VATS-stepwise resection of a giant bulla in an oxygen-dependent patient

We report a case of a giant bulla in a 16-year-old boy who was oxygen and wheelchair dependent. He had been diagnosed with Marfan's syndrome and had severe kyphoscoliosis. The giant bulla occupying his entire left thoracic cavity compressed the contralateral lung. Until referral to our hospital, a bullectomy had been deferred during the preceding 5 years because of his poor pulmonary function and severe chest wall deformity. The patient was considered a candidate for thoracoscopic bullectomy. A stepwise resection technique was used. First, the bulla should be emptied by aspiration or wall perforation. Second, the redundant wall of the bulla should be resected by a looped ligation without opening the cavity. Third, a stapled resection of the downsized bulla should be performed. After a successful bullectomy, his subjective symptoms and pulmonary function improved. The reduction of the bulla makes bullectomy easily and decreases the number of staplers, and reduces operating time compared with opening the bulla and suturing it. Therefore, when treating a giant bulla, we recommend a stepwise resection technique.