A bulla is a thin-walled air-filled space within the lung that can grow large enough to compress healthy lung, cause persistent breathlessness, become infected, bleed, or rupture into the chest cavity. There are two distinct groups of patients who benefit from surgery: those who are breathless because a large bulla is compressing otherwise functional lung, and those who are not particularly breathless but have a complication — a pneumothorax, an infected bulla, coughing up blood, persistent chest pain, or a suspected cancer in or near the bulla. In carefully selected patients, keyhole surgery to remove the bulla can deliver substantial and durable improvement — or definitively treat the complication. Mr Lawrence Okiror is the sole operator at London Bridge Hospital and at Guy’s and St Thomas’ for bullectomy and the wider lung volume reduction pathway, performing virtually all cases as keyhole VATS or robotic operations using a reinforced staple line to minimise post-operative air leak.
Last reviewed: April 2026 · Mr Lawrence Okiror FRCS(CTh) FRCSEd(CTh) · GMC 6150382
A pulmonary bulla is a thin-walled air-filled space within the lung larger than 1 cm in diameter. It forms when alveolar walls progressively break down — most often as part of smoking-related emphysema, but also in alpha-1 antitrypsin deficiency, Marfan’s syndrome, Ehlers-Danlos syndrome, after cocaine or cannabis exposure, in HIV, and following severe COVID pneumonia. A giant bulla is one that has grown large enough to occupy more than one third of the hemithorax — the chest cavity on that side. In some patients, a single bulla can fill most of one half of the chest.
The clinical importance of a bulla is not just that it occupies space. The wall of the bulla is less elastic than normal lung — meaning that when the patient breathes in, air enters the bulla preferentially and stays there, while the surrounding healthy lung is squashed and unable to expand fully. Over time, the bulla tends to enlarge, the surrounding lung becomes progressively compressed, and the patient becomes progressively more breathless even though much of their underlying lung tissue is still functional. The diaphragm is flattened, the chest wall mechanics change, and breathing becomes inefficient.
A bulla can also cause problems even in patients who are not particularly breathless. It can rupture into the pleural space and cause a pneumothorax. It can become infected. The thin-walled vessels in its membranes can bleed, producing haemoptysis. It can cause persistent chest pain from air trapping. And, occasionally, a lung cancer can develop in or adjacent to a bulla — sometimes hidden by the bulla on imaging.
Smoking-related emphysema is the most common cause, but bullae also occur in alpha-1 antitrypsin deficiency, Marfan’s syndrome, Ehlers-Danlos syndrome, after cocaine or cannabis exposure, in untreated HIV, after severe COVID pneumonia, and occasionally without any obvious associated condition.
Cause matters for prognosis and for whether smoking cessation, alpha-1 replacement, or addressing other contributory factors should be addressed before or alongside surgery.
Patients with bullous lung disease who benefit from surgery fall into two clearly different groups, with different referral patterns, different urgency, and different conversations at the multidisciplinary meeting.
Group 1 · The breathless patient
Compressive Bulla, Functional Adjacent LungA large or giant bulla compressing surrounding lung tissue that is otherwise reasonably functional. The patient is breathless on exertion, has hyperinflated lungs, and has a flattened diaphragm on imaging. The objective of surgery is to remove the bulla so that the compressed adjacent lung can re-expand, the diaphragm can return to a more normal contour, and breathing mechanics can improve.
The clinical picture closely overlaps with patients considered for lung volume reduction surgery, and the published outcome data are similar — sustained improvements in lung function, walking distance, and quality of life in carefully selected patients.
Best outcomes when the bulla is large, localised, ideally unilateral, and the compressed adjacent lung shows good capillary filling on imaging.
Group 2 · The non-breathless patient
A Complication of the BullaPatients who are not particularly breathless but who have developed a problem caused directly by the bulla. Each of the following is a recognised, distinct indication for surgical removal in published thoracic surgical literature:
This group is often missed on the standard COPD pathway because their primary problem is not breathlessness.
Why the distinction matters in practice: patients in Group 1 are typically referred through the same pathway as candidates for lung volume reduction surgery and endobronchial valve therapy — via respiratory medicine, often after pulmonary rehabilitation. Patients in Group 2 are often referred from emergency medicine, general medicine, or via incidental imaging findings. Both groups benefit from the same multidisciplinary surgical assessment, but the conversations are different. The non-breathless patient with a complication is sometimes told the bulla is “incidental” or “not the cause” — in many cases, that is incorrect.
Bullectomy is one of the older operations in modern thoracic surgery and has a substantial published evidence base from contemporary international series. The selection framework is mature; the outcomes are well-quantified; and the durability of benefit, while not unlimited, is real.
The selection framework
Anatomy of the bulla: large (more than half a hemithorax), localised and unilateral, demonstrably enlarging over time.
Function of the bulla: non-ventilated, non-perfused on V/Q SPECT-CT — meaning the bulla itself contributes nothing to gas exchange.
Compression index: high — ideally a Mineo compression score of 3 or greater out of 6, indicating significant compression of adjacent lung.
State of compressed lung: good capillary filling, good xenon washout — suggesting the lung is re-expandable and will function once the bulla is removed.
Severity of underlying emphysema: minimal or no diffuse COPD is ideal — though contemporary data show diffuse emphysema is not an absolute contraindication.
Medical fitness: younger age, normal heart, no cor pulmonale, no significant comorbidities, no significant weight loss.
What the published outcome series show
In the largest contemporary series of giant bullectomy — Krishnamohan et al, Mayo Clinic, Annals of Thoracic Surgery 2014 — 63 patients with median bulla size 14 cm underwent surgery. Around two thirds of breathless patients reported symptomatic improvement, and FEV1 improved from a median of 1.0 litres pre-operatively to 1.4 litres post-operatively. Operative mortality was 3 percent. Importantly, underlying diffuse emphysema did not adversely affect functional outcomes — reframing earlier assumptions that diffuse disease ruled the operation out.
The Schipper et al, Washington University series (Annals of Thoracic Surgery 2004) covering 43 patients showed significant immediate functional improvement that declined gradually over time but was preserved at three-year follow-up. The Palla et al five-year follow-up series (Chest 2005) confirmed the durability question: improvement is real, slowly diminishes with the natural progression of underlying disease, but the post-operative state remains better than baseline.
As with lung volume reduction surgery, benefit is greatest when the patient stops smoking before and after operation, completes pulmonary rehabilitation, and is operated on by a team that performs the procedure regularly.
Mr Okiror performs bullectomy almost always as a keyhole (VATS) operation, occasionally robotically. Open thoracotomy is reserved for the small minority of cases with dense pleural adhesions — typically from previous pleurodesis, prior thoracic surgery, or longstanding pleural inflammation — where keyhole access is not safe.
Two or three small incisions, each typically less than 2 cm, made in the side of the chest under general anaesthesia with single-lung ventilation. A thoracoscope provides a high-definition camera view; instruments are passed through the other ports.
The bulla is identified, mobilised from any adhesions to the chest wall or diaphragm, and resected at its base using a surgical stapler with a reinforced staple line — specifically chosen to minimise the risk of post-operative air leak from the staple line, which is the most common complication of bullectomy.
A single chest drain is left in the pleural cavity to evacuate air and any fluid as the lung re-expands. The drain is typically removed once the lung has fully re-expanded and the air leak has resolved — usually within a few days, occasionally longer. Where there is a pneumothorax history, pleurodesis is added to reduce the risk of recurrence.
Honest disclosure on air leak
A prolonged post-operative air leak — meaning continued bubbling on the chest drain beyond about five days — occurs in around 30 percent of bullectomy patients across published series. Reinforced staple lines reduce this rate substantially, but do not eliminate it. Most prolonged air leaks resolve with continued chest drainage and time. A minority require additional intervention. This is not a rare event and patients should know about it before surgery rather than after.
Hospital stay is typically 5 to 7 days for a straightforward bullectomy, longer if a prolonged air leak develops. Most patients are back to light activities within 2 to 3 weeks of operation, and to normal exercise tolerance progressively over 6 to 12 weeks.
All three procedures aim to make breathing more efficient by removing or deflating diseased lung tissue — but they are used for different patient phenotypes, and the choice between them is made at the multidisciplinary meeting based on imaging and lung function.
Removes a single large bulla, leaving the rest of the lung intact. Best for patients with one or two clearly defined large bullae, with surrounding lung that is reasonably preserved.
Resects the most damaged portion of generally emphysematous lung — typically upper-lobe predominant — where there is no single dominant bulla but rather diffuse heterogeneous disease.
Bronchoscopic placement of one-way valves to deflate a target lobe. Suitable when there is no single dominant bulla and Chartis assessment confirms absence of collateral ventilation.
For severe diffuse emphysema without a dominant bulla, see the emphysema treatment page, which covers EBV therapy and lung volume reduction surgery in detail. Mr Okiror is the sole operator for bullectomy, LVRS, and EBV at London Bridge Hospital and at Guy’s and St Thomas’.
Bullous lung disease, lung volume reduction surgery, and endobronchial valve therapy are managed under a single specialist pathway. Mr Okiror is the sole operator for all three procedures at London Bridge Hospital and at Guy’s and St Thomas’ NHS Foundation Trust — one of the centres nationally commissioned for the Advanced Emphysema Surgical Service. The same operator selects, performs, and follows up every case across both NHS and private settings.
Patients have travelled from across the Middle East, including from Kuwait and Saudi Arabia, for surgical treatment of bullous lung disease and lung volume reduction at London Bridge Hospital. International cases are managed through Mr Okiror’s private secretary, with imaging review, treatment planning, and timeline coordination arranged before the patient travels. Where the operation is straightforward, recovery and discharge can be planned around a return travel date; where the case is more complex, the timeline is extended to accommodate full post-operative recovery.
For private patients at London Bridge Hospital, the same multidisciplinary team that runs the GSTT Advanced Emphysema Surgical Service handles each case — including the monthly MDT meeting, which uniquely incorporates a lung transplantation physician and surgeon from Harefield Hospital. This integration of transplant expertise into the routine MDT is uncommon and is one of the things that most distinguishes the service.
Patients with a known bulla are sometimes told there is nothing to do unless symptoms become severe. That is sometimes correct. It is also sometimes a missed opportunity — particularly when a bulla is enlarging, is causing complications, or is compressing functional lung. Three questions are worth asking before accepting watchful waiting as the only plan.
Bulla size, the proportion of the hemithorax it occupies, and any change on serial imaging are the most important predictors of whether surgery is appropriate. If your previous CT has not been formally compared to a more recent one, that comparison is worth doing.
Whether bullectomy will help depends on whether the compressed adjacent lung is functional enough to take over once the bulla is removed. V/Q SPECT-CT and other imaging answer this question objectively and are the basis of the published selection framework.
There is a difference between “not for surgery” assessed by a respiratory physician and “not for surgery” assessed by a thoracic surgeon who performs the operation regularly. For complex cases, a specialist surgical opinion is the right standard — and is reasonable to ask for.
A second opinion appointment with Mr Okiror is typically available within 2–3 days at London Bridge Hospital. Bring CT chest imaging (current and prior, where available), recent spirometry and lung function tests, and any treatment recommendation already made.
Bullectomy is performed privately at London Bridge Hospital, which offers the level of intensive care, respiratory medicine, and bronchoscopy support appropriate for patients with severe lung disease undergoing major thoracic surgery. For straightforward unilateral bullectomy in well-selected patients without significant comorbidity, surgery can also be delivered at The Lister Hospital Chelsea.
For complex bullectomy — particularly when there is significant underlying emphysema, prior pleurodesis or thoracic surgery, severe gas trapping, relevant cardiac disease, or international travel logistics — surgery takes place at London Bridge Hospital, where the perioperative support and inpatient capability match the complexity of the patient.
Outpatient consultations — including for second-opinion patients told elsewhere that no further treatment is possible — are also available at HCA outpatients in Canary Wharf and the City of London. Same-day or next-day virtual consultations can be arranged for patients in other regions or internationally.
Insurance and self-pay: Mr Okiror is recognised by all major UK private medical insurers including AXA, BUPA, WPA, Vitality, Cigna, and Aviva. Bullectomy involves significant inpatient and post-procedure care, particularly when a prolonged air leak develops — transparent estimates are provided by Jo Mitchelson before any commitment is made — 020 7952 2882 or pa@lungsurgeon.co.uk. International self-pay packages can be priced separately and include all hospital, surgical, anaesthetic, and inpatient costs in a single transparent estimate.
If your problem is pneumothorax
A pneumothorax from a bulla, or without underlying disease?For pneumothorax in young, otherwise healthy patients without large bullae — including catamenial pneumothorax linked to thoracic endometriosis — the dedicated pneumothorax page covers VATS bleb resection and pleurodesis. When a pneumothorax is associated with a giant bulla, the operation typically combines bullectomy with pleurodesis as covered above.
Bullectomy is available privately at London Bridge Hospital and The Lister Hospital Chelsea, with consultations within 2–3 days and surgery typically within days of completed workup. The same operator and the same multidisciplinary team handle both NHS and private cases.
Bullectomy is also available on the NHS through Guy’s and St Thomas’, where Mr Okiror is the sole operator for the wider lung volume reduction pathway. NHS waiting times from referral to intervention are typically several months. All options — NHS and private — are discussed openly at every consultation.
Refer for assessment — let the multidisciplinary team determine whether surgery is appropriate. Consider specialist surgical opinion for any of the following:
A brief referral letter with current CT chest, recent spirometry, and any prior imaging for size comparison is sufficient. Private assessments within 2–3 working days.
Contact Jo Mitchelson: 020 7952 2882 — pa@lungsurgeon.co.uk
AI-assisted referral letter generator: For GPs page →
Common questions from patients with a known bulla considering surgery, from families seeking a second opinion, and from referring clinicians weighing whether to refer.
Book a Consultation →Or call Jo Mitchelson:
020 7952 2882
Private appointments at London Bridge Hospital within 2–3 working days. Mr Okiror reviews investigations personally and advises honestly whether bullectomy is possible and appropriate.
Jo Mitchelson, Private PA · 020 7952 2882 · pa@lungsurgeon.co.uk
St Thomas’ #1 UK · Guy’s #2 UK · London Bridge Hospital #10 UK · Newsweek World’s Best Hospitals 2026
Disclosures
Mr Okiror has received speaking and consulting fees from Pulmonx Corporation, the manufacturer of Zephyr endobronchial valves. This relationship is disclosed in his published peer-reviewed research (including J Clin Med 2023;12(4):1348) and is provided here in line with GMC Good Medical Practice and ABPI Code of Practice standards on transparency of industry relationships. Treatment recommendations are made by the multidisciplinary team based on patient phenotype and the published evidence base, not by individual clinician preference.
EBV therapy and lung volume reduction surgery for severe emphysema without a dominant bulla
Pneumothorax TreatmentCollapsed lung — VATS bleb resection and pleurodesis for primary spontaneous pneumothorax
Specialist Second OpinionIndependent review for patients told no further treatment is possible