Robotic Enucleation of an Intra-Pancreatic Insulinoma in the Pancreatic Head

This video vignette illustrates a robotic approach to enucleation of an intra-pancreatic insulinoma in the pancreatic head. This case involves a 42-year old woman who presented with sweating, tremor and episodes of hypoglycemia. A fasting test confirmed endogenic insulin overproduction.

Endoscopic ultrasonography showed a non-bulging, hypoechoic lesion which was fully within the pancreatic head. The patient was diagnosed with an intra-pancreatic insulinoma. On these endoscopic ultrasonography images, the hypoechoic lesion is clearly visible and measures approximately one centimeter with a distance of one millimeter from the main pancreatic duct.

Four eight millimeter trocars are introduced above the umbilicus and two five millimeter laparoscopic assistant trocar are introduced on either side of the umbilicus. The distance between all trocars is approximately seven centimeters. Precise handling is enabled by 3D vision, a magnified view and a 3-2-1 scaled movement ratio of the instruments.

The procedure starts with he mobilization phase. By mobilizing the hepatic flexure of the colon. Then a liver retractor is positioned.

The gastrocolic ligament is divided so the lesser sac is opened. The mobilization moves from lateral to medial, this mobilization continues until hepatic flexure of the colon is freed. Hereafter the Kochers Manoeuvre is performed until the left renal vein is identified and the right gastroepiploic vein is dissected free and ligated using a vessel suture.

By retracting the pancreas and duodenum with a third robotic arm, the abdominal aorta and the inferior vena cava can be exposed entirely. The right gastroepiploic vein is identified and divided with a laparoscopic sealing device. Finally, the pancreatic head is further mobilized.

After the mobilization phase, the endoscopic ultrasonography probe is introduced to identify and locate the insulinoma and the trajectory of the pancreatic duct. The location of the lesion is then marked using a cautery hook. A traction suture is used to control the lesion during the enucleation with the monopolar curved scissors.

The traction suture is used to lift and stretch the lesion from the adjecent pancreatic parenchyma, thus facilitating a nucleation with the diathermic scissors and a bipolar energy device. The procedure continues with the dissection phase. The third robotic arm retracts the lesion, the other two instruments proceed with the enucleation.

The cutoff finger of a sterile surgical glove is used to extract the specimen. The roof of the pancreatic duct is visible at the bottom of the enucleation site. A sealant patch is placed on the defect in the pancreatic parenchyma.

A drain is introduced and advanced up to the pancreatic tail. Emulase levels in the produced fluids can detect post-operative pancreatic fistula. Histopathological examination revealed a great one, well-defined neuroendocrine tumor measuring 1.5 centimeters.

Post-operative pancreatic fistula required a endoscopic pancreatic sphincterotomy, after pancreatic stent placement was not successful resulting in a grade B pancreatic fistula. The production of the abdominal drain declined to a negligible production and was removed on post-operative day 20. Without any further complications.

The patient was discharged on day seven, post-operatively. Robotic enucleation of insulinomas seems feasible. Still future perspective studies should confirm this suggestion.

We believe that the described technique with adequate ultrasonography, guided localization of the lesion could be a valuable alternative for open enucleation. Further studies are needed to compare short and long term outcomes after robotic, open and laparoscopic enucleation.