Empyema and Pneumothorax Surgery: Decortication and Modern Technique

Surgery should never be offered to every patient with hyperhidrosis; a detailed assessment is required first, and all non-surgical options, oral medication, local treatment, creams, and Botox, should be exhausted first. Surgery is reserved only for high-grade hyperhidrosis where the hands are literally dripping, since every form of surgery carries some side effects, and the benefit of dry hands has to be weighed against them. Patient selection and precise technique matter more than the surgery itself: robotic assistance allows accurate identification of the ganglia, which is very difficult by standard VATS, and Dr. Khandelwal's own technique of setting the sympathetic chain close to the third ganglion with a grey ramicotomy at that level has produced good results with fewer side effects than older, less precise approaches.

Devices like Novalung or ECMO are sometimes loosely called artificial lungs, but these are only a transition to tide a patient over, not a permanent solution. Xenotransplantation for lungs is not a reality and is still limited to animal labs, with no near-term prospect of harvesting an animal lung for human transplantation. What is genuinely advancing is ex vivo lung perfusion (EVLP), where a harvested lung is brought to a lab and optimised before transplant, this has meaningfully increased organ utilisation and allows transplant surgery to be done electively rather than only at odd hours, though it remains expensive even in Western countries.

Technology has made the world smaller, so practically everyone is living next door to expertise now. Any case can be raised by email or WhatsApp, with a response guaranteed within 24 hours, and the case can often be investigated or even treated locally with guidance if the necessary technology and facilities are available there. When the expertise or facilities are genuinely not available locally, the patient can then be brought to India, but sharing the case first, even just to check whether it meets the threshold for referral, is always the right first step.

Surgery isn't just about surgeon skill, it also depends on OT infrastructure and trained technical staff, and not everything required can be exported to run a camp abroad. A more practical model already in use is a structured online OPD: patient details and reports are shared in advance on an agreed schedule, and the African doctor partner, the Jivo team, and the Indian specialist jointly review the case and decide what can be treated locally versus what genuinely needs travel to India, with real patient satisfaction from this approach so far.

A large number of patients from various African countries have been treated, most commonly for bronchiectasis and various tumours of the lung and chest cavity, even without ever having personally visited Africa. For heart transplantation specifically, deceased-donor transplant is not possible for international patients under Indian law, so the more common referral for advanced heart failure from abroad is for an LVAD (left ventricular assist device), which has very good outcomes and has itself reduced overall demand for heart transplant.

A video-assisted approach that deloculates the empyema cavity, drains it, and removes all pleural material through a complete debridement, requiring full 360-degree mobilisation of the lung. It is the standard treatment for stage two or three empyema, even in patients with fibrothorax.

At the first episode in high-risk individuals, when a chest drain continues to leak air for more than three to five days, or at a second or recurrent episode. Surgery involves single-port stapling of the causative bulla plus mechanical pleurodesis to prevent recurrence.