Intraoperative Palpation

Most insulinomas of the pancreas can be palpated by carefully exploring the pancreas at the time of surgery. The sensitivity of palpation is 75% to 95% in different studies and depends on the experience of the surgeon.23 Small tumors and those located in the pancreatic head and uncinate process are generally more difficult to palpate. The combination of IOUS and palpation has been reported to increase the sensitivity to 100%.42 Like IOUS, proper intraoperative palpation requires full mobilization of the pancreas.

FIGURE 79-9. Isotope-labeled somatostatin scanning. Indium 111-diethylenetriamine pentaacetic acid (DTPA)-octreotide scan of a patient with an insulinoma within the head of the pancreas at 24 hours (A) and 48 hours (B). The tumor is represented by a hot spot just medial to the right kidney (arrow). (From van Eyck CHJ, Braining HA, Reubi J-C, et al. Use of isotope-labeled somatostatin analogs for visualization of islet cell tumors. World J Surg 1993; 17:444.)

FIGURE 79-9. Isotope-labeled somatostatin scanning. Indium 111-diethylenetriamine pentaacetic acid (DTPA)-octreotide scan of a patient with an insulinoma within the head of the pancreas at 24 hours (A) and 48 hours (B). The tumor is represented by a hot spot just medial to the right kidney (arrow). (From van Eyck CHJ, Braining HA, Reubi J-C, et al. Use of isotope-labeled somatostatin analogs for visualization of islet cell tumors. World J Surg 1993; 17:444.)

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FIGURE 79-11. Intraoperative sonogram. A, Insulinoma of the tail of the pancreas. The arrows designate the insulinoma, which is hypoechogenic compared with the surrounding pancreas. B, A hypoechoic tumor (T) of the pancreas is visualized by intraoperative ultrasonography. Note that the pancreatic duct (arrow) and its proximity to the tumor are clearly shown. (A, From Kaplan EL, Arganini M, Kang S-J. Diagnosis and treatment of hypoglycemic disorders. Surg Clin North Am 1987;67:395-410. B, From Zeiger MA, Shawker TH, Norton JA. Use of intraoperative ultrasonography to localize islet tumors. World J Surg 1993;17:448.)

FIGURE 79-10. Endoscopic ultrasonography of the pancreas. A, Preoperative localization of a suspected insulinoma of the pancreatic neck. B, Transgastric fine-needle aspiration confirmed the presence of an insulinoma, which was later resected by enucleation. (Courtesy of Rameez Alasadi, MD.)

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