The WALANT technique: the advantages of wide awake hand surgery

When undergoing hand surgery, you may be surprised to learn you can stay awake during the procedure. This is not painful and has many benefits over traditional surgery due to no general anaesthesia being needed. Mr Philip Mathew, a hand and wrist orthopaedic surgeon, explains what this safe method of hand surgery involves. Discover what this procedure is, its benefits, who can have it and its success rate.

What is WALANT hand surgery?

WALANT refers to a technique of providing pain relief for an operation. It stands for Wide Awake Local Anaesthetic No Tourniquet. Essentially, it means that you can be awake during the surgical procedure.

You will have injections to numb the area that you are going to have the surgery on and there will be no tourniquet required during this procedure. A tourniquet is a tight cuff that is usually applied on the arm and inflated to stop the blood flow. This reduced blood flow allows the surgeon to have a good visualisation of the area they will be operating on.

After the initial pain from the stab of the needle, you should no longer feel any pain. You will feel some of the movements made by the surgeon when the operation starts but this will not hurt - the injected medication mixture has additives that help with this. It takes about half an hour from the time of injection for the full effects to manifest. We wait for this period prior to taking you in to have the surgery so you are completely comfortable during the procedure.

Some patients prefer to listen to music and others prefer to chat with the surgeon. More recently, specialist centres offer virtual reality headsets so that you can keep yourself distracted or entertained during the entire procedure.

How does it compare to the more traditional methods?

Unlike WALANT surgery, more traditional operations are done under a general anaesthetic or regional anaesthetic. Both involve additional measures.

General anaesthetic is where an anaesthetist gives you medication through an intravenous cannula (needle) into your arm to make you go to sleep. They then insert a tube down your throat to help you breathe. This anaesthesia requires you to:

1. Have a pre-assessment check to determine your safety to have a general anaesthetic
2. Stay starved for 4 to 6 hours before surgery
3. Have a tourniquet on your arm
4. Stay in hospital for 3 to 4 hours after the surgery to ensure the effects of the anaesthetic have worn off
5. Have someone take you home after the procedure

Some patients may experience a degree of nausea and soreness at the back of the throat when they wake up from the anaesthetic.

A regional anaesthetic is where an anaesthetist gives an injection (usually under ultrasound guidance) to numb the nerves in the neck or in the upper arm. They will put an intravenous cannula (needle) into your arm and may, in certain cases, give some medication to sedate you. This anaesthesia requires you to:

1. Have a pre-assessment check to determine your safety to have a regional anaesthetic
2. Stay starved for 4 to 6 hours before surgery - in the rare event that the pain block does not work, you may need to have a general anaesthetic
3. Have a tourniquet on your arm

The entire arm can stay numb for 8 to 10 hours and will feel like a dead weight during this period. You may also need to top up with adequate pain killers before the anaesthetic wears off.

What are the advantages of WALANT hand surgery?

WALANT has quite a few advantages when used for the right patient:

1. There’s no need for an extra trip to the hospital for pre-admission tests
2. There’s no need for intravenous cannula insertion
3. As there is no recovery time, less time is spent at the hospital
4. It’s not necessary for the patient to have someone to accompany them – this is often the case with sedation
5. You can talk to the surgeon during the surgery for post-operative advice on how to look after the hand and how much time you should take off work, etc.
6. You can watch parts of the procedure, if interested. The visual memory helps to motivate the patient in post-operative therapy and recovery
7. No need to have a tourniquet, which has been shown to cause pain if on for longer than 15 minutes
8. No need to alter, stop or change any of your regular medication
9. If the procedure takes a little longer, you can move or relax your arm to get comfortable again and then the surgeon can continue with the operation
10. You can sit up and leave after the surgery once your discharge paperwork is complete, without having to recover from sedation or a general anaesthetic.

Who can have this procedure?

This procedure is suitable for most patients undergoing surgery on the hand and wrist for conditions such as carpal tunnel decompression surgery, base of thumb arthritis surgery, trigger finger release and fracture fixation.

It may not be suitable for patients who:

• are needle phobic
• have an intellectual disability
• have significant bleeding disorders
• are very young (some older children may be suitable)

Very rarely, patients may be allergic to the anaesthetic itself and hence may be unsuitable. However, hand surgeons assess each patient carefully and discuss the option of using the WALANT technique before delivering any anaesthetic.

What is the success rate of WALANT?

WALANT, if done by a surgeon experienced in the technique, on the right patient for the right indications is a very successful procedure. It helps improve the patient’s experience and provides a good and safe alternative to the traditional technique of using a general anaesthetic.

Reference : doi:10.1186/1753-6561-9-S3-A81 Lalonde: Wide awake local anaesthesia no tourniquet technique (WALANT). BMC Proceedings 2015 9(Suppl 3):A81

Don’t hesitate to contact Mr Philip Mathew, a leading specialist in all areas of hand and wrist surgery, for professional advice. Click here to see his profile and get in touch.