Wide-Awake Surgery

Wide-Awake Surgery

How one technique is changing the game for hand operations

When Joanne Falco lost feeling in her left hand in 2017, she knew she’d have to schedule carpal tunnel surgery yet again. A prolific crafter who uses her hands daily, Falco had been plagued by carpal tunnel syndrome for the past decade — and she was not looking forward to another operation.

She hated the idea of stepping into a hospital and prepping for the surgery, which releases a pinched nerve that causes pain and motor limitation in the hand. So when orthopedic surgeon Paul Papierski, MD, of Chicago Hand & Orthopedic Surgery Centers, said he could repair her carpaltunnel in his office using local anesthesia, she immediately signed up. “I thought, as long as the office is clean and sterile, then that’s the way I want to do it,” Falco says.

In-office surgery

Traditionally, any kind of hand surgery, including carpal tunnel surgery, takes place in the operating room of a hospital with a tourniquet affixed to the patient’s arm to reduce blood flow. The patient is completely sedated with general anesthesia, and a medical team performs the operation.

But the technique that Falco chose, called WALANT surgery (Wide Awake Local Anesthesia No Tourniquet), is quickly gaining popularity in the United States for its effectiveness and ease. Surgeons have also successfully used the WALANT technique to repair tendons and treat hand and finger fractures.

The WALANT method is quick and easy. In the doctor’s office, a surgeon injects lidocaine, a numbing agent, with a small needle. The surgeon then injects epinephrine into the patient’s hand, which has a similar effect to a tourniquet in that it reduces blood flow. When the area is sufficiently numb, and with the patient awake, the surgeon begins the procedure. Afterward, the patient is immediately able to go home.

With its use of in-office local anesthesia,the surgery is almost like going to the dentist, Papierski says — and patients love it.

“Almost uniformly, my patients will say, ‘Boy, that was so much better than when I had to go under!’” Papierski says. And because wide-awake surgery is simpler and less expensive than the traditional method, he frequently recommends it to his patients.

“Gas anesthesia has risks,” he says, along with discomfort to patients who often wake up feeling groggy, nauseous and in pain. “I find that it’s actually saferto do [wide-awake surgery] with my sicker patients or patients who are older.”

A safe surgery

At NorthShore University HealthSystem, orthopedic surgeon Robert Gray, MD, has performed so many wide-awake surgeries that he invented a syringe gun that better delivers the local anesthesia. He sees many benefits to the wide-awake technique.

Wide-awake surgery with local anesthesia “leads to shorter time in the hospital for the patients, lower overall cost to the patients and the insurance company, and a greater ability to evaluate my work while still having the ability to change it,” he says.

“When doing tendon repairs or tendon transfers, I can make sure everything works properly before leaving the operating room, because the patient can give me feedback right away.”

What’s most interesting about the WALANT method is that it’s nothing new, says Patrick Reavey, MD, assistant professor of surgery and orthopedics at UChicago Medicine. Hand surgery with local anesthesia has long been performed, but it hasn’t always been considered safe. Until the 1950s, doctors mistakenly believed that using epinephrine during hand surgery would cause nerve and tissue damage.

“It’s an old-school belief that you shouldn’t use epinephrine near the fingers,” Reavey says. “But there are people who have spent their careers doing this safely. Enough surgeries have been done to demonstrate that, in the appropriate patient, [the WALANT method] should not cause those devastating complications.”

“The biggest advantages are the convenience to the patient,” Reavey adds, ticking off the benefits: less time waiting in the hospital, no food restrictions the day of surgery, the ability to drive oneself to and from surgery, immediate recovery after surgery and the ability to return to work the same day. Costs are also less without an anesthesiologist.

With its use of in-office local anesthesia, the surgery is almost like going to the dentist.”

But while the WALANT method is simple and generally very safe, Reavey cautions that it’s not appropriate for all patients. “In patients with evidence of blood vessel disease or Reynaud’s disease, we wouldn’t do this,” he says. But for healthy patients with no evidence of disease, the risks of the surgery are “no different” from traditional surgery, plus there’s not the risks from general anesthesia.

Papierski agrees that wide-awake surgery is not for everyone. “If patients have a lot of anxiety in general, and they don’t like the sight of blood or knowing what’s going on, [they] are probably better with sedation.” Patients who are fearful of needles might also have difficulty with the wide-awake method, Papierski says, although the needles are generally much less painful than those used for a standard injection.

“We use a really skinny needle, and it’s amazingly small. It’s not as bad as a bee sting by any means, and it’s probablymore like a mosquito bite,” he says. “We inject the anesthetic in a really gradual way before moving the needle elsewhere.Nobody feels a second needle stick.”

Wide awake hand surgery infographic

Convenience considerations

After two previous carpal tunnel surgeries, Joanne Falco thought the WALANT method seemed like the easiest way to go, so she agreed to try it — and the result was positive.

“It was just a really casual experience,” Falco says. “We were listening to soft background music during it.” Between the general sedation she experienced a decade ago and the WALANT method she had in 2017, Falco says the WALANT method wins by a mile.

“I really prefer the local, the way Dr. Papierski did it,” she says. “It was much less stressful — just no big deal.”

Immediately after the operation, Falco went home with her husband to recover, free of the nausea and dizziness she has experienced in the past after surgery. Six weeks later, Falco was back to crafting again, her hands at full function thanks to Papierski and the WALANT method.

Above photo: Robert Gray, MD, delivers local anesthesia to a patient with a syringe gun before performing wide awake surgery. Courtesy of the NorthShore Orthopaedic Institute

Originally Published in the Spring/Summer 2018 issue