Operative Approach

Operative exposure may be achieved through a bilateral subcostal or long midline incision. Upon entering the peritoneal cavity, a thorough exploration is performed to exclude metastatic disease. Tru-Cut needle or wedge biopsy of any suspicious liver lesions is performed and suspicious lymph nodes are sent to the pathologist for frozen section analysis. A generous Kocher maneuver is then performed from the level of the right gonadal vein to the aorta medially. At this time, the head and neck of the pancreas may be carefully palpated (Fig. 79-13A). The omental bursa is then divided to the left of the midline, allowing access to the lesser sac. Mobilization of the body and tail of the pancreas is then begun in the usual fashion, by dividing the peritoneum along the inferior aspect of the gland. The inferior mesenteric vein may be divided at this point if necessary. Careful visual inspection and manual palpation of the body and tail of the pancreas are then undertaken (Fig. 79-13B). To examine the posterior aspect of the gland, the spleen must be mobilized by incising its attachments to the diaphragm, kidney, and colon. IOUS may now be performed.

FIGURE 79-13. A, After a generous Kocher maneuver of the duodenum, the pancreatic head should be palpated between the thumb and fingers. B, The gastrocolic omentum is divided and the stomach is elevated. The body and tail of the pancreas are gently mobilized. The areas can now be visualized and palpated carefully. (From Findley A, Arenas RB, Kaplan EL. Insulinoma. In: Percopo V, Kaplan EL [eds], GEP and Multiple Endocrine Tumors. Padova, Italy, Piccin Nuova Libreria SpA, 1996, p 314.)

FIGURE 79-15. A distal resection was performed for this large lesion of the tail of the pancreas. A lymph node metastasis was present; thus, this was a malignant insulinoma.

FIGURE 79-13. A, After a generous Kocher maneuver of the duodenum, the pancreatic head should be palpated between the thumb and fingers. B, The gastrocolic omentum is divided and the stomach is elevated. The body and tail of the pancreas are gently mobilized. The areas can now be visualized and palpated carefully. (From Findley A, Arenas RB, Kaplan EL. Insulinoma. In: Percopo V, Kaplan EL [eds], GEP and Multiple Endocrine Tumors. Padova, Italy, Piccin Nuova Libreria SpA, 1996, p 314.)

When an insulinoma has been located, an attempt to enucleate it should be made, regardless of its location within the gland (Fig. 79-14). Distal pancreatectomy is performed in the setting of multiple lesions within the body and tail (see Fig. 79-6) if the lesion is large and malignancy cannot be excluded (Fig. 79-15) or if the lesion abuts the pancreatic duct. Enucleation of lesions intimately associated with the pancreatic duct predictably leads to fistula formation. Most lesions of the head of the pancreas are enucleated (Fig. 79-16). Only rarely should a pancreaticoduodenectomy be performed for a benign lesion. Occasionally, the Whipple procedure may be indicated for a malignant lesion of the head or uncinate process with regional nodal involvement.

FIGURE 79-14. An insulinoma of the inferior surface of the body of the pancreas is demonstrated. This was easily enucleated.

IOUS is invaluable when performing enucleation of lesions in the head of the pancreas. Care must be taken to avoid injury to the main pancreatic and common bile ducts. Cannulating the common bile duct through the cystic duct and inflating the balloon at the ampulla of Vater may also be employed. However, the main factor in preventing a fistula is to stay immediately on the capsule of the tumor and to use gentle, blunt dissection.

FIGURE 79-15. A distal resection was performed for this large lesion of the tail of the pancreas. A lymph node metastasis was present; thus, this was a malignant insulinoma.

FIGURE 79-16. A, Insulinoma of the head of the pancreas (arrow). These lesions can almost always be enucleated. During enucleation, careful blunt dissection should be used immediately on the capsule of the insulinoma to prevent damage to the common bile or pancreatic duct, which could result in a fistula. B, This lesion was carefully enucleated and proved to be benign.

FIGURE 79-16. A, Insulinoma of the head of the pancreas (arrow). These lesions can almost always be enucleated. During enucleation, careful blunt dissection should be used immediately on the capsule of the insulinoma to prevent damage to the common bile or pancreatic duct, which could result in a fistula. B, This lesion was carefully enucleated and proved to be benign.

If MEN 1 is suspected, a thorough exploration of the pancreas is mandatory to exclude multiple lesions. Additional lesions may then be enucleated. However, in most instances of MEN 1, a distal pancreatectomy with enucleation of any remaining lesions of the head of the pancreas is preferable.

Finally, if all efforts at exploration fail to identify the primary lesion, the operation should be terminated and the patient referred to a center of excellence. Although blind distal resection of the pancreas was advocated in the past, the development of modern localization studies such as EUS and ASVS allows the eventual detection of almost all insulinomas.45

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