Wide-awake hand surgery

Sept. 22, 2017

Many hand surgery procedures such as carpal tunnel release, tendon repair and removal of masses can now be performed under local anesthesia alone, avoiding the use of sedation or general anesthesia. The technique — known as wide-awake local anesthesia, no tourniquet (WALANT) — is sometimes performed in the surgeon's office.

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 anesthesia 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 the hand, multiple well-executed studies have disproved that myth.

The ability to safely control bleeding and extend the duration of local anesthesia allows hand surgeons to perform many procedures with minimal bleeding and without the use of sedation, general anesthesia or a painful tourniquet to control bleeding. WALANT also can be used safely in patients who have medical complications or take blood thinner medications — factors that might otherwise preclude surgery.

"After incorporating wide-awake hand surgery in my practice, I've had patients specifically request this technique," says Julie E. Adams, M.D., an orthopedic surgeon at Mayo Clinic's campus in Rochester, Minnesota. "It's a game-changer in terms of quality of care and improved patient satisfaction."

At Mayo Clinic, WALANT is used for:

  • Trapeziectomy
  • Dupuytren's contracture release
  • Fracture fixation
  • Ligament repair
  • Osteotomy
  • Joint replacements in the fingers
  • Peripheral nerve procedures at the wrist and elbow
  • Tendon and soft tissue procedures in the elbow, forearm, hand and wrist

Advantages for patients

Avoiding sedation or general anesthesia during hand surgery typically:

  • Helps patients recover and return to normal activities more quickly
  • Prevents the possible side effects and complications of sedation or general anesthesia, such as nausea
  • Eliminates intravenous injections
  • Eliminates the need for the patient to stop or "bridge" anticoagulant medications such as warfarin

Costs for patients and the medical system, and the amount of medical waste, are generally lower with WALANT.

The wide-awake procedure also allows surgeons to assess and adjust tension for tendon transfers, check the integrity of tendon repairs, and look for gapping with active motion following flexor tendon repair.

"Postoperative pain and swelling are less," says Peter C. Amadio, M.D., an orthopedic surgeon at Mayo Clinic's campus in Minnesota. "I've also noticed that using this technique plus multimodal non-narcotic pain management protocols results in a decreased need for any postoperative narcotic analgesics."

Dr. Adams performs wide-awake hand surgery in the operating room in Rochester and also in her clinical office at Mayo Clinic Health System in Austin, Minnesota. "Patients sit in a reclining chair for their procedures," she says. "I typically mark and then inject them, and let them relax while the lidocaine with epinephrine takes effect. While the block sets up and the arm is prepped and draped, I see a few other patients in the clinic.

"I then do the WALANT procedure. Some patients listen to music or watch television, but other patients enjoy watching the procedure. It's a great way to get patients engaged in their own care," Dr. Adams says. "Afterward, most patients say they wish they hadn't waited so long to have surgery, and ask, 'Why would anyone go under sedation for this procedure?' "

"Many patients have thanked me after an operation," Dr. Amadio says. "But it was only after I started doing wide-awake surgery that patients began telling me they enjoyed the operation and learned something from it."

For more information

Adams JE. Top 10 reasons for staying awake during hand surgery. Speaking of Health. Mayo Clinic Health System. 2017.

Adams JE. What to expect: Carpal tunnel surgery in the clinic. Mayo Clinic.