Background: There is debate regarding the optimal management of small-bowel neuroendocrine tumours (SBNETs), particularly concerning upfront resection in various clinical presentations. While symptom phenotypes are known to influence survival, their impact on technical surgical quality—especially in the emergency setting—remains poorly defined. This study evaluates whether symptom phenotype compromises the delivery of guideline-concordant surgical care. Methods: A retrospective analysis of 108 consecutive SBNET resections (2000–2023) at a specialized tertiary centre was performed. Patients were stratified into four phenotypes: obstructive/perforation (n = 54), carcinoid syndrome (22), asymptomatic/incidental (22), and other symptoms (9). Operative metrics, including lymph-node harvest (LNY) and margin status (R0/R1), were compared alongside overall survival (OS). Results: Symptom phenotype was a predictor of operative urgency and approach. Obstructive cases required emergency surgery in 50% of instances compared to ≤11% in all other groups (p < 0.001). Synchronous liver metastases were most prevalent in the carcinoid syndrome phenotype (50%) and lowest in the asymptomatic group (5%) (p = 0.002). Despite these disparities in presentation and urgency, technical quality markers were uniform across all groups : median LNY ranged from 10 to 13 p = 0.426), R1/R2 margin rates were statistically similar ($p = 0.290$), and median length of stay was 8 days for all cohorts (p = 0.311). Multivariable analysis identified the asymptomatic phenotype as independently protective for OS (HR 0.42, p = 0.032), while liver metastasis was the strongest adverse prognostic factor (HR 3.25, $p < 0.001$) Conclusions: Symptom phenotype dictates operative urgency and reflects disease burden but does not compromise the technical standards of surgery in a specialized unit. These findings suggest that high-quality, guideline-concordant lymphadenectomy is achievable even in emergency obstructive presentations, and correspondingly, access to specialized surgical oncology expertise may be sought even in obstructed patients to ensure technical quality is maintained.