This case demonstrates robotic enucleation of a pancreatic neuroendocrine tumor with regional lymphadenectomyin a patient previously treated for an ileal neuroendocrine tumor.

The patient initially presented with small bowel obstruction, and workup revealed a 1.7 cm well-differentiated ileal neuroendocrine tumor (WHO grade 1, Ki-67 <3%). He underwent laparoscopic small bowel resection, with pathology demonstrating pT3 pN1 disease with two of three regional lymph nodes involved.

Subsequent staging with DOTATATE PET/CT demonstrated intense radiotracer uptake in two nodular structures posterior to the pancreatic neck within the peripancreatic/gastrohepatic ligament region. Although initially interpreted as possible nonregional nodal metastases, the imaging characteristics and anatomic location also raised the possibility of a primary intrapancreatic neuroendocrine tumor.

Given the limited distribution of disease and the diagnostic uncertainty, surgical exploration was recommended.

Robotic staging laparoscopy demonstrated no peritoneal metastatic disease. Intraoperative ultrasound localized a 2 cm lesion within the superior–posterior aspect of the pancreas. The lesion was carefully enucleated from the pancreatic parenchyma, and regional peripancreatic lymphadenectomy was performed.

Final pathology demonstrated a well-differentiated grade 1 pancreatic neuroendocrine tumor (Ki-67 ~1.3%). Importantly, the tumor was surrounded by pancreatic parenchyma without associated lymphoid tissue, supporting the interpretation that the lesion represented a primary pancreatic neuroendocrine tumor rather than nodal metastasis. Five additional lymph nodes were negative for malignancy.

This case illustrates the diagnostic complexity of neuroendocrine tumor staging, and demonstrates robotic techniques for suprapancreatic exposure, intraoperative ultrasound–guided localization, pancreatic tumor enucleation, and regional lymphadenectomy.