Illuminating the Uncinate: Advanced Indocyanine Green Fluorescence and Ultrasound-Guided Robotic Enucleation of a Pancreatic Insulinoma in a Challenging Position.

Insulinoma is a rare, functioning pancreatic neuroendocrine tumor (PanNET) that typically presents with clinical manifestations associated with fasting hypoglycemia in accordance with Whipple's triad. Although most insulinomas have benign biological behavior, the severity of hypoglycemic symptoms necessitates prompt diagnosis and management. Surgical resection remains the treatment of choice, and parenchyma-sparing techniques, such as enucleation, are preferred when the tumor is solitary. However, when the tumor is located in anatomically challenging regions, the surgical approach can present significant difficulties, limiting the use of parenchyma-sparing surgery. We report the case of a 54-year-old female with an insulinoma localized to the uncinate process of the pancreas in a critical position due to its close proximity to the mesenteric vessels. The tumor was successfully managed with robotic enucleation using the da Vinci XI platform. Intraoperative imaging with ultrasound, complemented by indocyanine green (ICG) fluorescence imaging, provided real-time visualization of the hypervascular lesion and its relationship to nearby vascular structures, allowing for precise demarcation and safe resection. This case illustrates the advantages of combining advanced intraoperative imaging techniques with robotic surgery to achieve a parenchyma-sparing resection with minimal morbidity. The discussion highlights current literature and emerging evidence on the use of ICG and near-infrared (NIR) fluorescence in pancreatic surgery, underscoring its potential to improve outcomes in the management of pancreatic neuroendocrine tumors.