Objective: To assess the results of twelfth rib resection as a direct posterior surgical approach to subphrenic abscesses in case of failure of percutaneous drainage, abandonment of percutaneous drainage in view of a too high risk of perforation of adjacent organs, or contamination of the pleural space, or an inaccessible abdomen. Design: Retrospective study. Setting: University hospital, The Netherlands. Patients: 17 patients who required rib resection for subphrenic abscesses that developed after infected necrotising pancreatitis, splenectomy, or anastomotic disruption. Interventions: 18 rib resections. Main outcome measures: Outcome and morbidity. Results: Twelfth rib resection was successfully in 13 of 17 patients. Four patients died from multiple organ failure despite subsequent (re) laparotomies for additional surgical drainage. Conclusion: Twelfth rib resection can be useful for the treatment of subphrenic abscesses in selected patients.