Published online Nov 10, 2015. doi: 10.4253/wjge.v7.i16.1197
Peer-review started: May 6, 2015
First decision: June 2, 2015
Revised: June 22, 2015
Accepted: August 25, 2015
Article in press: November 7, 2015
Published online: November 10, 2015
Processing time: 198 Days and 6.7 Hours
Insulinomas are rare pancreatic neuroendocrine tumors that are most commonly benign, solitary, and intrapancreatic. Uncontrolled insulin overproduction from the tumor produces neurological and adrenergic symptoms of hypoglycemia. Biochemical diagnosis is confirmed by the presence of Whipple’s triad, along with corroborating measurements of blood glucose, insulin, proinsulin, C-peptide, β-hydroxybutyrate, and negative tests for hypoglycemic agents during a supervised fasting period. This is accompanied by accurate preoperative localization using both invasive and non-invasive imaging modalities. Following this, careful preoperative planning is required, with the ensuing procedure being preferably carried out laparoscopically. An integral part of the laparoscopic approach is the application of laparoscopic intraoperative ultrasound, which is indispensable for accurate intraoperative localization of the lesion in the pancreatic region. The extent of laparoscopic resection is dependent on preoperative and intraoperative findings, but most commonly involves tumor enucleation or distal pancreatectomy. When performed in an experienced surgical unit, laparoscopic resection is associated with minimal mortality and excellent long-term cure rates. Furthermore, this approach confers equivalent safety and efficacy rates to open resection, while improving cosmesis and reducing hospital stay. As such, laparoscopic resection should be considered in all cases of benign insulinoma where adequate surgical expertise is available.
Core tip: Insulinomas have always fascinated physicians and surgeons alike, due to the difficulties in: (1) diagnosing them; (2) obtaining accurate preoperative and intraoperative localization; and (3) actually performing the operation safely and effectively. Laparoscopy stands out in the current literature as the approach of choice, and is employed for virtually all benign insulinomas. Enucleations for insulinomas in the head and body, as well as distal pancreatectomies for lesions in the body and tail of the pancreas, have been shown to be safe and effective in the current series. Laparoscopic intraoperative ultrasound localization has emerged as a standard adjunct to these procedures.