Robotic small bowel resection with mesenteric lymphadenectomy and intracorporeal enteroenterostomy for well-differentiated ileal neuroendocrine tumor with regional nodal metastases and diffuse hepatic metastatic disease.

The patient presented with a grade 1 (Ki-67 2%) well-differentiated neuroendocrine tumor of the terminal ileumwith mesenteric nodal metastases and numerous small hepatic metastases identified on cross-sectional imaging and DOTATATE PET imaging. The patient had no clinical or biochemical evidence of carcinoid syndrome, although chromogranin A was elevated at 524. Genetic evaluation was performed due to family history suggestive of a hereditary syndrome, but no actionable germline mutations were identified.

Because the diffuse hepatic metastases were not amenable to surgical cytoreduction or liver-directed therapy, operative management focused on resection of the primary tumor and regional nodal disease to reduce the long-term risk of small bowel obstruction, mesenteric ischemia, bleeding, or perforation—well-recognized complications of untreated small bowel neuroendocrine tumors.

Robotic staging laparoscopy confirmed the absence of peritoneal carcinomatosis. The terminal ileal primary tumor and associated mesenteric nodal disease were resected en bloc with regional mesenteric lymphadenectomy. Indocyanine green fluorescence angiography was used to confirm adequate bowel perfusion prior to creation of a robotic intracorporeal stapled enteroenterostomy.

Final pathology demonstrated a 1.8 cm well-differentiated grade 1 ileal neuroendocrine tumor invading through the serosa (pT4) with metastatic tumor in 4 of 4 regional lymph nodes (pN1) and negative surgical margins.

The patient recovered without complications and was discharged home on postoperative day three.

This video demonstrates robotic surgical management of metastatic small bowel neuroendocrine tumor, highlighting techniques for mesenteric nodal dissection near the superior mesenteric vessels and minimally invasive bowel reconstruction.