retropleural and retroperitoneal spaces may need to be connected to gain full access to the spine/ spinal canal and to place the instrumentation. The retroperitoneal space is entered by dividing the costal cartilage of the 11th or 12th ribs [ 22 , 32 , 37 , 52 ] and the psoas muscle is bluntly split en route to the spine [ 4 , 6 , 17 , 24 , 45 , 48 , 54 ]. The extent of associated rib removal depends on both individual anatomy and required surgical access dimensions. In contradistinction to the origi­nal descriptions of thoracolumbophrenic access [ 37 , 38 ], extensive division of the diaphragm itself is not required. Only the most proximal diaphragmatic insertions on the thoracolumbar spine (L1, L2) are dissected off the lateral spinal surface to connect the retropleural and retroperi­toneal spaces [ 11 , 17 , 45 , 55 ] – schematic line drawing). Overlying skin, soft tissues, pleura, diaphragm, and peritoneal sac are retracted by multiple valves of a table-fi xed retractor to allow for simultaneous visualization of supra- and infradiaphragmatic extensions of the combined approach. Closed chest tube drainage usually is not required. If a visceral pleural leak (i.e., air fi stula) or a parietal pleural tear should occur that cannot be addressed by direct suture or applica­tion of a sealant (e.g., a fi brin-coated collagen sponge), a small chest tube is placed directly through from the approach site. Otherwise, a single large vacuum drain (12Ch) is left in the retropleural space to promote reattachment of the parietal pleura to the chest wall for 3–4 days. Mid-thoracic (true) ribs are approximated and secured with nonabsorbable sutures. The wound is closed anatomically in layers, with the skin either sutured or sealed with cyanoacrylate. Postoperative chest X-rays to exclude clinically relevant pneumo-/hemothorax are obligatory before discharge of the patient from the ICU.