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To analyze the characteristics and outcomes following enucleation and pancreatic resections of insulinomas.Retrospective cohort study; prospective database.Academic, tertiary, and referral centers.Consecutive patients with insulinomas (symptoms of hyperinsulinism and positive fasting glucose test) who underwent surgical treatment between January 1990 and December 2009.Operative morbidity, tumor recurrence, and survival after treatment.A total of 198 patients (58.5\% women; median age, 48 years) were identified. There were 175 (88\%) neuroendocrine tumors grade G1 and 23 (12\%) neuroendocrine tumors grade G2. Malignant insulinomas defined by lymph node/liver metastases were found in 7 patients (3.5\%). Multiple insulinomas were found in 8\% of patients, and 5.5\% of patients had multiple endocrine neoplasia type 1. Surgical procedures included 106 enucleations (54\%) and 92 pancreatic resections (46\%). Mortality was nil. Rate of clinically significant pancreatic fistula was 18\%. Enucleations had a higher reoperation rate compared with pancreatic resections (8.5\% vs 1\%; P = .02). Multiple endocrine neoplasia type 1 was significantly associated with younger age at onset (P < .005) and higher rates of malignancies and multiple lesions. Median follow-up was 65 months. Six patients (3\%; 5 patients had neuroendocrine tumors grade G2) developed tumor recurrence. Four patients (2\%) died of disease. New exocrine (1.5\%) and endocrine (4\%) insufficiencies were associated only with pancreatic resections.Outcomes following surgical resection of insulinomas are satisfactory, with no mortality and good functional results. Recurrence is uncommon (3\%), and it is more likely associated with neuroendocrine tumors grade G2. Insulinomas in multiple endocrine neoplasia type 1 are at higher risk for being malignant and multifocal, requiring pancreatic resections.