Operative Approach

Operation is the ultimate localization procedure in diagnosis and usually the definitive step to end the treatment of insulinoma. A laparoscopic approach may also be attempted for selected patients whose insulinomas are identified by transgastric ultra-sonography preoperatively. A bilateral subcostal incision or an upper midline incision can be used. See Figure 13-15 for an illustration of the relevant anatomy. Initial exploration should involve careful assessment of the liver for metastatic disease.

The pancreas is exposed by dissecting the omen-tum from the transverse colon throughout its length. The omentum and stomach are retracted superiorly, lysing adhesions between the posterior wall of the stomach and the pancreas. The lesser sac is entered and the retroperitoneum is exposed with careful palpation of the entire surface of the pancreas (Figure 13-16). A Kocher maneuver is performed to mobilize the duodenum anteriorly and to allow bimanual palpation of the head and uncinate process (Figure 13-17). Special attention is paid to any area suspicious for a tumor on preoperative or intraoperative localization studies.

At our medical center, we routinely use IOUS not only to localize the tumor but also to see its rela-

Figure 13-13. Intraoperative sonogram demonstrates the sharply marginated mass, which is predominantly hypoechoic and is situated in close proximity to the splenic vein and artery.

The Success Rates of the Localization Techniques

Intraoperative Ultrasonography

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