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Is Wide-Awake Hand Surgery Right for You?

Surgery on hands, wrists and more, done without anesthesia, is growing in popularity with doctors and patients alike

By Barbra Williams Cosentino

You're comfortably ensconced in a reclining chair with your right arm, hand facing upward, extended on a padded board at your side. Your surgeon is sitting next to you, deftly gliding a scalpel near your finger as the two of you discuss baseball, vacation plans and the merits of dark chocolate versus bittersweet. Soft music plays in the background. After a while, the surgeon instructs, "Spread your fingers as wide as you can for me," and you do so.

A person during a wide awake hand surgery appointment. Next Avenue, wide-awake hand surgery
Wide-awake hand surgery is done with regional or local anesthetic given by the surgeon, so no anesthesiologist needs to be present  |  Credit: Getty

The procedure is almost over. "Good job," the doctor says cheerily, as he stands up and removes his sterile gloves. You get up from the chair, say a hearty thank you, and soon, hand surgery done, you're in your car, driving home. Driving yourself home.

According to data presented at the 2022 Annual Meeting of the American Association for Hand Surgery, WALANT, the acronym for Wide-Awake Local Anesthesia No Tourniquet Surgery, has grown in popularity. This is due to its cost savings, safety, positive outcomes and a high patient satisfaction rating.  

Wide-awake hand surgery is done with regional or local anesthetic given by the surgeon, so no anesthesiologist needs to be present.

Wide-awake hand surgery can be used for a number of hand and wrist procedures, some of which include carpal tunnel release surgery, trigger finger and most other finger surgeries, Dupuytren's contracture release, removal of cysts and some tumors, tendon transfers and releases, and flexor tendon repairs. 

Benefits for Hand or Wrist Procedures

"Because of the lack of general anesthesia, we have no concerns that a cardiac or pulmonary condition would preclude you from having surgery," says Dr. Karan Desai, a hand surgeon at Orlando Health Jewett Orthopedic Institute, who specializes in hand and upper extremity surgery as well as microsurgery. 

Wide-awake hand surgery is done with regional or local anesthetic given by the surgeon, so no anesthesiologist needs to be present. Lidocaine or Bupivacaine, local anesthetics that numb the area, and epinephrine, which causes constriction of blood vessels, are injected into the surgical site.

The use of epinephrine decreases the amount of bleeding, making an almost bloodless operative field. It also eliminates the need for a tourniquet and its attendant risks, including hematoma formation (collection of blood) and damage to upper extremity muscles, neurovascular structures and the skin.

A common myth is that there is a high risk of digital ischemia (inadequate blood flow to the fingers) with epinephrine, but many studies have shown the safety of using the lidocaine-epinephrine combination in controlled amounts. 

Why Wide-Awake Hand Surgery?

According to Desai, "WALANT allows the surgeon to make intra-operative assessments by having patients move their fingers through the full range of motion during the procedure. Particularly in a tendon repair, where there is the risk of a postoperative rupture, the likelihood of gapping can be assessed, and minute corrections made as necessary."

Having the patient able to actively participate has been found to be associated with the excellent clinical outcomes reported with wide-awake hand surgery.

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Pain Can Be Minimized - Plus, You Can Watch

Other benefits of Wide-Awake Local Anesthesia No Tourniquet surgery include:

·      EKGs, chest x-ray or preoperative blood tests are unnecessary.

·      Patient can eat breakfast and take usual medications (some surgeons prefer that the patient consult with their cardiologist about stopping blood-thinners several days before surgery).

·      No intravenous is needed. 

·      Lack of general anesthesia increases safety for patients with cardiac, pulmonary or other medical conditions, and reduces postoperative nausea, vomiting and grogginess.

·      Patient can watch surgery if desired (appreciated by proponents of patient autonomy) and, by observing, may better understand the expected results and the need for postoperative hand rehabilitative procedures.

·      Wide-awake hand surgery has been found to decrease the risk of adhesion formation. 

·      Less postoperative pain and reduced need for opioids for pain relief.

The majority of children and many adolescents will be unable to stay still enough to tolerate the procedure. Other contraindications to WALANT include extreme anxiety, peripheral vascular disease or previous vascular injury, clotting or bleeding disorders, hypersensitivity or allergy to lidocaine, ongoing infection, polytrauma or surgeon's anticipation of an extremely complex, time-consuming operation that will take more than two hours.

Procedures Increased During Pandemic

Introduced more than ten years ago by Canadian hand surgeon Donald H. Lalonde, WALANT gained increased popularity during the global pandemic, when non-urgent and elective in-hospital surgeries were being postponed to preserve resources and staff.

Wide-awake hand surgery can be done in a physician's office without an anesthesiologist present since the patient receives no sedation and no general anesthesia and therefore needs no intubation or frequent monitoring of vital signs.

During the height of the COVID crisis, a variety of procedures were done in what was referred to as a Low-Resource Operating Room (LROR) using local and regional anesthetic techniques within a hospital. This utilized many fewer surgical supplies, sterile draping, health care personnel and other resources that would be normally used for surgery with an unconscious patient.

Wide-awake surgery is a particular boon for those who might be less likely to have traditional surgery because of comorbid medical conditions or advanced age.

One regional medical center in Annapolis, Maryland, performed sixteen wide-awake hand surgeries in April 2020. The procedures varied and addressed disease or disorders of varying body parts including the hand, thigh, knee, ankle and foot. While anesthesiologists were present for more than half of the cases, there were no incidents when the surgeon had to switch mid-procedure to general anesthesia. 

Wide-awake surgery without general anesthesia (and without the use of conscious sedation, which is used for colonoscopies and certain tests and procedures) has been done before, with Cesarean sections for a baby's delivery being the most obvious one.

Certain types of neurosurgery (surgery on the brain to treat conditions such as tumors) is performed with an awake patient because as the surgeon is operating on specific areas of the brain which control movement or speech, the patient can be asked to speak or move a body part. 

Relatively recent use of wide-awake surgical methods, which are cost-effective and allow the patient to avoid the possible negative effects of general anesthesia, include those done for orthopedic procedures such as repairing ankle fractures or surgeries on the spine such as spinal fusions or laminectomies. While still performed relatively rarely, it is probable that they will gain favor as the benefits and positive outcomes are seen.

Wide-awake surgery is a particular boon for those who might be less likely to have traditional surgery because of comorbid medical conditions or advanced age.

"I've done WALANT surgery on a ninety-year-old with excellent results," says Desai. "This technique allows painful, debilitating conditions to be taken care of in a safe and effective manner."

barbra consentino, writer
Barbra Williams Cosentino RN, LCSW, is a psychotherapist in Queens, N.Y., and a freelance writer whose essays and articles on health, parenting and mental health have appeared in the New York Times, Medscape, BabyCenter and many other national and online publications. Read More
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