentle retraction, ligate the ligament under vision |
| Diaphragm takedown | Phrenic nerve branches | Circumferential peripheral incision, 2 cm cuff from the costal margin |
| Retroperitoneum | Peritoneum, ureter, spleen or liver | Sweep the peritoneal envelope medially as one unit; do not buttonhole it |
| Body exposure | Artery of Adamkiewicz (T9-L2, usually left) | Ligate segmental vessels at the mid-body, away from the foramen |
| Body exposure | Great vessels (aorta, IVC) | Gentle blunt mobilisation after segmental ligation; vascular surgeon on standby |
Complications
| Complication | Prevention | Management |
|---|---|---|
| Major vessel injury (aorta or IVC) | Segmental ligation before mobilisation; vascular surgeon available | Direct pressure, proximal and distal control, primary repair or graft |
| Cord ischaemia (Adamkiewicz) | Mid-body ligation, evoked-potential monitoring, staged clipping | Avoid further ligation, maintain perfusion pressure, urgent imaging |
| Diaphragmatic injury or hernia | Circumferential peripheral incision, meticulous repair to the cuff | Intra-operative repair; delayed hernia repair if missed |
| Peritoneal or visceral injury | Blunt medial sweep of the peritoneal envelope | Repair any buttonhole, protect abdominal contents |
| Atelectasis and respiratory failure (most common) | Early mobilisation, incentive spirometry, thoracic epidural analgesia | Chest physiotherapy, bronchoscopy, ventilatory support if severe |
| Pleural effusion or pneumothorax | Correct chest tube placement and management | Drainage, tube adjustment |
| CSF leak or dural tear | Careful corpectomy, identify dura | Primary repair, sealant, bed rest, lumbar drain |
| Wound or deep infection | Prophylactic antibiotics, meticulous closure | Debridement, antibiotics, retain or remove implants per judgement |
Anterior thoracolumbar approaches carry the highest respiratory morbidity of all spinal approaches - rib resection, diaphragm division, one-lung ventilation and postoperative pain combine to cause atelectasis, effusion and pneumonia. Multimodal analgesia (including a thoracic epidural), aggressive chest physiotherapy and early mobilisation are as important to the outcome as the surgery itself.
Extensile options. Extend proximally along a higher rib (resecting the 4th or 5th rib reaches the mid-thoracic spine T5-T8) for upper thoracic corpectomy or release, without taking the diaphragm down. Extend distally by carrying the incision into the flank and developing the retroperitoneal plane further along the psoas, transitioning into the anterior retroperitoneal (flank) approach to reach L2-L5 and the lumbosacral junction without further diaphragm division. For VATS-assisted selected corpectomies, thoracoscopy provides thoracic visualisation through ports while the diaphragm and retroperitoneum are approached through a small muscle-splitting incision, reducing chest-wall morbidity. Many thoracolumbar injuries are best managed by a combined anterior decompression and reconstruction with a posterior instrumented fusion - the anterior stage is performed first in lateral decubitus, the wound closed and a chest tube placed, and the patient then repositioned prone for posterior pedicle-screw instrumentation. Closure. Meticulously repair the diaphragm back to the 2 cm peripheral cuff using heavy interrupted non-absorbable sutures - a sound, watertight repair prevents herniation and preserves respiratory mechanics. Ask the anaesthetist to re-expand the lung, then place a large-bore chest tube through a separate dependent stab incision (directed apically) connected to underwater seal. If a formal thoracotomy was made, approximate the ribs with heavy pericostal absorbable sutures; close the abdominal wall muscles in layers over the retroperitoneum (add a retroperitoneal drain if oozing persists); close the subcutaneous layer and skin. Obtain an upright chest radiograph in recovery to confirm full lung expansion, chest tube position and the absence of pneumothorax or haemothorax, plus AP and lateral spine radiographs to confirm graft and implant position.
Procedures Through This Approach
- Thoracolumbar corpectomy - for burst fractures, vertebral body tumour, and pyogenic or tuberculous spondylodiscitis (the classic Hodgson-Stock anterior debridement and strut).
- Anterior cord and conus decompression - removal of retropulsed middle-column bone from the anterior thecal sac under direct vision.
- Anterior release and fusion for deformity - discectomy and correction of thoracolumbar kyphosis or scoliosis (the Dwyer cable-and-screw lineage).
- Anterior column reconstruction - strut graft, femoral ring allograft or expandable cage with a lateral plate or rod-and-screw construct.
- Biopsy of an accessible anterior lesion when image-guided biopsy is non-diagnostic.
Viva & Exam Focus
THORACOTHORACO — the operative sequence
DANGERDANGER — the structures at risk
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A 32-year-old man falls from height and sustains a T12 burst fracture with retropulsed bone and an incomplete cord injury. Imaging shows significant canal compromise. Describe your approach.”
“During exposure for a T11 corpectomy you are about to ligate the segmental vessels on the left. How do you protect the anterior spinal cord blood supply?”
“On day one after a thoracoabdominal corpectomy the patient is hypoxic, with reduced air entry at the left base and a chest radiograph showing atelectasis and a pleural effusion. How do you manage this?”
Position & setup
- Lateral decubitus, usually LEFT side up (aorta safer than IVC, liver avoided)
- Break the table or use a kidney rest to open the rib-to-iliac-crest window
- Dependent axillary roll to protect the brachial plexus
- Double-lumen tube for one-lung ventilation
- Neuromonitoring (SSEP and MEP) when decompressing the cord
- Confirm the side and level with imaging before incision
Incision & rib resection
- Incision along the rib one to two levels above the target vertebra
- 10th or 11th rib typical for the T12-L1 junction
- Split latissimus, serratus and external oblique in line with fibres
- Strict subperiosteal rib dissection to protect the intercostal bundle
- Resect the rib segment and save it for graft
- Enter the pleura through the rib bed; divide the inferior pulmonary ligament
Diaphragm management
- Divide the diaphragm circumferentially along its costal attachment
- Leave a 2 cm peripheral cuff for repair
- Circumferential peripheral incision preserves the phrenic branches
- Provides the corridor between chest and retroperitoneum
- Repair with heavy interrupted non-absorbable sutures at closure
- A watertight repair prevents herniation and preserves respiration
Deep dissection & segmental vessels
- Sweep the peritoneum medially as one intact envelope off the psoas
- Identify the psoas, the genitofemoral nerve and the great vessels
- Ligate segmental vessels at the vertebral MID-BODY, away from the foramen
- Protects the artery of Adamkiewicz (T9-L2, usually left)
- Mobilise the aorta off the anterior longitudinal ligament
- Confirm the level with a marker and intraoperative radiograph
Structures at risk
- Artery of Adamkiewicz - anterior cord infarction if injured
- Great vessels (aorta, IVC) - catastrophic bleeding
- Diaphragm and phrenic nerve - respiratory function
- Segmental and intercostal vessels - bleeding, ischaemia
- Lung - atelectasis, injury, respiratory failure
- Peritoneum, ureter, spleen, liver, sympathetic chain, thoracic duct
Closure & drains
- Repair the diaphragm to the peripheral cuff
- Re-expand the lung before closure
- Place a chest tube through a separate dependent stab
- Approximate the ribs if a formal thoracotomy was made
- Close abdominal wall muscles in layers; retroperitoneal drain if needed
- Upright chest radiograph in recovery to confirm lung expansion
References
Guidelines, registries and global practice. The anterior thoracoabdominal approach is a globally established technique whose principles converge across examination systems. Anterior decompression and reconstruction are recommended when retropulsed middle-column bone or tumour compresses the cord or conus from directly anterior, or when the anterior column must be reconstructed for load sharing and sagittal alignment. AO Foundation emphasises anterior decompression and column reconstruction for significant canal compromise and anterior column deficiency, with preservation of segmental perfusion and neuromonitoring. NICE / BOA-BOAST guidance supports surgical decompression for incomplete cord injury with persistent compression and combined anterior-posterior strategies for complex injuries. AOSpine / TLICS classification guides the need for anterior decompression when the middle column retropulses into the canal. The thoracolumbar junction is the most frequently injured region of the spine, reflecting the transition from rigid thoracic kyphosis to mobile lumbar lordosis, and anterior thoracic and thoracolumbar surgery carries higher respiratory morbidity than posterior surgery, consistent across reported series. In high-resource settings, expandable cages, anterior plating or rod systems, double-lumen anaesthesia and routine neuromonitoring are standard; in resource-limited settings the same decompression is achieved with rib or tricortical iliac strut autograft and posterior instrumentation, accepting a larger role for the posterior or lateral extracavitary route to avoid formal thoracotomy. Consent should cover respiratory complications and the need for a chest tube (the most common morbidity), major vessel injury (rare but potentially fatal), cord ischaemia from injury to the artery of Adamkiewicz (rare but devastating), diaphragmatic and phrenic effects, infection, and the possible need for a combined posterior procedure.
Anterior Spinal Fusion for Pott's Disease (the Hodgson-Stock Operation)
The landmark Hong Kong description of radical anterior debridement and anterior strut fusion for tuberculous spondylitis. It established direct anterior exposure of the diseased vertebral body as the route for thorough decompression and structural support, demonstrating that excision of the diseased body with anterior grafting could control infection and paraplegia in Pott disease. It forms the conceptual foundation of modern anterior thoracolumbar surgery.
Anterior Correction of Scoliosis (the Dwyer Apparatus)
Introduced anterior instrumentation of the thoracolumbar spine using a cable-and-screw construct for scoliosis correction, showing that the anterior approach allowed discectomy, correction of rotational deformity and short-segment fusion. It established the anterior route as a platform for both decompression and deformity correction and paved the way for later anterior single-rod and dual-rod systems.
Perioperative Complications of Anterior Spinal Fusion in the Thoracic and Lumbar Spine
A large review of perioperative complications following anterior spinal fusion surgery in the thoracic and lumbar spine in adults. Major complications were uncommon overall in experienced centres, but respiratory and pulmonary complications were the most frequent approach-related morbidity, underscoring the importance of approach selection, anaesthetic technique and meticulous closure.
Perioperative Complications of Anterior Procedures on the Spine
Reviewed perioperative complications across anterior spinal procedures, including thoracic and thoracolumbar approaches. Pulmonary complications were prominent, particularly with thoracotomy and diaphragm takedown, and approach-related morbidity increased with longer operative time, greater levels exposed and combined procedures. The findings support multimodal analgesia, lung-protective anaesthesia and early mobilisation.
Application of Thoracoscopy for Diseases of the Spine
Introduced video-assisted thoracoscopic surgery (VATS) to spinal disease as a minimally invasive alternative to open thoracotomy, demonstrating thoracoscopic visualisation of the thoracic spine for discectomy, biopsy and anterior release with reduced chest-wall morbidity. It established the foundation for thoracoscopically assisted thoracolumbar corpectomy.