Thoracoscopic Resection of a Giant Tension Bulla

The patient was a 67-year-old male with chronic obstructive pulmonary disease (COPD), pulmonary Mycobacterium avium complex infection, a left lower lobe pulmonary nodule, and a 30 pack-year smoking history. He presented with progressive dyspnea on exertion and was found to have a giant right lower lobe tension bulla. Two bronchoscopic attempts at the placement of endobronchial valves were aborted due to profound hypotension on induction. 
 
Preoperative imaging demonstrated significant enlargement of the right lower lobe bullous emphysema. Comparison with prior imaging showed marked worsening of diaphragmatic flattening with loss of lower lobe markings, indicative of a tension bulla. The compressive effects of the bulla likely contributed to the patient’s impaired pulmonary and cardiac function. A quantitative lung perfusion scan demonstrated zero percent perfusion of the right lower lobe, consistent with a nonfunctional giant bulla that contributed no effective respiratory function. As this tension bulla was likely contributing to the patient’s cardiopulmonary dysfunction, the decision was made to proceed with thoracoscopic resection of the bulla. 
 
Upon entry to the chest, the giant right lower lobe bulla was visualized, with its neck transitioning into healthy lung parenchyma. To improve working space and visualization, the bulla was deliberately punctured and decompressed with surgical forceps. The inferior aspect of the bulla was resected from the diaphragm using hook electrocautery. A 45 mm blue load stapler was then utilized to transect the bulla at its interface with healthy lung parenchyma. Peristrips made from bovine pericardium were used to reinforce the staple line and minimize the risk of air leak. The specimen was retrieved through the posterior port. A 24 French drain was placed, and the lung was reinflated. 
 
Postoperative imaging demonstrated restoration of the normal right hemidiaphragm contour. At his two-week follow-up, the patient reported marked improvement in exercise capacity and satisfaction with his outcome. 

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