PMC3904682_01
Initial chest radiograph of the patient. (PA view) showing a giant bulla (increased hyperlucent zone) of the left apex (A). HRCT showing axial (B) and sagittal (C) image (lung window) with a big lucent area without real definable walls.
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F1
Intra-operative VATS-image of the giant bulla. Visualisation of bulla (A), local resection (B & C) and pleurectomy (D).
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F2
The giant bulla was located at the apex of the lower lobe with total compression of the left upper lobe and pleural irritation [Figure  2A]. Bullectomy was done with two 60 mm Endo-GIA (Gastro-Intestinal Anastomosis) linear endoscopic stapling devices (Covidien , Norwalk, CT, USA) without extra suture reinforcement [Figure  2B and C]. Subsequently an extensive stripping of the parietal pleura was carried out [Figure  2D].
Follow up (post-operative) chest radiograph (PA view) of the patient showing a normal lung parenchyma of the left apex.
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F3
Chest radiography showed good expansion of the left lung without pneumothorax or residual pleural effusion [Figure  3].