Multimedia article. Laparoscopic enucleation of a pancreatic insulinoma

Insulinoma is the most common functional neuroendocrine tumor of the pancreas. In most cases the lesions are benign, solitary, and located within the pancreatic parenchyma. Because of these characteristics, the majority of these lesions can be treated with simple enucleation. Advances in laparoscopic techniques have recently enabled the safe resection of pancreatic islet cell tumors and may provide patients with the benefits of minimally invasive surgery. This video demonstrates the technique of laparoscopic enucleation of a pancreatic insulinoma. The case presentation is that of a 40-year-old man who had symptoms of neuroglycopenia and was found to have elevated proinsulin levels during a 72-hour fast. Further evaluation included a CT scan, which revealed a 1.5 cm lesion on the posterior surface of the midbody of the pancreas. The video shows the operative technique of enucleation of the lesion, including positioning and trocar placement, performance of intraoperative ultrasound for tumor localization, and the use of specialized instruments (laparoscopic freer-elevator with a spatulated tip) that allowed enucleation of the lesion without excess handling of the tumor itself. The operation was performed in 105 minutes with minimal blood loss. The patient was fed clear liquid diet on the day after surgery and was discharged home on the third postoperative day. He had an uneventful recovery and has experienced no further symptoms.