(wide awake local anesthesia no tourniquet)
Imagine having hand surgery without having to go to an operating room, fasting the night before or even changing out of your clothes. Wide awake hand surgery is well described by its other name, WALANT, which stands for wide awake local anesthesia no tourniquet. This surgical technique utilizes lidocaine and epinephrine to eliminate pain and decrease bleeding. With this approach there is no need for intravenous insertion, monitoring or a tourniquet.
This technique was championed by Dr. Donald Lalonde, a Canadian plastic surgeon who observed the safe use of lidocaine with epinephrine during his training in the 1970’s. In the 1920’s there was a well held belief that epinephrine (a medication that constricts blood vessels) was not safe to use in the hand because of the risk of finger necrosis. A landmark paper by Dr. Keith Denkler dispelled the epinephrine myth. Before 1948, when lidocaine became available, the only local anesthetic was procaine. Before expiration dates were mandated by the FDA in 1979, procaine left on the shelf turned very acidic. More fingers necrosed with procaine without epinephrine than occurred with procaine combined with epinephrine, but epinephrine was blamed for the adverse effects because of its vasoconstrictive effect. This led to the development of phentolamine, an epinephrine vasoconstrictor rescue agent, in 1957.
After reading Denkler’s paper, Dr. Lalonde began to utilize lidocaine with epinephrine for all his hand surgeries in fingers with good fingertip blood supply. In 2005 he published a study of 3100 consecutive hand surgeries using epinephrine with no lost fingers or need for phentolamine. In 2017 Dr. Jin Bo Tang reported over 5000 cases with no cases of finger loss or phentolamine use.
WALANT is a safe and effective surgical technique that has many patient benefits that include:
-no nausea, vomiting, urinary retention, or other unwanted side effects associated with opiates or sedation
-less time in the hospital after the procedure
-no need for a tourniquet (helpful in patients with lymphedema or arteriovenous shunts)
-no need for preoperative testing
-no need for an IV
-no need to fast
-no need to stop anticoagulation medications in most cases
-no need to get undressed
Wide awake hand surgery is being practiced by an increasing number of hand surgeons in several countries. The use of this technique will continue to increase in the future because it is safer, more convenient for patients and surgeons, and more cost effective. Currently it is being used for some but not all hand surgeries.