Laparoscopic pancreatectomy for insulinoma

Insulinomas are rare tumors of the islet cells of the pancreas. They are solitary, small and benign. They may occur anywhere within the pancreatic gland. This video shows a laparoscopic pancreatectomy for insulinoma in a 52-year-old man with a BMI of 25.

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Laparoscopic pancreatectomy for insulinoma

Authors

B Dallemagne, S Perretta, L Soler, J Marescaux

Abstract

Insulinomas are rare tumors of the islet cells of the pancreas. They are solitary, small and benign. They may occur anywhere within the pancreatic gland. This video shows a laparoscopic pancreatectomy for insulinoma in a 52-year-old man with a BMI of 25.

Classification

live recorded

Keywords

Laparoscopy, pancreatectomy, insulinoma

Media type

Surgical video

Duration

25'34''

Publication

2011-01

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Subtitles

E-publication

WeBSurg.com, Jan 2011;11(01).
URL: http://www.websurg.com/doi-vd01en3151.htm

Laparoscopic pancreatectomy for insulinoma

1. Introduction 00'18''

The first case we have this morning promises to be quite interesting. We have an insulinoma in a 52-year-old man with a BMI of 25. The only medical history that he had previous to this was an appendectomy. He did ultimately present with Whipple\'s triad, which —no disrespect to Dr. Whipple— is one of the most obvious triads. He did have low blood sugar, high insulin and relief after administration of glucose. The work-up in terms of most significant labs: he had both elevated insulin and elevated C-peptide, indicating inherent production of insulin.

2. Intra-abdominal view 01'05''

You see here the organs and I can put the pancreas under transparency. The tumor is here. The benefit here is to have a better visualization of the patient’s anatomy. We have also the anatomical segments of the liver. What is important here is the location of the tumor, just close to the bifurcation of different veins —colonic vein here, splenic vein—, so it is very interesting to see that. Then I have the resection. I have two main trocars both on the right and left side. It is for my left and right hand. On the lateral side of the patient, I have another trocar, which will help with retraction. That is the initial set-up. Eventually, if we need some more trocars, we will adapt during surgery.

3. Gastrocolic ligament opening 02'17''

We divide the gastrocolic ligament, the omentum, just to get access to the pancreatic area. You see that I am using these special internal retractors to lift up the stomach. As I mentioned, we have opened the pancreatic area. The problem in this patient is that the fatness is quite extensive and we cannot see anything when we look at the surface of the pancreas. I can imagine that, based on the reconstruction, and CT-scan and MRI, the lesion should be somewhere here, but the problem with endocrine tumors is that it is sometimes difficult to find or to see anything. We have this reconstruction, a virtual model of the patient. I think that one very important thing for pancreatic surgery is to have ultrasound.

4. Peroperative ultrasound 03'41''

That is really the key, because you need some guide within surgery. So I use an ultrasonic probe and I hope that I will find this tumor. Just look at the outside view. You cannot see anything. I can just see it thanks to this probe. That is the problem with endocrine tumors: sometimes you cannot see them, even in open surgery it is difficult to find it, to palpate it. This is why, when we start pancreatic surgery, we have to use this sort of intraoperative tool. That is very important. You have a nice view of it here. I do not know what was the size described, it was about 2cm. We will check. I am controlling myself. I have a little remote control. I am changing. So it is 17. It is a laparoscopic camera. It is easy because I can manage everything. Usually when you are in the OR, people who know exactly how it works, so it becomes difficult. I prefer to control myself. Probably I will have to do a distal pancreatectomy because I cannot get this out and preserve the pancreatic duct. You are very close to the blood vessels… Yes. If I can preserve the vessels, I will do it. If not, I can divide the vessels at the origin and still preserve the spleen. We will check during the operation. At this point, the problem is to find the axis but I know thanks to the ultrasound, that it was somewhere here. This should be the lower border of the pancreas. We will open here and see what we find. Bernard, you are using the Ligasure® once again and in this case, it seems to be perfect for the reflux case. Yes, that is right, but the technology we have here has not been renewed for a while, so I am not very comfortable with that. That is why I am using the Ligasure®, which is very nice. I am getting used to that, I would say. At this point, if I am lost, I will always keep my ultrasonic probe on the table so that I can use it if needed. That is pretty impressive. So I can go here. Looks safe. Where is my portal vein? The small Endograb™ retractors he is using to retract the stomach are an interesting spin-off from NOTES. Here, you see a little bit the limitation of the shape of the Ligasure®. When I have to cut very little things, I am a little bit annoyed, as I do not have a very good cutting really on the tip of the device. Is that a good point of transection there? Yes, I think so, because my limit is there.

5. 3D reconstruction comparison 08'38''

We are looking at Luc Soler’s 3D reconstruction and it looks like that area is a good area. I will get these little veins. There is another one there. We trust our technology a lot, don’t we?

6. Dissection of pancreas superior border 09'11''

Now I am going to go a little bit on the superior border of the pancreas to free the capsule on this side. And, of course, before cutting the pancreas, we will check again with the ultrasound just to be sure. It is always very tough when it is so fat, because fat is very fragile and it is terrible. Just only manipulation of the tissues makes it difficult. You are along the splenic artery, right? Yes. We can see superior there the splenic artery, so if you follow that plane, maybe it is easier. Endograb™ on that. Manipulation is very tough. That is why I am very careful, because I do not want too much bleeding otherwise it is becoming very tough. You see, in one hand, and the aspiration in the other hand. There is nothing like bipolar. Bipolar is nice.

7. Freeing of splenic artery 11'16''

I’m just checking how I can try to preserve my artery. So I will come with a very nice instrument to do that because I want to free the splenic artery and see if I can free it first. See that’s probably one of the good things of this old instrument. The hook, in some situations, is still nice because it allows you to grab. Yesterday when we were seeing the movie about lymphadenectomy, I was wondering, Dr. Yang, if you sometimes use the hook. No, I don’t use the hook. I prefer to use an ultrasonic device along major vessels. You never had any situations when you could feel a bit more comfortable with your hook? No, I simply feel that the ultrasonic device is more secure bu,t as I mentioned, some Korean surgeons, he or she likes to use hook. If the cleavage plane is not too difficult, I will try to preserve because I know that the risk is a little bit less than with the Warshaw technique but of course if I have some trouble within the dissection, I will cut it. So for the audience, what do you usually consider the risk of splenic infarction with the Warshaw technique? It’s around 10%. It doesn’t mean that you need to do a splenectomy but the risk exists. Use clips. To put a loop early around the artery because you have the control of your main potential problem so I think it’s important. Have you decided how you are going to divide the pancreas yet? Probably I will have to try to make my channel for a stapler if I can. Now I will try to find my way.

8. Pancreas division 14'02''

If I can without too many problems, I will do with stapler. If I can’t, I will cut directly within the pancreas. We’d love to do that. We have the ultrasound image. OK, you have it there so my limit was here. So this is really the center of the tumor. It’s OK. I didn’t break my stapler, it’s the first good point. That’s difficult with a black suture in something that is oozing.

9. Hemostasis control 16'26''

We can control that afterwards if you want but just to get that hemostasis. So I’m not looking for the duct or anything. See the running suture is enough. It’s better. See this running suture is sufficient and afterwards, maybe if I want, I can do another run with the suture, but at least I’ve got my hemostasis. So here, we have the pancreas. This area was quite inflammatory and I’ve the feeling that the other part is not that much. So maybe I can do a preserving-vessel technique, we’ll see. So now it’ll become a little bit easier but tedious because we have to control progressively all the little veins and the little arteries all along the vessels. So it’s true that the Warshaw technique is quicker and I’d say as soon as we have some tumor with a potential suspicion of malignancy, we do the Warshaw technique. We don’t look into the idea of preserving the vessels. When we have an obvious benign disease, I think it’s probably interesting to try to preserve as much as possible. Yes, I like to save the artery when possible. We are working in an insulinoma so I don’t have to respect the same principles. See on the main screen. So we’ll see what I can do with the Ligasure®. Lee, what do you think of my suspension device? The vessel loop that I’m using is not excellent because it breaks rapidly. We are finished. As I told you, there are little issues with the distal part of the pancreas because when we were together in this area, we’ve seen that it was really stuck on the pancreas. Moreover, I’d say that the anatomy of the patient in this tunnel is not very easy so I had some bleedings all around. Finally we controlled that with both the Ligasure® —very good—, and some clips. We will of course leave a drainage. We control a little bit hemostasis in the fat. We had some luck using radiofrequency burn with a device to burn it and then transect. The ultrasonic is good too. The Harmonic® scalpel is good to transect the pancreas.

10. Specimen removal 23'22''

What we’re going to do is to remove the specimen and we’ll open the specimen. Can we see you take one of the Endograbs™ off? I think the audience does not quite understand how you put those on. It’s a very simple system. It works through a 5, of course here I have a 10, but it works through a 5. See I have this little thing there. I will catch this and then I will release it. There it is. I will take the other one. See I can catch the little hook and you see it’s a very large system. So now I have a sheath and I will insert it or remove it.