Laparoscopic Distal Pancreatectomy and Splenectomy for Insulinoma

Abstract

Abstract

Introduction:

Insulinomas have an incidence of 1.5 to 2 per million people yearly. ¹ They most commonly occur as benign, solitary, and sporadic tumors. They are located exclusively in the pancreas. The clinical picture of an insulinoma is characterized by Whipple's triad of symptoms of hypoglycemia, documented low blood glucose, and relief of symptoms upon administration of glucose. ² The two most common procedures performed for insulinoma are tumor enucleation and distal pancreatectomy. ² These surgeries can be safely performed laparoscopically in selected cases.^3,4 This case report presents a laparoscopic distal pancreatectomy and splenectomy for an insulinoma in the body of the pancreas.

Case:

A 53-year-old female presented to our institution with 2 years of symptoms consistent with neuroglycopenia, including confusion, blurred vision, and episodic syncope. She had documented hypoglycemia and was being treated with Proglycem. A supervised fast revealed evidence of endogenous hyperinsulinemia (glucose 45 mg/dL, insulin 5.8 mcIU/mL, C-peptide 1.3 ng/mL, and a negative sulfonylurea screen). A pancreatic protocol CT scan revealed a 1.1 cm hypervascular lesion at the junction between the body and the tail of the pancreas, deeply seated in the parenchyma and in close proximity to the pancreatic duct. In addition, six subcentimeter hypervascular lesions were identified on the liver. An Eovist-enhanced hepatic MRI was performed to characterize the liver lesions, and the results were most consistent with benign perfusion abnormalities. The decision was made to proceed with a laparoscopic distal pancreatectomy and splenectomy. The patient was placed in a modified right lateral decubitus position with 45 degrees of angulation. Pneumoperitoneum was obtained with a Veress needle in the left upper quadrant and access was achieved with an optical 12-mm trocar. Three other trocars were placed. The falciform ligament was dissected and a liver ultrasound performed, which also suggested that the liver lesions were benign perfusion abnormalities. The splenic flexure of the colon was mobilized using the Harmonic scalpel. The lesser sac was entered by incising the gastrocolic omentum outside the gastroepiploic vessels. The short gastric vessels were divided allowing medial and cephalad rotation of the stomach, thereby exposing the pancreas. The inferior border of the pancreas was fully dissected, and endoscopic ultrasound was utilized to identify the neoplasm. A plane of transection proximal to the tumor was marked using electrocautery. A retropancreatic tunnel was bluntly created keeping the splenic vein and artery with the pancreas. The pancreas and vessels were retracted upward using an umbilical tape. The pancreas, splenic artery, and splenic vein were transected using two firings of an EndoGIA stapler utilizing purple loads buttressed with Peri-Strips. The superior border of the pancreatic tail and the spleen were fully mobilized using the Harmonic scalpel. The specimen was removed using a 15-mm EndoCatch bag. Negative margins were confirmed by a frozen section.

Conclusion:

This video demonstrates the author's approach to a laparoscopic distal pancreatectomy and splenectomy for insulinoma. The patient had an uneventful postoperative course and was discharged home on postoperative day two with normal blood glucose levels.

All authors declare no conflicts of interest.

Runtime of video: 5 mins 15 secs