The periosteum of the posterior wall of the rib and the parietal pleura are now divided as a single layer to enter the chest cavity. There is no need to deflate the lung for this level of exposure. Instead, the lung is retracted cephalad with a laparotomy pad. The diaphragm is now in view. A curvilinear incision is made in the posterolateral part of the diaphragm leaving a 2-cm rim of diaphragmatic insertion into the costal margin (Fig. 62.1b). The anterior extent of the diaphragmatic incision varies from one patient to another but can be extended to the costal margin if needed. The posterior extent of the diaphragmatic incision is to the medial arcuate ligament (lumbocostal arch) over the psoas muscle (Fig. 62.2). The plane between the diaphragm and the peritoneum is developed. The plane is gradually extended using blunt dissection, taking care not to injure the peritoneum or the underlying spleen. This is best achieved by staying away from the proximal aspect of the diaphragm where there is not enough extraperitoneal fat. Instead, you should dissect inferiorly where there is abundant extraperitoneal fat. Extending the diaphragmatic incision and developing the extraperitoneal plane are done simultaneously.

Once the posterior extent (the medial arcuate ligament) of the diaphragmatic incision has been reached, a radiolucent self-retaining retractor blade is used to retract the diaphragm medially. This blade should be carefully applied as it may injure the spleen, kidney, or their blood supply. Dissection is now carried out between the left crus of the diaphragm and the psoas muscle fibers, both of which take origin from the anterolateral aspect of the lumbar vertebral bodies (Fig. 62.2). A combination of blunt dissection and electrosurgery is used to free those fibers from their attachment to the anterior longitudinal ligament of the spine. Above the level of the diaphragm, the pleura covering the spine is incised vertically. The intercostal vessels are usually preserved. The greater splanchnic nerve is usually encountered immediately beneath the pleura overlying the spine and is easily retracted away from the vertebra in question.

The upper part of the psoas muscle is bulky, and it obscures the entire lateral aspect of the vertebral bodies. Gradually divide as much psoas fibers as needed in order to adequately expose the spine. As the psoas muscle fibers are being divided, care should be taken to identify and control the segmental vessels going to the diseased vertebra. Bipolar electrosurgery should suffice to control those vessels. Remember that you will continue to look for and deal with those vessels as you extend your dissection laterally toward the vertebral pedicle. Other segmental vessels should be preserved. The radiculomedullary artery of Adamkiewicz originates from the intercostal and/or lumbar arteries on the left side in 70 % of patients, frequently at the T8–L1 vertebral level. Injury to this artery can result in spinal cord ischemia. Your dissection does not need to reach the midline anteriorly. The spine surgeon is only interested in the anterolateral aspect and the pedicle of the vertebral body. Too much medial dissection is unnecessary and is associated with the risk of injuring the aorta and its branches.

As the psoas muscle fibers are gradually shaved off of the spine, the diseased vertebra begins to emerge. Remember that discs are convex and vertebral bodies are concave. In case of a fracture, the vertebral height is diminished and there is an associated hematoma. Use two 18-gauge spinal needles to mark what you believe is the body of the vertebra above and the body of the vertebra below. Those needles should fit in the operative field perpendicular to the waist of the vertebral body as this is how the screws will need to be positioned. Use fluoroscopy to confirm the level of exposure. At this point, the spine surgeon begins his/her part of the procedure.

Upon completion of the spine surgeon’s part, the exposure surgeon places a chest tube through a separate stab incision in the intercostal space above the main incision. This allows the lung to re-expand fully and also helps to drain blood. The tube can be removed if there is no residual pneumothorax and the fluid output is less than 150 cc/day. The diaphragm at the medial arcuate ligament is now approximated with a 0-PDS suture which is continued in a running fashion. The intercostal muscles and serratus anterior are repaired with 0-Vicryl running sutures. The skin is closed with either staples or subcuticular suture.