Chapter 88

Giant bullae are space-occupying lesions that cause compression of the surrounding lung parenchyma with impairment of lung function. The bullae arise from emphysematous projections of destroyed lung tissue. Hence they differ from blebs, which are localized collections of air between visceral pleural layers without underlying parenchymal disease.1 Giant bullae can be classified into three types based on morphology: Type I bullae have a narrow neck and are superficial, type II are superficial as well but have a broad neck, and type III are both broad and deep.2

The most common symptoms are dyspnea and chest pain. Pneumothorax, hemoptysis, and other complications such as infections that arise within the bulla can occur, but these sequelae are rare. Evaluation usually begins with a chest x-ray. Often a giant bulla is mistaken for pneumothorax, and the thoracic surgeon is consulted for placement of a chest tube. Chest CT scan usually delineates the extent of the bulla and shows the degree of compression of surrounding lung tissue.

The indication for intervention is defined as the presence of symptoms in a space-occupying bulla that is compressing the surrounding lung parenchyma. CT scan of the chest is the preferred imaging modality. It can show the full extent of the bulla and whether there is evidence of vascular crowding or compressed lung surrounding the bulla. Ideally, the bulla should occupy greater than one-third of the hemithorax to be suitable for resection. Pulmonary function tests indicate various degrees of obstructive disease. Those with markedly decreased forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), or diminished diffusion capacity of the lung for carbon monoxide (DLCO) with evidence of hypoxemia and hypercarbia are at an increased risk for perioperative complications as well as lack of improvement or even worse outcome with resection. The ideal patient for surgery is young, has normal cardiac function and only minimally diminished pulmonary function, and is still quite functional despite the dyspnea. Clearly, such patients have several options available, and bullectomy by means of video-assisted thoracic surgery (VATS) may be the most appropriate procedure. The Monaldi procedure may not be the best option for patients with other comorbidities, end-stage lung disease, deep extension of the bulla to the hilum, or inability to tolerate complications that may occur with resection.

The Brompton group provides the best description of this technique.3 The procedure begins with planning of the incisions based on the preoperative chest CT scan (Fig. 88-1). The incision is placed where the bulla comes closest to the chest wall (Fig. 88-2), provided that it is not at an awkward place, that is, over the scapula or so far posteriorly that it would interfere with chest tube placement. The operation is performed in the OR with general anesthesia. The patient is positioned to optimize access to the planned incisions. A small VATS-type incision is made at the predetermined site. The ...

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