Indocyanine Green-Assisted Laparoscopic Enucleation of Insulinoma in a Pediatric Multiple Endocrine Neoplasia Type 1 Patient

Introduction: Indocyanine green (ICG) fluorescence is an innovative and promising tool in minimally invasive surgery, providing real-time anatomical and functional visualization. 1 – 3 Its use in pediatric patients remains limited. 4 ICG fluorescence facilitates intraoperative localization of insulinomas by taking advantage of their rich vascularization: After intravenous administration, the tumor appears as a hyperfluorescent area, and subcapsular injection allows continuous visualization, as the intravenous form provides only a brief fluorescence signal. 1 , 5 To date, no pediatric cases of insulinoma associated with multiple endocrine neoplasia type 1 (MEN1) resected with ICG guidance have been reported. We present the first pediatric case at our institution where ICG was used to achieve a targeted and conservative resection, avoiding extensive pancreatectomy and its sequelae. 6 – 8 Materials and Methods: An 11-year-old male with fasting hypoglycemia and genetically confirmed MEN1 was diagnosed with pancreatic insulinoma. Preoperative localization was accomplished through 68 Ga-DOTATATE and 18 F-DOPA PET/CT, in combination with pancreatic magnetic resonance imaging. A laparoscopic enucleation with ICG assistance was planned. The patient was placed in the supine position. Four trocars were used (10 mm umbilical optic and 5 mm in the left flank, left paraumbilical, and epigastrium). Intravenous ICG was administered in bolus (0.2 mg/kg, solution of 25 mg in 10 mL sterile water). Fluorescence became visible within 60–120 seconds under a near-infrared system. A hyperfluorescent area corresponding to a lesion in the pancreatic body was identified. Enucleation was performed with blunt and sharp dissection, ultrasonic dissector, and reinforcement with mechanical stapling. A drain was placed in the operative field. Results: Operative time was 110 minutes. ICG provided accurate localization of the tumor, enabling complete resection without segmental pancreatectomy. Postoperative course was favorable, with normoglycemia from the mediate postoperative period and no complications. The patient was discharged in good condition. Conclusions: This is the first case in our institution where ICG was applied in pediatric pancreatic surgery. The technique was safe and effective, allowing precise resection with maximal preservation of healthy pancreatic tissue. ICG fluorescence is particularly advantageous for superficial tumors, 1 , 3 , 4 especially in pediatric patients with long life expectancy and high recurrence risk if complete resection is not achieved. 6 – 8 Further studies are needed to standardize dosage, timing of administration, and its combination with intraoperative ultrasound. Patient Consent Statement: The authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure. The authors declare no conflicts of interest or commercial associations in the last 3 years. Runtime of video: 4 min 9 sec.