By David I. Katz, MD
Hand surgeons have the ability to perform surgery without general anesthesia, sedation, or the need for a tourniquet on the arm. Local anesthetic is gently injected into the affected area of the wrist, hand, or fingers – similar to how dental or dermatologic procedures are performed. During surgery, the patient remains alert and comfortable, while afterwards patients can get up and go home without any of the side effects of sedation. This form of surgery has come to be known by its acronym WALANT, which stands for: wide awake local anesthesia no tourniquet.
WALANT offers significant advantages for patients. While modern anesthesia is one of the safest areas of medicine, there are always potential side effects and risks with sedation and general anesthesia. This is especially true for individuals with multiple medical problems. Less sedation is safer than more sedation – and the safest sedation is no sedation at all.
Before surgery involving anesthesia, many patients are required to go to the hospital or surgery center for tests and/or lab work. With WALANT, there is no need for preoperative testing since patients do not receive sedation. This eliminates the need to take even more time off work or school before surgery.
The night before surgery typically means having nothing to eat or drink after midnight, including the morning of the procedure. This requirement is important for patients receiving sedation or general anesthesia. However, with WALANT, patients can eat and drink normally the morning of surgery as they will not receive any of the typical anesthesia medicines. This is particularly helpful for diabetic patients and patients on blood thinners, as they can follow their typical diet and medication regimens around the time of surgery.
Surgery with sedation commonly involves starting an IV in the arm. For patients undergoing wide awake hand surgery, there is typically no need for an IV – discomfort is limited to a single brief prick of a small needle to numb the hand. WALANT also eliminates the need for a tourniquet on the arm which can cause some degree of soreness after surgery.
Lidocaine and epinephrine (the typical combination of medicines used in WALANT) are two of the safest and most widely tested injectable drugs used in humans. Since 1950, dentists have injected literally billions of doses of these same two medications in their offices with no preoperative testing, no IV insertion, and very few side effects. Over the last 20 to 30 years, hand surgeons have established the safety of injecting lidocaine and epinephrine into the wrist, hand and fingers.
During the procedure, patients who are awake and alert have the added advantage of being able to talk to their surgeon. This time is well spent discussing the postoperative care of the hand and how to avoid complications. Patients should feel free to ask their surgeon questions about the procedure as well as things to look out for afterwards. At times patients may even be able to see their anatomy which can help with their recovery. None of this is possible when asleep or sedated during a typical operation.
Without sedation, patients avoid many of the possible undesirable side effects associated with anesthesia and opiates. After wide awake hand surgery, there is no nausea, vomiting, urinary retention, or constipation. This means less time in recovery at the hospital or surgery center. Most patients are able to simply get up and go home after WALANT.
Wide awake hand surgery has meant greater convenience, less expense, and lower risk for many patients. While WALANT is possible for a variety of procedures, it is not feasible for all surgeries. Additionally, some patients may not be suitable candidates to undergo wide awake hand surgery – and other individuals may simply choose to have anesthesia for their operation. There are many different factors that go into the decision to have wide awake hand surgery. If interested, feel free to ask your surgeon if it is a good option for you!
Dr. David Katz is a board certified orthopedic surgeon specializing in the treatment of the hand, wrist and upper extremity. His research in the field of orthopedics has been published in leading medical Journals and has been presented at multiple national meetings. Dr. Katz specializes in both the operative and non-operative treatment of hand, wrist and upper extremity conditions.