Ultrasound-guided Robotic Enucleation of Functioning Insulinoma

Abstract

Purpose: Insulinoma is the most common functional pancreatic neuroendocrine tumor . Since the high prevalence of benign form, pancreatic parenchymal sparing surgery is suggested for well differentiated single lesion <2cm located at >3mm from the main duct. We present the case of a 57-year old caucasian man who presented with severe hypoglycemia episodes needing intravenous continuous infusion of glucose, despite medical treatment. Materials and Methods: CT scan, and RM were unable to detect the lesion, while a subsequent echoendoscopy showed an hypoechoic 1.5 cm lesion located at the head of the pancreas, far from the main duct but in contact with the duodenum and the anterior pancreaticoduodenal artery. Endoscopic biopsy showed a well differentiated insulinoma.During multidisciplinary discussion surgical therapy was indicated and consent for enucleation or pancreatoduodenectomy was shared.Robotic approach was considered feasible: after exposure of the anterior surface of the pancreas, ultrasound examination confirmed the location of the lesion. Nodule mobilization from the duodenum was achieved by bipolar section of few duodenal vessels, while dissection from the gastroduodenal and the anterior pancreatic artery was performed by sharp dissection with shears and by bipolar diathermy. Specimen was extracted with a small endobag and frozen section confirmed the nature of the lesion. After enucleation, glucose infusion was stopped and normal glicemia remained stable without any glucose support. Results: Postoperative course was uneventful and the patient was discharged at 4th postoperative days with normal insulin and glucose values. Conclusions: Enucleation is a well established indication for single insulinoma but the feasibility of the resection relies on dimension, site and the need of precise intraoperative image location and careful dissection. In our case robotic enucleation under ultrasound guidance was a safe and feasible technique avoiding a standard pancreatoduodenectomy procedure.