ABSTRACT
The chest of the infant is relatively short in its longitudinal axis, so a posterolateral incision entering the chest through the fifth intercostal space will provide adequate exposure for most procedures. The compliant ribs can be widely retracted and it is not necessary to remove or transect a rib. Care must be taken to avoid fracturing the ribs with the rib spreader by ensuring that they are adequately mobilized anteriorly and posteriorly. The length of the incision and the choice of rib space to be entered will depend on the procedure to be performed. For esophageal atresia, a higher approach through the fourth or third space is usually best, while an approach below the fifth space is required for access to the diaphragm (bearing in mind that in the infant the liver is relatively large and elevates the right hemidiaphragm) or to the distal esophagus on
the left. The axillary approach through a short cosmetic incision in an axillary skin crease provides access to the upper thorax without dividing major muscles. The posterior incision, which curves upwards around the scapula, is rarely required.
