Laparoscopic enucleation of a pancreatic insulinoma

Insulinoma is the most common pancreatic endocrine neoplasm. Treatment is by excision. In the pre-laparoscopic era, the enucleation was performed by laparotomy, but surgeons have shown that it can be performed laparoscopically. Preoperative localization is important in planning port placement and in guiding laparoscopic ultrasonography if necessary. When enucleation is performed, the pancreatectomy provides no oncologic advantage.

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Laparoscopic   enucleation   of   a   pancreatic   insulinoma

Authors
B Dallemagne, S Perretta, J Marescaux
Abstract
Insulinoma is the most common pancreatic endocrine neoplasm. Treatment is by excision. In the pre-laparoscopic era, the enucleation was performed by laparotomy, but surgeons have shown that it can be performed laparoscopically. Preoperative localization is important in planning port placement and in guiding laparoscopic ultrasonography if necessary.
When enucleation is performed, the pancreatectomy provides no oncologic advantage.
Classification
complex cases
Keywords
Laparoscopic enucleation, pancreatic insulinoma
Media type
Duration
19'00''
Publication
2009-01
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Jan 2009;9(01).
URL: http://www.websurg.com/doi-vd01en2533.htm

Laparoscopic   enucleation   of   a   pancreatic   insulinoma

2. Pancreatic tail dissection- spleen mobilization 01'00''
Initially when facing this sort of problem, you’ve got the pictures and I think it is in the lateral part of the pancreas. First thing, how to approach this problem? In the pancreas, you have 2 options: when you have to work on the tail of the pancreas, the first option is to go from the medial part of the pancreas and then work on the tail; that’s what we used for example, tumors. The 2nd option is to work from the lateral side, that is to come from the spleen. So for treatment options, it could be either pancreatic resection or enucleation. So it’s a very subcostal positioning of the ports and now you can see I’m working on the splenic flexure. I could work with the hook for example. The idea is to get all the block of the spleen and the tail of the pancreas falling down on the right side of the patient. It is to get some access and some surface to work. Now what about your landmarks? The problem is to try not to go behind the kidney, which is there. This is the colon. This is the splenic flexure. Probably we have to pass in front of Gerota’s fascia and I think this is Gerota’s fascia so I should find some cleavage plane somewhere here. This was a glimpse of the tail of the pancreas. I can feel it there so I’m just trying t find this cleavage plane. The idea is initially when I go there, I like to have this idea of the plane and you’re right that I’ll cut this one and let the spleen fall down. I think that probably the plane is here. So I’ll go up. There are some adhesions there. I think you must dissect here much higher to completely open the lienorenal ligament to the parietal wall and this will put tension on the spleen and let the spleen fall down but you must go for the next 10cm up. Of course, I place the instruments not as high as for an adrenalectomy because I have to be a little bit lower down in order to work on the pancreas. So I try to be as high as possible to get this space open. This is the tail probably. So what we’ve done is continue to mobilize the spleen, which is falling down progressively as you can see. We’ve seen the adrenal here and the stomach is there so we’re coming at the angle of His. So everything is getting down. It’s important to go there as all the things are falling on the side. The spleen is free until the left crus so the spleen is completely out of the operative field without any manipulation and I think it’s very important to avoid any bleeding. If you’re used to the ultrasonic… Yes but sometimes I’ve used it for example for hiatal surgery, that’s not bad because the tip is very atraumatic. But I’m a bit annoyed since I’d like a cutting part there that I don’t get. What’s your general position regarding resection versus excision or enucleation? We’re used to enucleating them if they are less than 2cm and not close to the duct. Yes, that’s right but no matter if it’s in the tail or the head of the pancreas. We know that for the head of the pancreas, we try of course to make an enucleation in the majority of the cases. They’re usually in the tail, aren’t they?
3. Transoperative ultrasound and pancreatic enucleation 07'39''
It’s a little bit in the parenchyma. I thought initially that it was on the surface of the pancreas but we’ll inspect now a bit more deeply and see if we can imagine something somewhere. You’ve seen the tumor. I don’t know what size it is, it’s quite large. It’s just on the vessel. I just mark the place. What I should also do is to check if I can see the Wirsung’s duct. There are a lot of vessels around there. It’s difficult because it’s on the tail of the pancreas very distally and I think the size is less than 1cm. you are at the limit of resolution for your ultrasound. The only problem when we are dealing with quite a large tumor like this, there is more chance to injure pancreatic duct and of course to get some fistula. I think you can see the duct right at the bottom. We’re outside of the Wirsung’s duct. It will take you longer to enucleate that and take it off the vessel than it will to do a distal pancreatectomy I think because it’s right against the duct, it’s against the vein and against the artery so it will take a long time. I think you can save the spleen, now you must dissect between the spleen and the upper pole of the pancreas and you’ll probably get the vein. Even if you took the vessels, you haven’t taken any short gastric vessels. You’re right but I’ll try to feel and to open just a bit the pancreatic capsule and see. We’re discussing the pros and cons of distal pancreatectomy versus enucleation. Usually the experience of the department, when it is always on the head of the pancreas, we’re trying to do an enucleation; when it is distal, we do a distal pancreatectomy, and if possible with preservation of the spleen. To do an enucleation will be quite difficult I think. I will introduce another trocar for the assistant to help me in retracting the pancreas now. So we’ll free the anterior surface of the pancreas. Here again we see the interest of the wide dissection of the spleen; previously you can see that we have tension on the vessels; it’s very easy to get to the small arteries and veins. Sometimes when you work on this side, you have to adjust your mind because of the position of the patient and the circumvolution of the artery. We see if I can preserve all these vessels. It’d be quicker to divide but we know that spleen preservation even if we keep the short gastrics, in about 20% you can have a splenic infarction and if we can avoid that in this sort of tumor, it might be interesting. When we do a distal pancreatectomy with spleen preservation coming from the medial side, it’s the same. It takes time just to get those little branches; it’s a little bit tedious sometimes. It was in this area that we had the tumor. It’s gone. We’re going to remove this specimen and then we will send it to the pathologist just to be sure and we are checking with the perioperative glycemia and insulinemia. A very nice information we got from the anesthesiologist is that glycemia is normal. So I’ve detached probably all the outflows from the tumor and we have suppressed the release of insulin because during the whole operation we had problems with glycemia. If you have to do again the same operation, what would be your approach? The same or the anterior one? The same. I know that Bernard Dallemagne prefers the anterior approach but due to the analysis of the pictures… She had glycemia of about 0.5 – 0.4 and now she’s 1.2 – 1.3 so I think it’s done but of course we’ll confirm that with the pathologist. What about the pancreas as you’ve enucleated it? Do you do anything else? I will place a stitch just to close a bit, it doesn’t prevent anything. I’ll check a bit inside to see if by accident we can see the duct but usually we can’t see it. So I’ll just close the capsule like this. We still need to put clips. It looks like an insulinoma.