The anterior lumbar approach for spinal pathology is a powerful method to achieve reconstruction. It enables wide discectomy, restores disc and neuroforaminal height, optimizes sagittal alignment, and affords large cross-sectional area of endplates for spinal implants while avoiding neural retraction and posterior muscular damage. It is arguably underutilized given the need for a considerable volume of training and need for comfort with abdominal anatomy and vascular handling that is required in its safe application. The preparation of a patient and surgical setup as well as common techniques for anterior lumbar surgery are described in this chapter. Knowledge of assessment techniques and handling of vascular structures in their normal, anomalous, and pathological states is critical for safe and efficient performance of the procedure. Equally, recognition of vascular problems and measures to deal with them enables spinal surgeons to safely expand their indications for this technique which is aided through a multidisciplinary approach and collaboration with a vascular surgery service.