Thoracic Surgery from Basics to Robotics

Thoracic surgery treats diseases of the lungs, the pleura, the mediastinum, the chest wall and the diaphragm, and today most of it can be done through small incisions by video-assisted thoracoscopic surgery (VATS) or robotic surgery. Dr. Shaiwal Khandelwal, Director - Thoracic Surgery, Max Hospital, Gurugram, India, uses these approaches from infections such as tuberculous empyema through to lung cancer, mediastinal tumours and nerve reconstruction.

This guide maps the specialty from basics to robotics, explains the chest wall, trauma and diaphragm work in his practice, and sets out what international patients and referring doctors need to know about lung transplantation, referral and cost. The deeper clinical topics have their own articles, linked below.

How thoracic surgery moved from thoracotomy to VATS and robotics

For most of the twentieth century, chest operations meant a thoracotomy: a long incision between the ribs, with the ribs spread apart and the chest-wall muscles divided. VATS replaced much of this with a camera and long instruments passed through small ports. Robotic thoracic surgery uses similar ports, but the surgeon operates wristed instruments from a console with a magnified, high-definition three-dimensional view.

In Dr. Khandelwal's practice, the robot's decisive advantage is vision. Structures that are difficult to identify by VATS, such as small nerves and the sympathetic ganglia, are seen very clearly on the robotic system, which also allows a very fine dissection.

The consistent goal is a pain-free operation and early discharge. Intercostal nerve blocks are used for pain control, drains come out within days, and patients go home, in his words, confident and healthy in the shortest possible time.

What thoracic surgery treats

Thoracic surgery covers four broad groups of disease: the pleura (the lining of the lungs and chest wall) and benign lung conditions; lung cancer and the mediastinum (the central compartment of the chest between the two lungs); the sympathetic nerves behind severe sweating; and the chest wall, chest trauma and the diaphragm.

Pleural and benign lung disease

Empyema, most commonly caused by tuberculosis in his practice, is treated by VATS decortication, freeing the trapped lung through a full 360 degrees. Pneumothorax, bronchopleural fistula, bronchiectasis, aspergilloma, mucormycosis, pulmonary sequestration, hydatid cyst, interstitial lung disease biopsy and lung volume reduction surgery for emphysema complete this group. The indications, techniques and recovery times are set out in empyema, pneumothorax and benign lung surgery by VATS.

Lung cancer and the mediastinum

Most lung cancer resections, including central tumours needing a sleeve lobectomy or pneumonectomy, are done by VATS or robotics, with a systematic mediastinal lymph node dissection in every case. The same platforms handle thymectomy for myasthenia gravis, thoracic outlet tumours, neurogenic tumours, mediastinal cysts and Boerhaave syndrome. These are covered in lung cancer and mediastinal surgery by VATS and robotics.

Hyperhidrosis and sympathetic nerve reconstruction

Severe sweating of the hands, armpits or feet that has failed non-surgical treatment can be treated by sympathetic surgery. Dr. Khandelwal performs a modified robotic operation and reverses the side effects of earlier sympathectomies with robotic nerve reconstruction, described in robotic hyperhidrosis surgery and ETS reversal.

Chest wall tumour surgery and reconstruction

All kinds of chest wall tumours, including sternal tumours, are resected, followed by reconstruction where needed. These cases are decided in a multidisciplinary tumour board, which brings in a reconstructive surgeon when a large tumour leaves a defect that must be rebuilt.

Very often, though, the lesion involves a single rib, and the incision can be kept small. In one patient with fibrous dysplasia of the tenth rib, a benign bone condition, the rib segment was removed endoscopically to reduce the size of the incision.

A second case shows how far the robotic approach can change an operation. A benign bone tumour was arising from the second rib, underneath the shoulder blade. The traditional operation would have meant a large thoracotomy, dividing all the muscles attached to the scapula, lifting the scapula and then resecting the rib segment, with considerable pain and deformity afterwards. Instead, the team went in with the robot from inside the chest, resected the segment of the second rib with the tumour from within, and removed the specimen through a tiny muscle-sparing incision.

Chronic chest wall sinuses and open windows

Discharging chest wall sinuses, left by tuberculosis or by a pleurocutaneous window or Clagett window created earlier for another disease, are a great problem for patients: uncomfortable and a source of social embarrassment. Dr. Khandelwal closes these windows and sinuses. The key is to resect all the diseased tissue and deal with the dead space left behind, which most often needs a muscle flap or the omentum, the fatty apron of tissue from the abdomen, to fill it. In one patient the harvested omentum was brought up through the space behind the sternum into the chest, where it filled practically all of the dead space and cured the discharging sinus.

Chest wall deformities

Chest wall deformities such as pectus excavatum (a sunken chest) and pectus carinatum (a protruding chest) are also treated, and the Nuss procedure for pectus excavatum is now done endoscopically. Pectus correction from the reconstructive surgeon's perspective is discussed in lymphoedema surgery, brachial plexus and pectus correction.

Chest trauma and rib fixation: when to fix rib fractures

Rib fixation is no longer reserved for a flail segment in a patient who cannot be weaned off the ventilator; it is now also used for non-flail fractures that cause excessive pain. In chest trauma, VATS is also used to drain a haemothorax (blood in the chest) and to remove bullets lodged in the mediastinum, the chest wall or the pleural cavity.

A flail segment is a section of chest wall that moves independently because several adjacent ribs are broken in more than one place. Under the earlier view, only such fractures in a patient who could not be weaned off the ventilator were fixed. Fixing painful non-flail fractures with plates also helps avoid future chest deformity. The pain control is very good: in Dr. Khandelwal's experience the need for pain medication falls away immediately after fixation, and these patients do not end up with chronic chest pain.

Diaphragm plication for a paralysed diaphragm

When the diaphragm is paralysed and pushed up into the chest, plication folds and tightens it. Dr. Khandelwal performs plication robotically, placing multiple sutures to return the diaphragm to its normal position; it can also be done by VATS. The postoperative chest X-ray shows the diaphragm back in its normal place.

How treatment decisions are made: the patient at the centre

His practice puts patient understanding and participation first. For complex situations there is always a multidisciplinary team meeting that includes the patient and family members, all the options are put on the table, and the decision is taken together with them. The team is also deeply involved in research and in developing new surgical techniques.

Lung transplant for international patients

Lung transplant availability in India for international patients

Very rarely, if at all. In Dr. Khandelwal's understanding, the government does not allow a deceased-donor (cadaveric) lung transplant for an international patient. This was done earlier, but not now. Under India's transplant rules, deceased-donor organs are allocated to a foreign national only when no suitable Indian recipient is available.

Lung transplant after tuberculosis

Lung transplantation after pulmonary tuberculosis is very challenging, particularly when the patient has developed fibrothorax, in which the lung is trapped inside a thick, rigid fibrous shell. A single-lung (unilateral) transplant may be possible, but it depends entirely on the individual case, and he will not make a generalised statement for this condition.

Lung transplant success rates

Outcomes of lung transplantation depend on the underlying disease. For pulmonary hypertension the results are good, and for other conditions they vary with the individual disease pathology.

Xenotransplantation, artificial lungs and ex vivo perfusion

Lung xenotransplantation, using lungs from animals, is still limited to animal laboratories, and Dr. Khandelwal does not see it reaching patients in the near future. Devices that are sometimes called artificial lungs, such as extracorporeal membrane oxygenation (ECMO), are a bridge to tide a patient over, not a permanent solution.

The new tool that is changing practice is ex vivo lung perfusion (EVLP). Many donor lungs are not in optimal condition because of trauma, aspiration or infection, so many are rejected, and transplants have had to be performed at odd hours to keep the cold ischaemia time short. With EVLP the harvested lung is brought to the laboratory, perfused and optimised. Utilisation of these very precious organs has increased a great deal, and the operation can be performed electively in the morning. EVLP is very expensive, even for Western countries.

How doctors and patients abroad can be referred

A doctor abroad can ask Dr. Khandelwal's team for an opinion on any case, and the patient travels only when the facilities or expertise to treat locally do not exist. He has operated on many patients from African countries, most of them for bronchiectasis and for tumours of the lung and the chest cavity.

Getting an opinion

For a doctor abroad facing a difficult case, he points out that technology has made the world smaller. Doctors can approach his team by email or WhatsApp, and he commits to answering within 24 hours. If the facilities and expertise exist locally, the patient can be investigated and treated locally, with his team guiding and supporting the local doctor. If they do not, the patient can travel for surgery.

Online OPDs

Jivo Healthcare also runs online outpatient clinics (OPDs): patient reports are sent in advance, a schedule is agreed, and the local doctor, the patient and the Indian specialist meet together to decide what can be treated locally and who genuinely needs to travel. Dr. Khandelwal describes this as a fantastic tool that his team already uses, with very high patient satisfaction.

Cost of thoracic surgery

There is no single figure for the cost of thoracic surgery. A lobectomy, a decortication and a sympathectomy each cost something different, and the cost depends on the individual case. Dr. Khandelwal is not involved in the financial side: once he has given his clinical opinion, the hospital's finance department prepares the estimate.

His answers to the doctors' questions in the session, on transplantation, hyperhidrosis and robotic nerve protection, are on the Live Discussion page. His background and practice are on his doctor profile, and the wider specialty is on the thoracic surgery hub.