Wide Awake Hand Surgery

Many hand surgery procedures such as carpal tunnel release, tendon repair and removal of masses can now be performed under local anaesthesia alone, avoiding sedation or general anaesthesia. 

The technique is sometimes performed as day surgery, known as wide-awake local anaesthesia, no tourniquet (WALANT), or with a tourniquet.

The key is lidocaine with epinephrine: typically 0.5 to 1 percent lidocaine 1:100,000 or 1:200,000 with epinephrine. Epinephrine extends the action of local anaesthesia and, as a vasoconstrictor, controls bleeding. 

For decades, dentists have safely used lidocaine with epinephrine to control bleeding during procedures. Although surgeons were long taught that the use of epinephrine with lidocaine was unsafe in hand, multiple well-executed studies have disproved that myth. The ability to safely control bleeding and extend the duration of local anaesthesia allows hand surgeons to perform many procedures with minimal bleeding and without sedation, general anaesthesia or a painful tourniquet to control bleeding. 

Wide Awake Surgery also be used safely in patients with medical complications or take blood thinner medications — factors that might otherwise preclude surgery.

The majority of the hand and wrist surgery we perform, when required, is “wide-awake, under local anaesthesia”. 

Occasionally, we will have to put a patient to sleep or put their arm asleep with a block. Still, we increasingly like to use local anaesthetic techniques.

 There are many advantages as it is beneficial when we need bio-feedback during the operation. One example is to move the fingers with a trial implant in place during joint replacements. If the range of movement is good and the implant feels stable, then the definitive implant will be put in. 

Once you have had your procedure, you will be taken back to the ward. If it is under local anaesthetic well, you will be on your way pretty soon out of the hospital, probably within an hour or so, which is not the case for general anaesthesia. 

Why is it done?

There are many advantages to performing WALANT hand surgery over general surgery which is why it is a popular choice for many surgeons.

The advantages of WALANT are:
 Advantages of “wide awake” hand surgery help both the patient and the hand surgeon.
⦁ No immediate post-operative pain
⦁ No post-operative grogginess or nausea 
⦁ Earlier discharge from the hospital may occur with a general anaesthetic.
⦁ More dynamic Surgery and Prof Imam can interact in real-time with his patient and the tissue he is operating on. 
⦁ It can sometimes be performed in the surgeon’s office rather than in an operating room
⦁ It avoids the complications and side-effects of general anaesthesia or sedation
⦁ You won’t be required to fast before the operation
⦁ The duration of the local anaesthetic injected into the hand can be extended if needed
⦁ The ability for you to move your fingers during the operation can be very helpful for surgeons
⦁ It can be carried out on patients with underlying medical problems who otherwise can’t undergo major surgery
⦁ Recovery is much shorter and you can return to normal activities quicker
⦁ The anaesthetist and nursing staff are no longer needed which represents a huge saving in time and money
⦁ The medical waste produced from this procedure is much lower so it is better for the environment

What conditions is this procedure used for?

Not every procedure can be performed using WALANT hand surgery, however, there is still a wide range of conditions for which it can be used:
Arthritic conditions
Nerve problems
⦁ Ligament repairs
Tendon disorders or repairs in the elbow, forearm, hand and wrist
Trigger finger release
Carpal tunnel release
⦁ Fracture fixation
⦁ Removal of masses
⦁ Soft tissue problems

What happens during the procedure?

The procedure is typically performed in the clinic setting. Upon arrival, the surgeon will discuss and detail the operation plan to you.
 Shortly before the operation, a mixture of local anaesthetic and very dilute adrenalin is injected into your hand to numb it. Normally, in conventional general anaesthetic hand-surgery, a tourniquet is used on your upper arm to stop too much blood flowing into the hand during the operation. However, in WALANT hand surgery, the small amount of adrenalin in the local anaesthetic solution temporarily restricts the fine blood vessels in the hand, which allows the operation to be performed without the need for a tourniquet.
 The skin will go white around the area of the injection but this does not stop larger arterial or venous blood flow. Your surgeon will then wait up to 15 minutes before making an incision on your hand. In the meantime, they will clean your hand thoroughly to prevent the chances of infection.
 Once the surgeon has completed the operation, they will clean the hand and close the incisions using stitches, which you will be able to see as you will be awake.

What is the recovery like?

The recovery depends on the type of surgery you had, but generally, it is very quick. Once the procedure is completed, you will be able to straight away talk to your surgeon about the subsequent steps. 
You will need to rest your hand and give it time for the incision wounds to heal before using it normally again. This may take between 7-10 days. You might also have to return to the doctor’s office to have the stitches removed.

Are there any possible complications?

There aren’t many complications and it’s rare for any to arise. However, some people have reported that their finger remains white (less blood flow) for up to four hours after the surgery, in which case, you should massage and try to rewarm the digit. If this doesn’t work, you may have to return to see the surgeon who will inject phentolamine at the same injection sites to reverse the effects of the local anaesthetic and adrenaline injection.

For more details, you can discuss that option in more details with Prof Imam or a member of the team

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