Insulinoma located in the uncinate process of the pancreas: laparoscopic resection

Insulinoma is the most common functional neuroendocrine tumor of the pancreas. Laparoscopic resection of insulinomas is feasible and safe. Laparoscopic ultrasound contributes to successful insulinoma localization and laparoscopic resection. This video shows a laparoscopic resection of an insulinoma located in the uncinate process of the pancreas.

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Insulinoma located in the uncinate process of the pancreas: laparoscopic resection

Authors

D Mutter, L Soler, J Marescaux

Abstract

Insulinoma is the most common functional neuroendocrine tumor of the pancreas. Laparoscopic resection of insulinomas is feasible and safe. Laparoscopic ultrasound contributes to successful insulinoma localization and laparoscopic resection. This video shows a laparoscopic resection of an insulinoma located in the uncinate process of the pancreas.

Mots-clés

Insulinoma, uncinate process, pancreas, laparoscopic resection

Type de vidéo

Vidéo chirurgicale

Durée

13'00''

Publication

2011-11

Popularité

Favoris

Favorites Media

Audio

E-publication

WeBSurg.com, Nov 2011;11(11).
URL: http://www.websurg.com/doi-vd01en3484.htm

Insulinoma located in the uncinate process of the pancreas: laparoscopic resection

1. Clinical case 00'10''

A 35-year-old male patient is taken to emergency admissions with a typical case of low blood sugar levels. He suffers from a general discomfort, dizziness and profuse sweating. On admission, blood sugar levels reach 0.35g/dL. The complementary workup confirms the presence of a typical insulinoma as evidenced by serum chemistries, with C-peptide, insulin and pro-insulin values which correspond to a typical insulinoma. A 6-hour long oral glucose tolerance test (OGTT) confirms the diagnosis, with a late drop of blood sugar levels, and insulin levels which remain high. Imaging studies including CT-scan and MRI are then performed. These exams confirm the presence of an adenoma, which presents as a tumor located at the uncinate process of the pancreas. It is a centimeter-wise, hypervascularized tumor, in direct contact with the junction between the 2nd and 3rd portion of the duodenum, as can be seen here. Posteriorly, it is in contact with the inferior vena cava. A laparoscopic intervention could well be an option for this tumor.

2. Patient position 01'18''

The intervention begins with positioning of the patient in a left lateral decubitus. The trocars are first introduced subcostally.

3. Duodenal mobilization 01'28''

The intervention is initiated with the mobilization of the duodenum in order to achieve a Kocher’s maneuver and to lower the hepatic flexure. The gallbladder can be seen on this image, with the inferior vena cava on the left hand-side. The hepatic flexure will gradually be freed from the duodenal attachments in order to progressively free the inferior part of the 2nd duodenum. This requires the mobilization of the right colon over a distance of several centimetres as well as the freeing of the 3rd duodenum.

4. Lesser sac access 02'19''

Here we access the lesser sac. The dissection is carried out using ultrasonic scissors. They allow for tissue color to remain unchanged, and provide very good exposure to the whole anatomy. The freeing of the 2nd duodenum is carried out anteriorly and then posteriorly. For that reason, it is necessary to gradually tilt the 2nd duodenum in order to dissect the entire anterior aspect of the vena cava, which is an important anatomical landmark, as seen on the preoperative image. Here the genu superius can clearly be identified; the peritoneal reflection will be opened. The anterior aspect of the vena cava will then be dissected. It will be used as an anatomical landmark in order to perform a Kocher’s maneuver. The surgeon is placed at the patient’s back. The freeing of the 2nd duodenum until the genu inferius is carried out step by step.

5. Complete vena cava freeing 03'43''

The vena cava is completely freed, and the adhesions between the vena cava and the posterior aspect of the pancreas can also be freed. This allows for a gradual tilt of the pancreas towards the patient’s left. Thanks to the patient’s position, a constant retraction of the pancreatic head as well as the 2nd duodenum is not necessary.

6. Exposure of pancreatic head 04'15''

The head of the pancreas is now properly exposed, and we can now see a slightly bulging and hypervascularized area, which could correspond to the position of the adenoma.

7. Intraoperative ultrasonography 04'30''

An intraoperative ultrasonography is carried out to confirm the lesion’s position and the congruence of this lesion with the preoperative imaging studies. The lesion itself is clearly identified. The mobilization of the duodenum is continued in order to tilt it completely and to be able to free it as safely as possible. Attention is now turned to the posterior aspect of the pancreas at the level of the uncinate process. Bipolar cauterization in the operator’s left hand, and ultrasound dissection are successively used. This helps to very safely cauterize the small veins that may be found. Very progressively, an extraction of the uncinate process of the pancreas is induced by progressively freeing the adhesions between the 2nd duodenum and the pancreatic head. The hypervascularized lesion is clearly identified. The ultrasonic dissection and bipolar cauterization help to obtain a safe dissection and to achieve control of the small vascular elements that may bleed during the dissection.

8. Lesion enucleation 06'13''

The lesion is truly enucleated. The enucleation is performed very progressively in a stepwise fashion in order to avoid any pancreatic lesion. The imaging studies also helped to show that Wirsung’s duct is distant from the lesion, with a safety margin higher than 5 to 6mm. Likewise, Vater’s ampulla is also located more than 5mm from the lateral border of the lesion. Dissection is then carried on in contact with the tumor in order to avoid any lesion to the Wirsung’s duct and to the common bile duct. The enucleation progressively includes the division of the fibrous elements as well as the progressive dissection of the pancreatic tissue in contact with the lesion--without any division of the pancreatic tissue though. In case of doubt as to the precise location of the lesion, a complementary intraoperative ultrasonography is carried out during dissection. It will help to ensure that it is really the lesion that is dissected and that sufficient distance is maintained away from the noble structures. Especially at this level, no vascular element is demonstrated. Dissection is performed by dissociating tissues and by no means by direct division within the tissue. Ultrasonic dissectors are very helpful in this case. Difficulties lie in the impossibility of grasping the tumor directly. Only tissues lying around the tumor may be manipulated. The tumor clearly becomes visible at this level. It is truly embedded in the pancreas. Yet, a cleavage plane may be found fairly easily. A few small vascular elements are controlled progressively either by using the ultrasonic dissector or bipolar cautery. The objective is to avoid any tumoral effraction. The lesion of the pancreatic parenchyma is also restricted to a minimum. The limits of the insulinoma are very well identified here. This tumor is relatively hard, homogeneous, and well-delimitated within the pancreatic parenchyma. The main risk of this surgery is either a potential vascular effraction or lesion of Wirsung’s duct or lesion of the common bile duct. This confirms the necessity to perform a progressive dissection in direct contact to the tumor. The tumor will be resected once introduced into a bag. The pathological exam will confirm the presence of an insulinoma that has been completely resected. The postoperative clinical outcome will also confirm that no other type of lesion was present. Indeed, this patient has not had any low blood sugar levels for more than 2 months. A final intraoperative ultrasonography will also corroborate the complete resection of the lesion. In contact with the pancreatic tissue, we usually protect the dissection area by application of a TachoSil® hemostatic pad. This pad helps to avoid any potential minimal pancreatic fistula should a small pancreatic duct have been injured during the dissection. A mere suction drainage is also left in contact with the dissection area. Food intake is resumed from the second postoperative day. The patient will stay at the hospital for 5 days. The lesion measures 17 by 12mm. On frozen section, an endocrine tumor is evidenced.