Chapter 2 What Is Wide Awake Hand Surgery?

10.1055/b-0037-142173

Chapter 2 What Is Wide Awake Hand Surgery?

Alistair Phillips, Nik Jagodzinski, Donald H. Lalonde

Wide awake hand surgery is well described by its other name, WALANT, which stands for wide awake local anesthesia no tourniquet. The only two medications most patients are given for wide awake hand surgery are lidocaine for anesthesia and epinephrine for hemostasis. We inject tumescent lidocaine and epinephrine in large enough volumes to be visible or palpable wherever dissection will be done (see Chapter 3). This is a form of extravascular Bier block injected only where you need it, but without the painful tourniquet.

Clip 2-1 Introduction to wide awake hand surgery.

Lidocaine and epinephrine are probably two of the safest and most widely tested injectable drugs that are used in humans (see Chapters 3 and 6). Dentists have injected billions of doses of these two medications in their offices since 1950 with no preoperative testing, no monitoring, no intravenous insertion, and very few adverse events.
Like dental procedures, we can perform wide awake hand surgery with no preoperative testing, no insertion of an intravenous line, and no monitoring, because the only medications we inject are lidocaine and epinephrine. After the procedure, the patient simply gets up and goes home.

Traditional surgery performed with general anesthesia and a tourniquet.

PATIENTS LOVE WALANT

They have no nausea, vomiting, urinary retention, or other unwanted side effects associated with opiates or sedation.
They spend less time at the hospital for the procedure, because postoperative recovery time is just minutes, since they receive no sedation and no opioid medications. They can just get up and go home, as they would do after a visit to the dentist.
They have no need to have someone stay with them the evening after the surgery. Following outpatient procedures with general anesthesia in many facilities, patients are required to have a responsible adult stay with them for 12 to 24 hours. This is difficult for many patients, especially if they have children.
Patients get to know and talk to their surgeon during the surgery for advice on how to care for the hand postoperatively, time off work, and other issues.
There is no downtime from work or need for a babysitter when they go for preoperative testing for sedation on a day before the surgery.
Hand surgery under pure local anesthesia is not expensive. Many patients in developing countries could afford hand surgery if they did not have to pay the large costs associated with sedation and general anesthesia in the main operating room.
Patients do not have to obtain an unnecessary ECG or chest radiographs, attend an anesthesia consultation, or undergo preoperative blood tests.
There is no unnecessary insertion with a 20-gauge intravenous cannula. All the patient will feel is a single brief prick with a 27- or 30-gauge needle in the hand when the local anesthetic is injected (see Chapter 5).
Patients can see repaired structures working during the surgery after a loss of function such as tendon laceration, tenolysis, tendon transfer, hand fracture, or Dupuytren′s contracture. This visual memory helps motivate them throughout postoperative therapy and recovery.
Patients do not need to endure a tourniquet for even 5 minutes. We tell all our trainees that they need to put a tourniquet on their own arm or forearm for 5 minutes before they ever say, “Patients tolerate it well.” The true meaning of this phrase might be, “Patients let me do it, even though it hurts.”
The fact that there is no need for a tourniquet is advantageous in patients who have lymphedema or arteriovenous shunts in the forearm.
Patients do not need to fast or change medication schedules before the procedure, which is particularly helpful for diabetic patients.
Patients with sore elbows, shoulders, or backs can position themselves comfortably for hand and elbow surgery, because there is no tourniquet or anesthesiology equipment preventing them from shifting out of an uncomfortable position. They can easily turn on their side during the procedure.
Patients do not need to get undressed for surgery when we use field sterility.
WALANT is safer for patients than sedation, especially for individuals with medical comorbidities. All anesthesiologists agree that less sedation is safer sedation. The safest sedation is no sedation.
Surgeons are less likely to operate on the wrong hand or the wrong finger if the patient is wide awake with no sedation.
Trauma patients can undergo surgery during the day in minor procedure rooms instead of in the middle of the night in the main operating room. They do not need hospital admission to wait for or recover from sedation. Surgeons and nurses are more likely to be able to perform surgery well when rested during daytime hours than while tired at night.
There is no need to discontinue anticoagulation medication in most cases, because the epinephrine provides enough hemostasis that the wound dries up nicely.
It is possible to see a patient in consultation and operate on him or her the same day, because there is little to no preoperative workup required for pure local anesthesia. This is much less expensive and more convenient for patients who have to travel long distances to the surgeon′s clinic or office.