Right lateral decubitus position with gamgee roll under right chest. Further gamgee over left face and between legs. Left arm over the head. Mark the tip of the scapula and the vertebral column. Place a small gamgee on the hip and affix a tape across the table over the hip.

Prep and drape with ioban. Make a thoracotomy incision below the edge of the scapula, just large enough to work. Dissect down to the ribs, using small langenbeck retractors.

Open the intercostal space into the pleura, and use the forceps to protect the lung. Use a small wet swab unfurled, scrunching it up as it is pushed in pushing the lower lobe away. Use the malleable retractor to place over the swab to retract the lung anteriorly away for the arch.

Identify the RLN, arch, subclavian and visualise the space under the arch on either side of the PDA that needs to be opened. Use diathermy on 10-15 and enter the mediastinal pleura on both sides of the PDA. Use a right angle from below – feel the tip before using it. Avoid touching the RLN. Use the pleura/adventitia on the arch to get some space under the arch.

Tie down with 4/0 silk and place a ligaclip.

Use saline to test for air leak and bleeding. Suck everything out. Place 2-3 intercostal stitches and do a Valsalva manoeuvre to prevent pneumothorax. Muscle in layers (usually mass closure as very thin layers).