Place the patient in the lateral decubitus position with the left side up. Prep and drape the entire left upper extremity, draping it sterilely out of the operative field.

Incise the skin and subcutaneous tissue from the lateral paraspinous area at T1, along the medial caudal border of the scapula, under the axilla to the costal cartilage of the 3rd rib (Fig. 16.1).

Carefully divide each subsequent muscle layer down to the level of the rib, sectioning portions of the trapezius, latissimus dorsi, rhomboid major, and serratus posterior (Fig. 16.2, 16.3), as needed. Careful dissection with electrocautery and meticulous cauterization of each muscle bleeding point allows exposure to the outer periosteum of the 3rd rib with a minimal amount of bleeding. As the muscle layers are divided, retract the scapula cephalad and medially to tense the muscle tissue for easier cutting. Palpate cephalad for identification of the 3rd rib (Fig. 16.3). Remember that the 1st rib is situated inside the 2nd; this is important for reaching the correct rib level.

For pathology such as large tumors of the cervicothoracic junction, several ribs, including the 1st can be resected, allowing for a large working area to C6. The limiting factor is that a stable rib must be left for support of the scapula [2].