We compared the results of 327 transthoracic (TT) resections and 82 transhiatal (TH) resections for carcinoma of the oesophagus operated on between July 1982 and June 1991. Significantly more patients with carcinoma of the lower third of the oesophagus (54% versus 28%) and with increased pulmonary risks for surgery (61% versus 22%) were selected for the TH approach as compared with the TT approach. Results showed comparable intraoperative complications between the two groups. 5% of patients in the TH group required a thoracotomy for control of haemorrhage (3 patients) and repair of bronchial tear (1 patient) which occurred during the transmediastinal dissection. Postoperatively, mechanical ventilation requirement and complications involving the cardio-pulmonary systems were similar between the two groups. Anastomotic leakage occurred in 3% and 4%, respectively for the TH and TT patients (p = NS), whereas hoarseness occurred in 16% and 5%, respectively (p = 0.001). The 30-day mortality rates and hospital mortality rates were comparable between the two groups as were the overall survival rates. Our results suggested that while TH resection did not diminish the operative morbidity and mortality rates overall, it is appropriate for patients with increased pulmonary risks to be preferentially selected for this approach, and for tumours located in the upper and lower portion of the thoracic oesophagus where dissection of the tumour can be carried out mostly under vision.