The rib directly overlying the lesion and the outlines of the affected and adjacent vertebral bodies are marked on the skin under fluoroscopy – schematic line drawing). The length of the skin incision depends on the intended procedure. For monosegmental spondylectomy and VBR, a 5–6 cm incision is adequate. Incisional length is extended to 8 cm for bilevel pathology or 10–12 cm for multiple segments – schematic line drawing). Sufficient mobilization of the skin and subcutaneous areolar tissue from the outer chest cage is important to permit soft tissue retraction craniocaudally and ventrodorsally during dissection and instrumentation. This will also allow for lateral instrumentation to be placed through additional thoracoports inserted one or two intercostal spaces above/below the rib resection site – schematic line drawing). An 8 cm rib segment is dissected subperiosteally and removed. The intercostal neurovascular bundle is mobilized off the costal sulcus, covered with a moist sponge and deflected into the chest cavity to avoid retraction-related intercostal neuralgia. Introducing the frame-retractor blades, the parietal pleural is then mobilized from the chest wall using blunt finger dissection or a peanut sponge – schematic line drawing). Mobilization of the parietal pleura is initialized around the rib removal site (i.e., ventrally and near the supra- and infrajacent ribs) before redirecting the retropleural dissection towards the spine. This will minimize the likelihood of pleural tears. The valves of a table-fixed frame retractor [30] are frequently adjusted during this process, facilitating retropleural dissection by keeping the interface between parietal pleura and chest wall under constant tension. The sympathetic chain, segmental vessels, thoracic duct (left-sided approach), and the azygous/hemiazygous veins are contained against the vertebral bodies within this areolar tissue layer [22, 32, 52] – schematic line drawing). Once the rib heads are visualized, an attempt can be made to mobilize the sympathetic chain off the spinal surface along with the pleura. Unlike the thoracic duct and veins, the sympathetic chain may be difficult to preserve and can be divided at the approach level without sequelae. Segmental vessels are isolated, ligated, and divided as dictated by pathology and surgical goal. If the ALL needs to be released during kyphosis correction, the dissection is carried between anterior vertebral surface and vessels to the contralateral side – schematic line drawing). Once the vessels are protected by a wide spatula, the ALL can be divided. Removal of the pedicles at the level of pathology allows for early identification of the spinal canal – schematic line drawing). To address lesions at the thoracolumbar junction, the 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-fixed 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 fistula) or a parietal pleural tear should occur that cannot be addressed by direct suture or application of a sealant (e.g., a fibrin-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.