- Positioning: 
- foley and appropriate IV access established; 
- place patient into left lateral decubitus position (L side up) 
- break table in the middle; 
- Incision and Exposure: 
- incision is made along 10th rib which then curves along anterior abdomen as appropriate (based on size of patient); 
- 10th rib is identified, the periosteum is incised, and the 10th rib is subperiosteally dissected. 
- the bone is cut and and is then removed from the costochondral junction; 
- periosteal bed is opened, exposing the pleural cavity. 
- using metzenbaum's the pleural cavity is opened widely along the bed of the 10th rib; 
- the incision is then carried thru the diaphram; 
- the retroperitoneal fat is identified; 
- using blunt dissection w/ 2 fingers, the interval between the retroperitoneal fat and the diaphram is dissected around the diaphram to the edge of the spine; 
- a Finochetti retractor is placed using 2 lap sponges as cushions against the 9th and 11th ribs; 
- cautery is used to incise the diaphram along the margin of the diaphram costal junction all the way around to the vertebral bodies; 
- the peritoneum is dissected away from the abdominal muscles and the exernal, internal, and transversalis muscles are incised in line w/ the skin incision