Pleural tuberculosis (PT) is a common extrapulmonary manifestation of Mycobacterium tuberculosis infection, often managed conservatively with antitubercular therapy (ATT) and thoracic drainage. However, surgical intervention becomes imperative in refractory cases involving loculated pleural effusions, empyema thoracis, fibrothorax, and persistent pleural spaces. This review delineates the surgical indications, preoperative optimization, and operative strategies, including decortication, open window thoracostomy, and thoracoplasty. Decortication, performed via video-assisted thoracoscopic surgery (VATS) or open thoracotomy, facilitates lung re-expansion by excising fibrotic pleural layers. Open window thoracostomy serves as a palliative measure for chronic, non-resolving empyema, enabling continuous drainage and infection control. Thoracoplasty, historically employed for persistent pleural spaces, remains a salvage procedure in selected cases. Comprehensive perioperative care, including respiratory physiotherapy, nutritional rehabilitation, and stringent infection control, is critical for optimizing clinical outcomes. Long-term follow-up is essential to monitor disease resolution, prevent recurrence, and ensure sustained pulmonary function.