Key Points

• Preoperative workup for giant bullectomy includes cardiac risk assessment, pulmonary function testing, chest CT scan, and sometimes quantitative ventilation-perfusion scanning.
• Pulmonary function testing values are difficult to interpret without a chest CT.
• The best candidates for surgical benefit have dyspnea, an isolated bulla larger than 30% of the hemithorax, and a collapsed but otherwise normal underlying lung.
• Giant bullectomy in the setting of diffuse emphysema in the remaining lung is not a contraindication to surgery but may be better considered in the context of lung volume reduction surgery.
• Operative techniques include stapled bullectomy, excision, ligation, plication, and endocavitary drainage. These are accomplished with thoracoscopy, thoracotomy, or median sternotomy.
• Most patients can expect symptomatic and functional improvement. The duration of this improvement is dependent on the progression of emphysema in the remaining lung parenchyma.

Surgery for emphysema has a long, colorful, and sometimes controversial history. Many creative and thoughtful operations have failed to show benefit after closer scrutiny. Lung transplantation, lung volume reduction surgery (LVRS), and surgery for giant bullae have emerged as techniques that, when applied appropriately, can help this otherwise severely debilitated and desperate group of patients. This chapter reviews the history, classification, terminology, and pathophysiology of giant bullous lung disease as well as the indications, procedures, and outcomes of its surgical treatment.