Insulinomas are rare pancreatic neuroendocrine tumors, with 0.7–4 cases per million people per year. Their pathology stem from autonomous production of insulin, which can lead to episodes of profound hypoglycemia. Many are benign and amenable to surgical cure. However, a persistent challenge arises when presented with an occult insulinoma—biochemical evidence of a tumor without definitive preoperative localization. This chapter reviews current evidence and clinical rationale for managing non-localized insulinoma focusing on surgical exploration versus medical management. The risks and benefits of each approach are thus. Surgical excision, supported by intraoperative ultrasound (IOUS) and bimanual palpation, identifies lesions in over 90% of occult cases and achieves biochemical cure in nearly all identified. However, exploration involves considerable morbidity, including pancreatic fistula, intra-abdominal abscess, delayed gastric emptying, hemorrhage, wound infection, diabetes mellitus, and pancreatitis. Medical therapy with agents like diazoxide or somatostatin analogs can achieve symptomatic control, but in only 50–60% of cases, and has its own associated risk. While alternative endoscopic ablation techniques have emerged as minimally invasive alternatives, the evidence remains limited to small case series. Despite imperfect preoperative localization and potential morbidities, surgery remains the preferred approach in most cases of occult insulinoma. However, the decision requires ethical balancing between procedural morbidity, diagnostic uncertainty, quality of life, and patient preferences. In choosing between non-operative management of non-localized insulinomas and surgical exploration, we recommend surgical exploration. Surgery is overwhelmingly successful, with limited mortality while medical management mitigates symptoms in as few as 50% of cases. Increasing success of IOUS provides strong additional support to the surgery approach, even without definitive pre-operative localization or regionalization. We also recommend that surgical management of non-localized tumors proceed at high-volume centers with extensive experience.