Pancreatic endocrine neoplasias (pNENs) are uncommon but fascinating tumors with a rising incidence. In accordance to its location, size and grading, the decision to operate the patient should always be made in an interdisciplinary approach. This article provides a comprehensive review of the current literature addressing the current challenges in pNEN surgery and shows that patients with completely resected small pNENs generally have an excellent prognosis, but also that surveillance may be a powerful tool.