Insulinoma is a rare and elusive, but the most common, curable endocrine tumour of the pancreas. The incidence is estimated at 4 cases per million-person years.1 The ability to localise the tumour accurately before or during surgery is an important factor in the management of these lesions. In the event of failed localisation, a blind pancreatic resection is no longer recommended. The development of sensitive radioimmunoassays to detect endogenous hyperinsulinaemia resulted in extensive investigations to localise the tumour preoperatively, in the belief that this would reduce morbidity from pancreatic exploration. These pre-operative tests included ultrasound scans (USS), computerised tomography (CT), magnetic resonance imaging (MRI), selective angiography, transhepatic portal venous sampling (THPVS), endoscopic ultrasound (EUS), octreotide scans and calcium stimulation arteriography. There is a wide variation in the sensitivity of these tests and there is no clear consensus in the choice of these tests even amongst enthusiasts.2,3 Some believe that meticulous intra-operative exploration combined with intra-operative ultrasound (IOUS) has a higher sensitivity than pre-operative localisation tests. 4,5 We have reviewed our experience of these lesions to assess if pre-operative localisation tests are necessary and to formulate a rational management strategy for these lesions. Insulinoma is a rare, but curable, endocrine tumour. The ability to localise the tumour accurately before or during surgery is an important factor in the management of these elusive lesions, which has been extensively debated. We have reviewed our experience of these lesions to establish the role of localisation tests. SURGICAL ONCOLOGY

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The reverse-Trendelenberg position effectively lowers the CVP during liver surgery. It is easy to monitor, titrate and reverse, and avoids the need for complex pharmacological interventions. We recommend this position to liver surgeons and anaesthetists who have found it difficult to maintain a low CVP with the supine or Trendelenberg positions.

Seven patients who had functioning or non-functioning endocrine pancreatic tumours were investigated by magnetic resonance imaging. Combinations of fat suppressed T1 weighted spin echo and gradient recalled echo (n = 7), T2 weighted spin echo (n = 3) and gadolinium diethylamine triamine pentaacetic acid (Gd-DTPA) enhanced fat suppressed T1 images were acquired. Magnetic resonance imaging detected five of seven tumours prospectively (three of which were smaller than 10 mm) and a further 10 mm tumour retrospectively. Tumours were low signal on T1 weighted images and showed enhancement after Gd-DTPA. On T2 weighted images one tumour was hyperintense, and two were isointense with normal pancreas. Computed tomography, transabdominal ultrasound and angiography were performed in six patients but detected only one tumour each. Intraoperative palpation and ultrasound detected all tumours. If pre-operative imaging is required magnetic resonance imaging is the technique of choice to detect small endocrine pancreatic tumours.

A consecutive series of 227 inguinal hernias were repaired under local anaesthetic between 1976 and 1978 in the Oxford hospitals. A total of 187 of these operations was performed on a day-case basis. Data were available for analysis from 183 cases in whom there were 13 recurrences. The factor most strongly influencing the recurrence rate was the experience of a particular surgeon with the local anaesthetic technique. It was found that once 6 hernias had been repaired under local anaesthetic the chance of recurrence fell to a level of 2.5 per cent (which projects to 7.5 per cent at the end of 25 years). The recurrence rate for beginners (those who have repaired less than 6 hernias under local anaesthetic) was unacceptably high at 9.4 per cent (which projects to 28 per cent at the end of 25 years). Our recurrence rate was high in patients with a direct hernia in whom there were associated risk factors known to predispose to recurrence.