Wide Awake Hand Surgery

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
76
•
The purpose o most preoperative testing is to increase the sa ety o
sedation rather than to con rm the patient’s readiness or surgery.
Patients there ore do not incur the cost o time away rom work or
getting a babysitter while they go or the preoperative assessment or
testing required or sedation, because this will not be needed with
WALANT.
•
Many acilities require patients to have someone stay with them the
evening and/or night o sedation. There are no “babysitter” require-
ments or patients who have wide awake surgery. Patients can go
home, look a ter their children, and resume their normal activities
without having someone accompany them to look a ter them as they
recover rom sedation.
•
Surgeons give patients intraoperative education that may well de-
crease their risk o complications and reoperation and there ore de-
crease the costs associated with these events.
•
It is possible to see a patient in consultation and operate on him or
her the same day, because there is little or no preoperative workup
required or pure local anesthesia. This is a signi cant cost savings or
patients who have to travel long distances to the surgeon’s acility.2
D ECREASED COSTS AN D IN CREASED REVEN UE
FOR TH E SURGEON
•
Many surgeons have negotiated with their insurance providers or gov-
ernments to receive a acility ee or permission to be reimbursed or
per orming carpal tunnel procedures with WALANT in their o ces.
Many providers are receptive to the concept o increasing patient
sa ety and convenience while decreasing costs.
•
Educating patients while you inject a local anesthetic and operate on
them is time you do not need to spend talking to the patient in the
o ce (see Chapter 8).
•
O ce minor procedure rooms can obtain accreditation by the Ameri-
can Association or Accreditation o Ambulatory Surgery Facilities
(AAAASF) in the United States and the Canadian Association or Ac-
creditation o Ambulatory Surgical Facilities (CAAASF) in Canada or
procedures using pure local anesthesia (no sedation). Accreditation or
an operating room that does not use sedation is much easier and less
expensive to obtain than accreditation or a acility that uses sedation
or general anesthesia. I you do not use sedation, the costs o equip-
ment and medications related to sedation disappear.

Ch apt er 11 ° Reven u es In c r ease an d Co st s D ec r ease Wit h WALAN T
77
D ECREASED COSTS AN D IN CREASED PROFITABILITY
FOR TH E H OSPITAL, OPERATIN G FACILITY, AN D TH E
SURGEON
•
I you remove all o the costs o sedation, you eliminate many ex-
penses o traditional hand surgery or the hospital or operating acil-
ity. These include the ollowing:
–
Anesthesiologist ees, their allied personnel salaries, and the cost
o their medications and equipment
–
In the operating room, salaries or extra nurses who would be re-
quired with sedation
–
Salaries or recovery room nurses, because patients simply get up
and go home a ter surgery
–
All o the personnel required to process the sedation (such as pa-
tient greeters and test and in ormation processors)
–
Preoperative ECGs, blood tests, chest radiographs, and the salaries
o those who per orm them
–
Perioperative medical consultation costs required or sa e sedation
in patients with medical comorbidities
–
Full sterility costs, which are our times higher than or eld steril-
ity or carpal tunnel surgery3
•
Requiring ewer personnel decreases the cost o having the slowest
person in the team increase turnover time. A team is only as ast as its
slowest member. Each additional team member required or an opera-
tion increases the risk that a slower person will get on the team.
•
You eliminate the problem o “no beds in recovery/PACU,” because
there is no “recovery” required rom pure local anesthesia with lido-
caine and epinephrine.
•
One study showed that we could per orm twice as many WALANT
carpal tunnel procedures in the same time simply by moving the cases
outside the main operating room to a minor procedure room with
eld sterility2 (see Chapter 10).
•
Turnover time is less with eld sterility than with ull sterility. It takes
much less time to set up the cases, walk in the awake patient, and
drape him or her.
•
There is no need to wash the f oor between 5-minute eld sterility car-
pal tunnel procedures or to pay an employee to wash that f oor.
•
At the hospitals in many cities in Canada (Saint John, Ottawa, Re-
gina, and Calgary), most o the hand trauma surgeries are per ormed
in minor procedure rooms outside o the main operating room with
eld sterility in daytime hours. Main operating room evening and
night time premium costs or doctors, nurses, and other personnel are
avoided.
•
The risk o litigation decreases, because trauma cases reconstructed
during daytime hours are less likely to end up with complications than
those operated on at 2 AM because o operator and sta atigue. In
addition, the bond that occurs between the surgeon and the patient
with good intraoperative communication and education also de-
creases the risk o patient discontent and litigation.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
78
•
There is less risk o wrong-sided surgery with awake, unsedated pa-
tients.
•
WALANT trauma surgery in an outpatient clinic or emergency depart-
ment means that there are no delays waiting or availability o an
anesthetist, a scrub team, or a main operating room.
•
Intraoperative testing or tendon gapping with active movement a ter
repair has decreased the need or and costs o reoperation or compli-
cations such as tendon rupture and tenolysis2,4 (see Chapter 32).
•
Less expensive draping and gowning is required or eld sterility (see
Chapter 10).
•
Disposal o blood-soiled garbage is more expensive than regular gar-
bage disposal. There is less waste disposal o drapes and gowns.
•
There is no need or patient gowns, paper ootwear, and hats, because
patients do not undress or eld sterility surgery.
D ECREASED COSTS AN D IN CREASED PROFITABILITY
FOR PAYERS: IN SURAN CE COMPAN IES AN D
GOVERN MEN TS
•
Eventually, insurance companies and governments will understand
that sedation is not necessary or many surgeries o the hand. They
will become receptive to the concept o increasing patient sa ety and
convenience while decreasing costs and unnecessary garbage produc-
tion.1,5 The payer saves all o the costs previously described.
•
Eventually, insurance companies and governments will become aware
o evidence-based medicine that supports the concept that much less
expensive eld sterility is sa e or many hand operations. This will de-
crease their costs by at least 75% 3 (see Chapter 10).
References
1. Bismil MS, Bismil QM, Harding D, Harris P, Lamyman E, Sansby L. Transition to total
one-stop wide awake hand surgery service-audit: a retrospective review. JRSM Short Rep
3:23, 2012.
2. Lalonde DH. Wide awake flexor tendon repair and early mobilization in zones 1 and 2.
Hand Clin 29:207, 2013.
3. Leblanc MR, Lalonde J, Lalonde DH. A detailed cost and efficiency analysis of performing
carpal tunnel surgery in the main operating room versus the ambulatory setting in Can-
ada. Hand (N Y) 2:173, 2007.
4. Higgins A, Lalonde DH, Bell M, McKee D, Lalonde JF. Avoiding flexor tendon repair rup-
ture with intraoperative total active movement examination. Plast Reconstr Surg 126:941,
2010.
5. Chatterjee A, McCarthy JE, Montagne SA, Leong K, Kerrigan CL. A cost, profit, and ef-
ficiency analysis of performing carpal tunnel surgery in the operating room versus the
clinic setting in the United States. Ann Plast Surg 66:245, 2011.

79
Ch a P t e r 12
Th e “Bu y In ”: Ad min ist r at io n ,
An est h esio l o g y, N u r sin g ,
an d Payer s
Julie E. Adams, Michael W. Neumeister, Robert E. Van Demark, Jr.,
Carolyn L. Kerrigan, Peter C. Amadio, Donald H. Lalonde
GEN ERAL STRATEGIES TO MAXIMIZE TH E CH AN CES OF
SUCCESS IN IMPLEMEN TIN G TH E CH AN GES REQUIRED
TO D EVELOP WALAN T IN IN STITUTION S
•
Wide awake hand surgery has many bene ts or patients, surgeons,
acilities, and payers (see Chapter 2). However, making the transition
rom surgery with sedation requires some adaptation. Developing a
strategy to generate institutional buy-in can enhance one’s ability to
implement this technique into practice.
•
Getting buy-in rom colleagues, administrators, and payers may
require your investing unpaid time to set up meetings with key indi-
viduals to show them PowerPoint presentations and appeal to their
common sense to do what is best or patients.
•
It is best to be prepared with a short but compelling discussion o
what you wish to do, why you wish to pursue this route, and what you
believe the advantages will be. Feel ree to show them the next video
clip.
h eLp ADmin iSt r At o r S, n u r SeS, An eSt h eSio Lo g iSt S,
An D pAy er S u n Der St An D WALAn t
•
We have discussed all o the advantages o WALANT versus traditional
surgery with sedation and tourniquet in Chapters 2, 8, 9, 10, and 11.
Show these chapters and videos to your colleagues, including the re -
erences rom those chapters, to support the concept.
•
Seek out and involve chie stakeholders rom the start. It is more
e ective to arrange one-on-one meetings with videos o PowerPoint
presentations with key decision-makers be ore getting into the com-
mittee level.
•
Present a succinct but compelling case or why you think it is better or
patients, the acility, and other stakeholders.
•
Show them the evidence you have or why this is a better way.
•
Show them the evidence you have or why it is sa e and e ective.
Clip 12-1 Why
patients love
WALANT.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
80
•
Present it in a respect ul way, being certain to listen care ully to objec-
tions and concerns.
•
Validate their challenges in making change as you address those con-
cerns.
•
Be open to discussion and ask the stakeholders what they need rom
you to make this work. This can go a long way toward garnering
goodwill and buy-in.
•
It is best to make it a “win-win-win” situation or the stakeholders as
well as or you and your patients. Consider the perspective o your a-
cility colleagues and appeal to their needs.
•
Be f exible to accept and welcome (or even suggest) small steps to-
ward the desired goal. I leadership will not allow you to start doing
wide awake hand surgery in the ull extent you desire, but will allow
you a trial period or to do so within a more limited basis, that is still a
step orward which should be welcomed. As sta and leadership be-
come amiliar and com ortable with wide awake surgery, the indica-
tions and use can expand.
•
Some compelling arguments include that you can improve patient sat-
is action ratings, bring more work to the acility, increase the number
o patients and cases done in a day, decrease the sta count or many
procedures, open up ORs or “bigger” cases, and decrease the amount
o wasted materials.
•
In some acilities, suggestion o a “pilot study” or “quality improve-
ment project” or “new patient-centered care initiative” to validate
what others have done in the literature may help to dissolve resis-
tance.
•
Some sample narratives include the ollowing:
“Would it be OK to try this on a ew select patients and see how
things go?”
“Let’s do all the monitoring you want initially, and then see i we
truly need it.”
“Ok, I understand you don’t eel com ortable with this. Can you
help me understand why? What parameters would help you eel
more com ortable? Why don’t we start rom that point and see
how it goes with a ew cases.”
Next Steps
•
A ter meeting one-on-one with key leaders, arrange a meeting o the
“convinced” to create an action plan to institute the wide awake al-
ternative or at least some o the patients as a starting point. Doing it
in small steps may be wiser.
•
A ter you meet with key decision-makers one-on-one, consider creat-
ing a WALANT implementation group or committee with all the rest
o the stakeholders so they can express their concerns and address
them as a group.

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Introduction to Nursing Leaders
•
Introduce the WALANT concept to nursing leaders and key decision-
makers in the perioperative areas with one-on-one PowerPoint pre-
sentations and documents. Presentations to the rest o the nursing
sta can ollow later.
•
You can measure improved outcomes:
–
Nausea
–
Vomiting
–
Sta and material costs and waste
–
Patient time in hospital/clinic
–
Patient total cost o surgery
–
Number o times patient has a needle be ore the surgery
–
Pain o the needle(s) or the patient
–
Did you get to talk to your surgeon the day o surgery?
–
How long were you with the surgeon in a position that you could
ask questions?
–
Turnover time
–
Number o patients processed/time
–
Case delay and cancellation statistics
•
Discuss cost saving, increased sa ety with no sedation, increased sta
and patient satis action, quality improvement, improved e ciency,
improved surgeon satis action, the overall great experience or the pa-
tient and amily, and other relevant actors.
Introduction to Anesthesiologists
•
Explain to anesthesiologists that WALANT can ree them up to provide
care or the larger surgeries. Point out to these doctors and to nurses
that they personally get no monitoring when they go to the dentist.
You are planning to give exactly the same drugs they get at the den-
tist—only lidocaine and epinephrine within very sa e doses.
•
Try working with your anesthesiologist to inject only propo ol or the
2-minute local anesthetic injection part o the case. The patient could
then wake up and participate in movement o reconstructed parts
without a tourniquet. You could still educate patients and they would
remember i they are not given amnestic agents, which would void
their ability and opportunity to receive intraoperative education. In
addition, patients would not need nausea-producing opiates.
•
Choose quick, uncomplicated procedures to start, such as carpal tunnel
or trigger nger surgeries.
•
Choose tenolysis, f exor tendon repairs, and EI to EPL tendon trans ers
early. Operative personnel will therea ter easily understand the advan-
tages o patients being awake, cooperative, and pain ree without the
tourniquet and sedation. Team members will understand how better
outcomes can improve patient care in these operations.
•
Choose the rst ew patients wisely or their good disposition and co-
operative demeanor.
•
Other good cases to start without sedation are patients with severe
medical comorbidities in whom sedation or general anesthesia would
be extremely risky.

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82
Early Implementation
•
Obtain patient satis action surveys to demonstrate patient buy-in early
in your implementation process. The literature has good examples o
high patient satis action.1-3
•
Have sta satis action surveys sent out to nurses to get their input and
support.
•
The only current option in your acility may be the main operating
room with sedation. There may be no place to per orm WALANT or
hand procedures. Propose a “quality improvement project” that will
compare outcomes o carpal tunnel surgeries per ormed outside o
the operating room in a designated procedure room with eld sterility
and tumescent local anesthesia.
•
I there are minor procedure rooms already in existence in which
surgeons or dermatologists are removing skin cancers, determine
whether you can start by sharing their rooms or carpal tunnel surgery.
You can then progress to minor hand trauma.
in Su r An c e c o mpAn ieS An D pAy er S
•
Find out who the key decision-maker is in the insurance carriers or
government payers you deal with.
•
Request a meeting with these decision-makers and show them the
video clip rom this chapter and the documents that explain this new
approach, which will increase patient satis action and sa ety while in-
creasing productivity and decreasing costs.
•
Negotiate a acility ee or tray ee to per orm carpal tunnel surgeries
in your minor procedure rooms at the o ce, surgery center, or hospi-
tal. Explain the cost saving (see Chapter 11) when the surgery is taken
out o the main operating room and into the o ce. Surgeons can
bene t rom collecting the acility ee, and insurance companies can
bene t rom paying lower acility ees.
•
Eventually, insurance companies and governments will understand
that sedation and the main operating room are not essential or op-
erations such as carpal tunnel surgery. They will be happy to save the
money and increase their client/population sa ety and satis action. It
is to their great advantage to negotiate a lower acility ee with you
than what they pay the hospital.
PERCEIVED BARRIERS TO AD OPTIN G WID E AWAKE
H AN D SURGERY AN D H OW TO AD D RESS TH ESE ISSUES
g en er AL per c eiv eD BAr r ier S
The large number o bene ts o WALANT are listed in Chapter 2. Never-
theless, in many practices there will be individuals who perceive barriers
to implementation o this technique. We provide suggestions on how to
deal with these concerns.

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Sa e Injection o Epinephrine in the Finger
Many health care workers are still not aware that the old dogma that epi-
nephrine should not be used in the ngers is no longer valid.
Suggestions or Resolution
1. Provide them with Chapter 3 o this book.
2. Provide them with re erence papers.4-8
3. Demonstrate the reversal o epinephrine vasoconstriction in the nger
with phentolamine in your next simple hand operation, such as trigger
nger release, as explained and shown in a video in Chapter 3.
4. Show them the clip “History o the rise and all o the epinephrine
danger myth” rom Chapter 3.
Sa ety Concerns or Cardiac Responses to Epinephrine
E ects Without Monitoring
Suggestions or Resolution
1. Continue to monitor patients with portable monitors or the rst ew
months o your implementation process. It will eventually become
apparent that patients do not need monitoring or lidocaine and epi-
nephrine injection any more than they would at a dentist’s o ce.
2. Make the common-sense argument that monitors have not been used
or the millions o lidocaine and epinephrine injections that occur
every day without problems in dental o ces. Ask the objecting person
i he ever had a monitor when he personally had lidocaine with epi-
nephrine at the dentist’s.
3. Point out that there are areas in your hospital where doctors inject li-
docaine with epinephrine daily without monitors (Mohs surgery clinic,
plastic surgery skin cancer and nevus excision, line insertion, and other
instances).
4. When patients do have cardiac issues, decrease the concentration o
epinephrine to between 1:400,000 to 1:1,000,000 and per orm the
procedure wide awake in the main operating room with monitors.
5. Give them a copy o Chapter 6, “Dealing With Systemic Adverse Reac-
tions to Lidocaine and Epinephrine.”
“My Facility Is Not Set Up So That I Can Inject Patients
Be ore They Come Into the Operating Room”
Ideally, you should inject the local anesthetic at least 20 to 30 minutes be-
ore the incision is done to allow optimal epinephrine vasoconstriction.9
In some acilities, this may present a di culty in that there is no perceived
space available or preoperative blocking.
Suggestions or Resolution
1. Although 20 to 30 minutes is ideal, you can begin a procedure sooner
than that i necessary. You will need to tolerate initial temporary
bleeding, which is only mildly annoying.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
84
2. You can inject patients on stretchers in any preoperative holding area
or in the recovery room.
3. You can inject patients as soon as they arrive in the operating room
be ore you scrub and prepare and drape the patient.
4. Dr. Robert Van Demark, Jr., o San ord USD Medical Center, Sioux Falls,
South Dakota, recently persuaded his hospital to renovate a location
or wide awake hand surgery. See Dr. Van Demark’s comments in this
chapter or details.
“My Facility Requires a Witnessed Preinjection Time Out
or Pause: This May Be Di icult I I Inject Local Anesthetic
Outside the Operating Room”
Suggestions or Resolution
1. Start by per orming the injections in the holding area or recovery
room with a nurse there as a witness. They will probably eventually
come around to seeing that this may not be necessary in an awake
patient.
2. Point out that we developed the concept o time out in operating
rooms mostly to protect patients rom the risks o sedative medica-
tion. Patients cannot protect themselves while in a sedated state.
When a patient is totally awake, he or she can and likely would
answer the questions o health care providers. Although still possible,
wrong-sided operations are much less likely.
3. Point out that there are places in your hospital outside the operat-
ing room where doctors inject local anesthetics in unsedated patients
without time outs.
pAt ien t -per c eiv eD BAr r ier S
It will be essential to change the culture o patients’ expectations: per-
haps a amily member or riend had sedation or the same surgery and
they eel they need sedation.
Most Patient Concerns Arise From Fear o the Unknow n
Suggestions or Resolution
A calm, con dent attitude with so t-spoken, straight orward explanations
o the truth about how simple WALANT hand surgery can be is very reas-
suring or patients. Explain that the sa est sedation is no sedation. Use the
strategies discussed in Chapter 7 and point out all the bene ts o being
awake rom Chapter 2.
Fear o Pain
Suggestions or Resolution
1. Explain to patients that advances in local anesthesia make it possible
that smaller local anesthetic needles (27- or 30-gauge) hurt less than
the larger intravenous cannula needles commonly used or sedation
(20-gauge).

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2. Tell them that the only pain they will likely eel is one little stick rom
a tiny needle—and then deliver on that promise as outlined in Chap-
ter 5. Score yoursel each time you inject local anesthetic so you can
consistently deliver minimally pain ul injections.
Fear o Know ing What the Surgeon Is Doing, Hearing
Noises and Conversations
Suggestions or Resolution
Explain to patients that they can chose to know or not know what the
surgeon is doing, as they wish. I they would like to be totally “out o the
know.” they can bring in music with headphones and ignore the whole
event. I they change their mind and would like a “play-by-play” o the
surgery, this can easily be accommodated by experienced wide awake sur-
geons. Many patients do like to see parts o their surgery.
n u r Se-per c eiv eD BAr r ier S
It will be necessary to change the culture o nurses: most o their concerns
are a result o the act that they have never tried the wide awake ap-
proach. Most o the perceived issues go away quickly a ter even a short
exposure to the technique.
Most Nursing Concerns Come From Fear o the Unknow n
Suggestions or Resolution
1. As a rst step, meet one-on-one with key administrative nurses, as
outlined earlier in this chapter.
2. Have the nurses who seem more receptive to the WALANT concept be
the rst to try a ew cases.
Claustrophobia From the Drapes
Suggestions or Resolution
Explain to the nurses that draping is there to protect the patients and de-
crease the potential o in ection, not to drive patients crazy or unnerve
them. Draping that leaves the head ree o drapes can easily accommo-
date the concerns o such patients and maintain an ample sterile eld.10
What Happens I the Patient Feels Pain?
Suggestions or Resolution
The surgeon can always inject more local anesthetic and the pain will go
away. I the surgeon ollows the simple guidelines o tumescent local an-
esthetic administration (see Chapter 4) and minimal pain injection o local
anesthetic (see Chapter 5), this should be as in requent as patients wak-
ing up during general anesthesia. The only reasons patients may eel pain
during the surgery are that an insu cient volume o anesthetic solution
was injected or insu cient time was allowed or the local anesthetic to
take e ect. Just as airline pilots always make sure they have enough uel
to land at an alternate airport, surgeons or anesthesiologists giving the
local anesthetic should always be prepared to be able to inject more local
anesthetic volume while staying within the sa e dosage limit.

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I the Surgery Is More Di icult Than Anticipated, How
Do They Calm the Patient? Are the Nurses Responsible or
Conversing With the Patient?
Suggestions or Resolution
Nurses and surgeons both become responsible or creating a calm, relaxed
environment or the patient. Nurses will now communicate directly with
the patient or many things that they used to communicate with the an-
esthesiologist and the surgeon. In practice, the patient is easily calmed
i the surgeon and the nurse are relaxed with a matter-o - act attitude.
Surgeons and nurses who cannot remain calm and con dent should likely
not embark on surgery with a wide awake patient. The very worst case
scenario that may occur is that the surgeon might not be able to nish a
case unless he gets a general anesthetic or his patient. This would only
occur with poor patient selection and has never occurred in our practices.
I it did occur, we would simply close the skin and reschedule the patient
or a sa e, no-rush procedure with a general anesthetic.
Will Few er Nurses Be Needed?
Suggestions or Resolution
We may need ewer nurses with no sedation procedures, because many
o the problems that nurses solve are sedation- and general anesthesia–
induced issues. The surgical roles o the nurses do not change.
Are Nurses Liable I a Medical Emergency Happens?
Suggestions or Resolution
Nurses are no more liable in medical emergencies in wide awake patients
than they are or medical emergencies with patients in the holding area
or in the rest o the hospital.
Su r g eo n-per c eiv eD BAr r ier S
Changing the culture o surgeons: Most o the concerns o surgeons are
a result o the act that they have never tried the wide awake approach.
Most o the perceived issues go away quickly a ter even a short exposure
to the technique.
“I Cannot Work at My Facility Unless I Have an
Anesthesiologist in the Room”
Suggestions or Resolution
Ask your anesthesia provider to limit the injection to propo ol or the
2 minutes required or you to inject the lidocaine and epinephrine. As
soon as you have injected the local anesthetic, the anesthesiologist can
wake the patient. Avoiding all amnestics and opiates will allow you to
teach patients during the injection and the procedure and have them
remember your advice. They will not have nausea. They will also be able
to cooperate and show you movement o reconstructed structures with-
out the motor block. Alternatively, your anesthesiologist may change his
or her role to that o a consultant who is not necessarily present or your
whole case.

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“I Don’t Get Paid the Same I I Use WALANT”
Suggestions or Resolution
Set up meetings with your local insurance company executives or govern-
ment payers, as other surgeons have. Make the business case about how
the use o pure local anesthetic will cost them much less in the end. Ne-
gotiate with them to give you a acility ee to do the carpal tunnels in
your o ce that would cost them less than the acility ee at a hospital but
make it worth your e orts. (See Dr. Kerrigan’s comments in this chapter.)
Surgeons Will Now Be Forced to Talk to the Patient
During Surgery
Suggestions or Resolution
You can keep conversation to a minimum, but it is true that the wide
awake approach does pressure surgeons to talk to patients during sur-
gery. I you are the type o surgeon who does not like this type o interac-
tion, perhaps WALANT is not or you. However, this can be an excellent
intraoperative opportunity or patient teaching to decrease the risk o
unnecessary postoperative complications (see Chapter 8).
Patients Hear Conversations in the Operating Room
Suggestions or Resolution
Patients can hear what the operating room sta are saying. You must
take greater care in how you speak. See Chapter 8 or suggestions about
things to say and not to say in the operating room when patients are lis-
tening.
Di icult Surgeries Are More Transparent to the Patients
Suggestions or Resolution
Transparency about the di culty o surgery is not necessarily a bad thing.
When patients see a surgeon struggle to per orm a di cult case, they
gain an appreciation or the delicate nature o the problem. They under-
stand more readily why it may be di cult to get a per ect result. This has
o ten worked in our avor, because patients become more realistic in their
expectations and accepting o the limitations o surgery.
The Patient Know s When Residents or Students Are
Participating in Their Surgery
Suggestions or Resolution
We have ound that many patients gain a great respect or their good
ortune in having a master responsible or their surgery when they see
a surgeon teaching a resident to do part o a case. I the surgeon has a
calm, reassuring manner, this can be a very positive experience or the
patient. On the other hand, i a surgeon is rough and aggressive in his
teaching technique, the patient may be better o asleep.
1. Start by teaching the resident or medical student how to inject the
local anesthetic in a minimally pain ul way, as shown in Chapter 5.
The patient will then be quite amazed at how little pain he or she elt
during local anesthesia injection by the learner and will likely become

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much more willing to have the trainee do parts or all o the case un-
der the surgeon’s supervision.
2. For things to say and do while teaching residents during WALANT, see
Chapter 8.
3. It is true that the patient will be much more aware o who did which
parts o the surgery, especially i the surgeon is not there or part o
the operation. This increased transparency and truth-revealing to
patients may be too much or the surgeon to bear, in which case the
surgeon may pre er to have the patient asleep.
The Patient Is Aw are o Ine iciencies in the Operating
Room Such as Delays, Dropped Instruments, and Lack o
Needed Equipment
Suggestions or Resolution
Un oreseen things do occur, and personnel enter and leave the operat-
ing room. This is just part o the normal workaday li e o a surgical team.
When things go slightly awry, we can convey a sense o matter-o - act
calm that will reassure the patient with our attitude and our reaction to
adversity. In this way patients will witness us at our best behavior, not at
our worst behavior.
An eSt h eSio Lo g iSt -per c eiv eD BAr r ier S
Changing the culture o anesthesiologists: Most o the concerns o anes-
thesiologists are a result o the act that they have never tried the wide
awake approach. Most o the perceived issues go away quickly a ter even
a short exposure to the technique.
“How Do I Fit Into This?”
Suggestions or Resolution
1. I anesthesiologists only give propo ol or the local anesthetic injection
part and then wake the patient up, the patient eels no local anes-
thetic injection pain and retains the bene ts o the awake patient get-
ting intraoperative education and cooperation, with minimal nausea.
2. Alternatively, anesthesiologists who are interested in developing skills
in the injection o tumescent local anesthetic without sedation are
more than welcome to start using the technique. This would ree up
surgeon time. Anesthesiologists could be injecting local anesthetic
outside the procedure room while the surgeon operates on patients in
the procedure room. Anesthesiologists and surgeons may want to con-
vince payers that they should cover this service i they do not already.
3. An anesthesiologist may change his or her role to that o a consultant
who is not necessarily present or your whole case.

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“What I They Call Me Into a Room Where WALANT
Surgery Is Being Per ormed to Look A ter a Medical
Problem in a Patient I Have Never Met Be ore?”
Suggestions or Resolution
This would be the same as i a patient they had not met had a medical
problem in the preoperative holding area. None o the medical issues
arises rom sedation. Hence the anesthesiologist may not necessarily need
to become involved. The surgeon can trans er the patient to other doc-
tors to look a ter the medical problem.
“My Income May Decline”
Suggestions or Resolution
It is true that anesthesiologists’ income may decline i they do not adapt
to sedation- ree tumescent local anesthesia. However, this is not a good
reason to avoid WALANT surgery i it is better overall or patient care.
Pain Management May Be Out o Control
Suggestions or Resolution
In reality, this problem does not occur in practice. The surgeon can always
provide more local anesthetic i it is required. In addition, surgeons are
very capable o managing pain control with systemic medication. In act,
WALANT eliminates intraoperative systemic pain medications and their
adverse e ects.
“Sedation Is Better or Patients Than Pure Local Anesthesia”
Suggestions or Resolution
It is true that sedation with an anesthesiologist is sa er than sedation
without an anesthesiologist. However, it is not true that sedation is sa er
than no sedation. In act, it is quite the opposite. All anesthesiologists will
agree that less sedation is sa er than more sedation. The logical conclu-
sion is that the sa est sedation is no sedation. Dental o ces have used
only lidocaine with epinephrine very sa ely or over 60 years without
monitoring. Wrong-sided surgery is much less likely to occur in unsedated
patients than in those who are asleep or heavily sedated. All anesthesiolo-
gists struggle with the problem o nausea and vomiting. The wide awake
sedation- ree approach eliminates the nausea and vomiting issue.1
What Happens I the Patient Loses an Airw ay?
Suggestions or Resolution
Patients who are receiving pure local anesthetic with lidocaine and epi-
nephrine in the hand will not lose an airway. Even when dentists are actu-
ally obstructing the airway with dental procedures in their o ces, the loss
o an airway in that unmonitored setting is extremely rare, especially i
there is no sedation.

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per c eiv eD BAr r ier S f r o m t h e c u Lt u r e o f “Su r g ery n eeDS
SeDAt io n”
“We’ve Alw ays Done It This Way: Operating Rooms Need
a Surgeon and an Anesthesiologist” and “My Facility
Won’t Let Me Into an Operating Room Without an
Anesthesiologist”
Suggestions or Resolution
Many hospital operating rooms have dedicated “local anesthesia” rooms
where surgeons operate sa ely without any anesthesiology personnel.
Other hospitals have still not done it this way. Point out to concerned
personnel that dentists work under pure local anesthesia without an an-
esthesiologist. Local anesthesia without monitoring occurs in many other
parts o the hospital or skin cancer excision, minor procedures in the
emergency department, and procedures such as bone marrow aspiration.
“Sedation Controls Patients or Their Ow n Protection”
Suggestions or Resolution
Those o us who have been practicing wide awake surgery understand
that most patients adapt very well to pure local anesthesia. Most do not
require “protection” rom the reality o surgery.
“Sedation Improves Patient Satis action”
Suggestions or Resolution
There is no evidence that patients who receive sedation are more satis-
ed than those who do not. In act, there is level III evidence that patients
who have had wide awake carpal tunnel surgery are just as satis ed as
those who received sedation. However, those who had wide awake sur-
gery had less preoperative testing, less narcotic use, less nausea and vom-
iting, and less time at the hospital.
What About Patient Sa ety Checklists?
Suggestions or Resolution
We can still per orm the sa ety checklist with an awake patient. In act,
the patient becomes part o the checklist process. We created patient
sa ety checks because operating room sta made mistakes such as wrong-
sided surgery, giving patients medications that they were allergic to, and
other errors. Most o these issues actually arise because we have sedated
patients who cannot speak or themselves and protect themselves. I the
only medications that are given are lidocaine and epinephrine with no se-
dation, most o these operating room errors go away.

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O B S E R V A T I O N S F R O M S U R G E O N S
W H O P R A C T I C E W I D E A W A K E
H A N D S U R G E R Y
Dr. Carolyn L. Kerrigan, Dartmouth-Hitchcock Medical Center,
Lebanon, New Hampshire
•
Patients are generally not concerned, because I eel com ortable and
con dent with the approach, as does the team o clinic nurses who
support me. We take a very matter-o - act approach to explaining
what will happen; I just calmly explain the “usual” process. Since I eel
con dent, it is rarely a problem. I they raise the question about seda-
tion, I engage them in a conversation comparing it to WALANT. We
discuss having to be asting, needing to have an IV line started, need-
ing a driver, needing to stop certain medications, needing to get com-
pletely undressed, and needing to be wheeled on a stretcher. All these
things may make a patient eel more vulnerable and less in control. A
small number o patients express anxiety and a desire to take a mild
anxiolytic prior to the procedure, and I support them in this.
h o W i g o t o v er o BSt Ac LeS Wit h ADmin iSt r At io n
I had been doing hand procedures under local, with a tourniquet, and
with a single nurse in the operating room in a Canadian setting be ore
moving to New Hampshire. I learned and experienced that with a local
anesthetic, one nurse, and a lean set o instruments, I could do many di -
erent types o hand procedures. When I moved to Dartmouth 18 years
ago, it was natural to do carpal tunnel and trigger ngers in the clinic set-
ting. One o the other surgeons was already doing this—the big change
or the nurses and administration was that I wanted to do endoscopic
procedures outside the main operating room. Initially, they told me that
this would be impossible. It took some convincing, borrowing equipment
rom the operating room, and developing a business case or return on
investment until the administrators understood the advantage to patients
and the nancial bottom line.
h o W i g o t o v er St u mBLin g BLo c kS Wit h n u r SeS
Patience and persistence. Ask them to try it once. Make sure that you start
with a nurse who has OR experience. Give them training to the compe-
tency. For a nurse who has never been in an operating room, it is intimi-
dating to set up a sterile eld, open a tray o surgical instruments and as-
sist at surgery. Find an early adopter and you will gradually win over their
peers when they see how easy and uncomplicated it is or patients com-
pared to what they have had to do be ore.

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h o W i g et pAiD
I work in an academic medical center. Our clinic is physically attached to
the inpatient hospital. There is a revenue management group that over-
sees all the billing and coding or the organization. They track a provider’s
productivity based on RVUs (relative value units). Charges, payments,
payer mix, technical ees are also considered during budget time and
throughout the year. The treatment rooms in our clinic are designated as
a “provider-based entity.” This is an organizational classi cation, granted
through the Centers or Medicare and Medicaid Services (CMS), which
identi es services rendered in speci cally designated locations as “hospi-
tal based.” This allows or a system o reimbursement that supports maxi-
mization o Part B reimbursement and Part A reimbursement o the tech-
nical components o the charge. Our organization can thus bill CMS and
commercial payers or both pro essional and technical ees. There is a
speci c process to go through to get this designation, and you will need
to work with your hospital administrator (at our hospital this was the
Senior Manager o Reimbursement) to know i it is possible and to make
it happen.*
Dr. Peter C. Amadio, Mayo Clinic, Rochester, Minnesota
•
WALANT surgery is resource riendly, because “wide awake” means no
or less need or sedating medications that prolong stays in ambulatory
care acilities and increase the utilization o nursing sta
•
Academic centers can be good places to introduce wide awake tech-
niques, because they are under greater competition or resources but
manage more complex cases. Managing patients with less complex re-
sources is thus critically important.
•
Local anesthesia means no or much less intense involvement o anes-
thesiologists and their teams, operating room sta , and recovery room
sta .
•
Not using a tourniquet saves on both resources and time, since hemo-
stasis is a part o the anesthetic technique rather than being achieved
with cautery, ligatures, or other methods. This reduces operative time,
and possibly even postoperative hematoma.
•
No tourniquet also means no tourniquet pain, no risk o tourniquet
palsy, and no risk o skin problems under the tourniquet.
•
I requently use the LANT (local anesthesia no tourniquet) part o
WALANT even when patients are asleep. As soon as the patient is
anesthetized, we inject the lidocaine and epinephrine where we will
dissect. The epinephrine provides hemostasis so there is no let-down
bleeding rom the tourniquet i we inf ate it. The local anesthesia
means that less nausea-producing medication rom the anesthesiolo-
gist is required.
*You can nd guidance at w w.cm s.gov/Regulations-and-Guidance/
Guidance/Transm ittals/dow nloads/a03030.pd .

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•
Injecting local anesthesia in the holding area both allows more time
or the hemostatic e ect o the epinephrine to work and means you
do not waste time and money in the operating room inducing anes-
thesia.
•
Surgeons need to set aside less time or postoperative teaching when
patients observe and participate in their surgery.
•
There is little high-level evidence published to date to document bet-
ter outcomes or patient satis action with WALANT, compared with
more traditional alternatives. Nevertheless, in my own practice, I have
developed certain indications where I believe that WALANT, or vari-
ants o it, add value.
•
My top indications or WALANT are in such cases as tendon repair, ten-
don trans er, tendon gra t, and tenolysis. In these cases with long tour-
niquet times, we need patient cooperation. Beyond 10 or 15 minutes,
tourniquet pain and paralysis limit the use ulness o a local anesthesia
approach. WALANT nesses this by eliminating the tourniquet alto-
gether and allows the patient to remain com ortable, awake, and with
ull motor control o the hand. This motor control is very important to
check tension, pull-through, and integrity o tendon repairs under vol-
untary load. It is use ul to veri y complete lysis o adhesions, some o
which may be well proximal or distal to the initial zone o injury.
•
From a patient education perspective, the patient knows everything
that is going on, especially i he or she watches (which I always en-
courage). A better-in ormed patient is a happier patient and a better
partner in postoperative recovery.
•
Most important, patient cooperation is the key to setting tension and
checking motion a ter any kind o tendon surgery and in con rming
active motion a ter contracture releases.
•
I have ound WALANT to be help ul in having the patient help me set
the correct angle or various osteotomies, especially derotational oste-
otomies o the ngers.
•
I have more recently used WALANT when doing trapezium excisions,
to assess stability with active pinch a ter excision and capsular closure,
and be ore per orming any ligament reconstruction or other stabiliza-
tion procedure. I believe that this helps me better “personalize” the
procedure to each patient, rather than routinely either not doing a
reconstruction, as much o the literature recommends, or routinely do-
ing so, as many continue to do in practice.
•
My second main indication or WALANT is or cases in which intraoper-
ative patient teaching could be help ul in managing the postoperative
course. In act, this may actually be almost every case one does, since
even or shorter cases such as carpal tunnel or trigger nger, pointing
out tendons, nerves, what we do, why, and how we do it intraopera-
tively a ects postoperative activity. This can have a major impact on
patient understanding, cooperation, and satis action.
•
One limit is the length o the case. Few patients can tolerate many
hours o lying still on the operating table when ully awake, even i
their hand does not hurt. Having said that, we do encourage patients
to change their position i they are uncom ortable on the table. We

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have good access to the hand whether they are on their back or on
their side.
•
One major indication or WALANT is or cases in which a tourniquet
is contraindicated but a bloodless eld would be help ul. This would
include patients with lymphedema or dialysis access. Another would
be upper limb posttraumatic revascularization surgery with the need
or additional reconstruction. This avoids any risk that tourniquet may
pose to the integrity o the vascular reconstruction.
•
Another major indication or WALANT is or a patient receiving anti-
coagulants. The epinephrine in the anesthetic adds to the reliability o
hemostasis in these cases. By the time the epinephrine e ect is gone
in 4 to 6 hours, even a patient with reduced thrombogenesis will have
ormed a clot.
•
In my own experience with WALANT over the past 5 years in patients
aged 12 to 92, I have not had any WALANT-related complications and
have yet to have recourse to phentolamine to reverse epinephrine va-
soconstriction. Hemostasis has not been a problem.
•
I have been especially pleased that my patients seem to enjoy the ex-
perience. The ollowing types o comments are common.
“Thanks, doctor. I really enjoyed the surgery!”
“Could I have a DVD o the operation?” Usually this is as a me-
mento, but again not in requently the reason is given as “I want to
explain it to my amily,” which makes me especially happy, because
it shows that the patient understands what has just transpired well
enough to communicate it to others.
“People de nitely need to put this on their ‘bucket list.’ It was
great!”
•
In summary, I have ound WALANT to be very use ul. The technique
allows me to better personalize the care I provide to each patient,
engages the patients in their care, and has low morbidity.
Dr. Robert E. Van Demark, Jr., Sanford School of Medicine,
The University of South Dakota, Sioux Falls, South Dakota
•
I am an orthopedic surgeon employed by a large Midwestern
health system. In my practice, there are 13 orthopedists, 2 podiatrists,
2 primary care sports medicine physicians and 19 midlevel providers.
Our hospital has 29 operating rooms, with an additional 6 operating
rooms devoted to orthopedics.
•
Because o the rapid growth o our group, we began to have operat-
ing room access problems in 2013. At the same time, we started us-
ing WALANT or some o our hand cases. It became apparent that we
could move some o those cases out o the hospital setting and do
them in our o ce with WALANT. We could build a procedure room in
our o ce at a raction o the cost o a new operating room in the hos-
pital ($15,000 versus $5 million). The challenge was to convince all o

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the stakeholders that building a procedure room in the hospital would
be a win-win-win or everyone.
•
When we approached hospital leadership, they were reluctant to pro-
ceed with plans or a minor procedure room. We needed to address
our issues:
1. What is WALANT surgery?
2. Is WALANT surgery sa e or patients?
3. Will patients be satis ed with WALANT surgery?
4. Did this make nancial sense or the System?
What Is WALANT Surgery?
Initially there was some con usion concerning wide awake anesthesia. The
hospital administration thought we were planning to move a hospital op-
erating room to a procedure room. We needed to educate the administra-
tion on what constitutes WALANT surgery. The concept o “minor proce-
dure room eld sterility surgery” is new to many outside the spheres o
Mohs surgery and plastic surgery in the United States, but Canadian hand
surgeons have used it extensively or a long time.10 Field sterility includes
the ollowing components:
•
Extremity preparation with iodine or chlorhexidine
•
A single drape
–
Minor instrument tray
–
Sterile masks and gloves with no gowns
–
No prophylactic antibiotics
–
Local anesthesia only
Is WALANT Surgery Sa e or Patients?
Multiple studies have looked at the sa ety o doing wide awake
hand surgery in the outpatient setting. In a large multicenter study
o 1504 carpal tunnel procedures rom Canada, the super cial in ection
rate was 0.4% and the deep in ection rate was 0.0% . These ndings are
similar to the results o other reported series.11,12
Will Patients Be Satisf ed With WALANT Surgery?
Multiple studies have demonstrated high patient satis action.1-3 A two-
center study compared the patient’s perspective o wide awake anes-
thesia and local anesthesia with sedation. In comparing the two groups,
sedated patients spent more time in the hospital, required more preoper-
ative testing, and reported greater nausea and vomiting postoperatively.
The majority o patients in both groups (93% ) liked the anesthesia they
had received and would choose it again.1
A British study examined the patient experience reviewed in 100 consecu-
tive patients undergoing wide awake hand surgery. Most (91% ) elt that
the procedure was less pain ul or comparable to what they would expe-
rience rom a dental visit; 86% would pre er to have wide awake anes-
thesia i they needed hand surgery again; and 90% would recommend
WALANT to a riend.2

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Does This Make Financial Sense or the System?
Data have been published on the signi cant nancial savings o using a
procedure room instead o a hospital operating room. Costs associated
with an anesthesiologist, preoperative testing, IV sedation, intraoperative
monitoring, and recovery room personnel go away with the use o local
anesthetic.13-15
ADDit io n AL e v iDen c e
•
In addition to the cost savings, WALANT surgery is more e cient.
In one Canadian study, they per ormed twice as many carpal tunnel
releases at one quarter the cost by doing surgery in a minor procedure
room instead o the main hospital operating room.14 An American
study showed similar ndings.13 A study rom the U.K. reviewed
1000 patients treated with wide awake anesthesia or hand surgery
and showed a savings o £750,000 ($1,160,000) or the National
Health Service. Over a 10-year period, there was a total savings o
£2 million.16
•
Under the current reimbursement model, some hospitals have little
interest in adopting wide awake anesthesia. All o this is about to
change. With the passage o the Accountable Care Act (ACA) in 2010,
there will be a paradigm shi t in reimbursement. There will be a shi t
rom volume to value to control health care costs and to improve the
quality (outcomes) o care.17,18 One o the goals o the ACA is to “con-
trol costs by regulating health care delivery and reimbursement.” 17 As
part o the ACA, Accountable Care Organizations (ACOs) will play a
major role in this transition. An ACO is a network o health care pro-
viders that provides care to a de ned group o patients. To achieve
ACO designation, the ollowing guidelines need to be met 17:
–
”Express willingness to be accountable or quality, cost, and overall
care o Medicare bene ciaries or minimum o three years”
–
”Minimum o 5000 Medicare bene ciaries with a strong core o
primary care physicians”
–
”Legal structure to receive and allocate payments”
–
“Report on quality, cost, care-coordination measures, and meet
patient-centeredness criteria”
•
ACOs will be nancially responsible or this group o patients. ACOs
may be at risk or losing money i costs are higher than expected. In
addition, Medicare and insurers will o er nancial rewards or sav-
ing money and meeting quality guidelines.17 Payment to ACOs will be
an amount equal to a percentage o money saved through cost e -
ciency.17
•
When aced with this new economic reality o ACOs and bundled pay-
ments, hospitals and health care systems will be interested in adopting
new delivery systems that can be cost-e ective while providing quality
care with high patient satis action.

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r eSo Lu t io n
•
We began by marketing this option to Workers Compensation carriers
or local hand cases (as suggested by our vice-president). We are con -
dent that our community will receive this well.
•
Regardless o the nal orm and unction o the ACA, we eel pre-
pared or the uture. A dedicated procedure room or WALANT will
give our patients sa e, quality care with excellent outcomes and high
patient satis action.
After lengthy discussions, our administration agreed to renovate a hospital room into our new
WALANT procedure room. They put two walls in a preexisting large cast room to make it work, and
it is functioning well for us at very little cost.

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References
1. Davison PG, Cobb T, Lalonde DH. The patient’s perspective on carpal tunnel surgery
related to the type of anesthesia: a prospective cohort study. Hand (N Y) 8:47, 2013.
2. Teo I, Lam W, Muthayya P, Steele K, Alexander S, Miller G. Patients’ perspective of wide-
awake hand surgery—100 consecutive cases. J Hand Surg Eur 38:992, 2013.
3. Koegst WH, Wölfle O, Thoele K, Sauerbier M. [The “wide awake approach” in hand sur-
gery: a comfortable anaesthesia method without a tourniquet] Handchir Mikrochir Plast
Chir 43:175, 2011.
4. Thomson CJ, Lalonde DH, Denkler KA, Feicht AJ. A critical look at the evidence for and
against elective epinephrine use in the finger. Plast Reconstr Surg 119:260, 2007.
5. Lalonde DH, Bell M, Benoit P, Sparkes G, Denkler K, Chang P. A multicenter prospective
study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the
Dalhousie Project clinical phase. J Hand Surg Am 30:1061, 2005.
6. Fitzcharles-Bowe C, Denkler K, Lalonde D. Finger injection with high-dose (1:1,000) epi-
nephrine: does it cause finger necrosis and should it be treated? Hand (N Y) 2:5, 2007.
7. Nodwell T, Lalonde DH. How long does it take phentolamine to reverse adrenaline-
induced vasoconstriction in the finger and hand? A prospective randomized blinded
study: the Dalhousie project experimental phase. Can J Plast Surg 11:187, 2003.
8. Chowdhry S, Seidenstricker L, Cooney DS, Hazani R, Wilhelmi BJ. Do not use epineph-
rine in digital blocks: Myth or truth? Part II. A retrospective review of 1111 cases. Plast
Reconstr Surg 126:2031, 2010.
9. McKee DE, Lalonde DH, Thoma A, Glennie DL, Hayward JE. Optimal time delay between
epinephrine injection and incision to minimize bleeding. Plast Reconstr Surg 131:811,
2013.
10. Leblanc MR, Lalonde DH, Thoma A, Bell M, Wells N, Allen M, Chang P, Mckee D, Lalonde
J. Is main operating room sterility really necessary in carpal tunnel surgery? A multi-
center prospective study of minor procedure room field sterility surgery. Hand (N Y) 6:60
2011.
11. Hanssen AD, Amadio PC, DeSilva SP, Ilstrup DM. Deep postoperative wound infection
after carpal tunnel release. J Hand Surg Am 14:869, 1989.
12. Harness NG, Inacio MC, Pfeil FF, Paxton LW. Rate of infection after carpal tunnel release
surgery and effect of antibiotic prophylaxis. J Hand Surg Am 35:189, 2010.
13. Chatterjee A, McCarthy JE, Montagne SA, Leong K, Kerrigan CL. A cost, profit, and ef-
ficiency analysis of performing carpal tunnel surgery in the operating room versus the
clinic setting in the United States. Ann Plast Surg 66:245, 2011.
14. Leblanc MR, Lalonde J, Lalonde DH. A detailed cost and efficiency analysis of perform-
ing carpal tunnel surgery in the main operating room versus the ambulatory setting in
Canada. Hand (N Y) 2:173, 2007.
15. Lalonde D, Martin A. Tumescent local anesthesia for hand surgery: improved results,
cost effectiveness, and wide-awake patient satisfaction. Arch Plast Surg 41:312, 2014.
16. Bismil MS, Bismil QM, Harding D, Harris P, Lamyman E, Sansby L. Transition to total
one-stop wide-awake hand surgery service-audit: a retrospective review. JRSM Short
Rep 3:23, 2012.
17. Adkinson JM, Chung KC. The Patient Protection and Affordable Care Act: a primer for
hand surgeons. Hand Clin 30:345, 2014.
18. Mathews A. Can accountable-care organizations improve health care while reducing
costs? Wall Street Journal, Jan 23, 2012.

99
Ch a P t e r 13
Per f o r min g Yo u r Fir st Cases
Wit h WALAN T
Andrew W. Gurman, Robert E. Van Demark, Jr., Günter Germann,
Jason Wong, Donald H. Lalonde
SUGGESTION S ON GETTIN G STARTED
Andrew W. Gurman
There are a number o wonder ul descriptions in this book about
WALANT and its use in some very complex surgical procedures. Chapter 1
o ers an atlas with clear descriptions o exactly where to place injections
o local anesthetic, how much to inject, and the correct ormulation o
injectate. For someone who has not used WALANT techniques, getting
started can seem ormidable. Here are some lessons I learned that I hope
are help ul.
•
Choose your rst cases care ully. Start small: trigger ngers, carpal tun-
nel releases, rst dorsal compartments, simple masses, and skin lesions.
Even i you never use WALANT or larger cases, this will still encom-
pass a signi cant percentage o your schedule.
•
Choose your rst patients care ully. Let them know what you are plan-
ning, and tell them that they are the rst on whom you are using the
technique. You have used local anesthesia be ore, so it’s OK to tell
them that, and explain that the addition o epinephrine means that
you may not have to use a tourniquet.
•
Put a tourniquet on the arm or your rst ew cases. You won’t use
it, but it’s com orting to have it in place until you see or yoursel
how well this works. As a corollary, you can place the tourniquet or
more complex surgeries and only inf ate it or very brie periods when
needed.
•
I still use a Penrose drain as a digital tourniquet or digital mucous
cysts and nail bed cases. Patients do not eel it with a good digital
block. (See Chapters 1, 4, and 5.)
•
Stay in your com ort zone. It takes a while to get com ortable with
WALANT or some cases. I you have any doubts about a particular
case, have the appropriate anesthesia personnel available in case you
need to convert to general anesthesia.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
100
t h e u Se o f WALAn t t ec h n iq u eS in c o n Ju n c t io n
Wit h g en er AL An eSt h eSiA
•

We all witness observable responses to pain ul stimuli, such as pulse
rate increases, blood pressure elevation, and limb withdrawal in pa-
tients under general anesthesia. These hard-wired events occur even
when sedation alters consciousness. WALANT techniques stop pain
impulses rom the tourniquet and nerve stimulation. The brain never
experiences the “attack” o surgery. Patients need ewer drugs dur-
ing the operation. This makes waking up and recovery time aster
and much easier. Patients need less postoperative opioids (which may
induce nausea), particularly i these are combined with a periopera-
tive regimen o acetaminophen and nonsteroidal antiinf ammatory
agents.
•
I inject local anesthetic in the holding area, just as or WALANT cases,
or a ter induction o general anesthesia, be ore prepping and draping
the patient. The advantage o injection in the holding area is that the
tumescent f uid spreads in the tissues, and hemostasis improves be-
cause the epinephrine has longer to induce vasoconstriction. However,
some patients will not tolerate the injections while conscious, or the
condition o the limb may require induction o anesthesia be ore it is
unwrapped or manipulated.
•
Although the use o bupivacaine is not a part o WALANT technique
or smaller cases, I inject 0.5% bupivacaine with epinephrine in the
deep layers as well as in the skin while closing larger cases, which helps
with postoperative pain control. (See Chapter 6 or more in ormation
on longer-lasting local anesthetics.)
TAKIN G TH E FIRST STEP
Robert E. Van Demark, Jr.
Perhaps the biggest obstacle to starting WALANT surgery is taking the
rst step. I you started practice be ore 2005, you probably weren’t ex-
posed to the WALANT concept in your training. Like me, you probably
have done most o your ambulatory surgery cases with a combination o
intravenous regional anesthesia, local with sedation, and/or general an-
esthesia. Usually this has worked well, except or the patients who had
tourniquet pain and narcotic hangovers with nausea and vomiting. That is
no longer the case when you per orm the surgery with local injection only
o 1% lidocaine with 1:100,000 epinephrine.
•
Patients can have break ast, take their medications, and drive to and
rom the hospital or surgery center or their procedure. One o my pa-
I still use general anesthesia for most large cases. However, injection
of lidocaine and epinephrine improves results in these cases as well. I
would like to acknowledge the work of David L. Nelson, MD, in Marin
County, California on postoperative pain management for providing
the basis of this practice. (See )
•

Ch apt er 13 ° Per f o r min g Yo u r Fir s t Cases Wit h WALAN T
101
tients, an 85-year-old with diabetes, drove to the hospital, underwent
a carpal tunnel release with WALANT, and drove himsel home. (How-
ever, see Chapter 7 or the potential legal problems to be addressed
with patients using this approach.)
•
Another advantage o this technique is that you get to spend some
time with patients and their amilies while you per orm the local an-
esthetic injection and the wide awake procedure. It provides a signi -
cant opportunity or patient education.
•
Patients express greater overall satis action when you per orm their
procedure with the minimal pain method outlined in Chapter 5.
It may seem like a giant leap o aith to per orm your cases with local an-
esthetic only. I have several suggestions or you i you are interested in us-
ing this technique.
Do So me h o meWo r k
There are several excellent articles published describing the WALANT
technique and medication dosages.1-4 They are well worth your time to
read, but their material is contained in greater detail in this book.
St Ar t SmALL
Don’t schedule a Dupuytren’s asciectomy as your rst WALANT case. I
started with a small case: a trigger nger with sedation on standby and
a tourniquet on the arm, but not inf ated. Once you see that this works,
you can progress to carpal tunnel releases and other procedures.
f o LLo W t h e r u LeS
The published literature and this book describe the WALANT technique
and local doses nicely: Do not try to innovate or create a new protocol in
your early experience with the technique. When you use 1:100,000 epi-
nephrine, the maximal vasoconstriction occurs approximately 26 minutes
a ter an injection.5 I you try to cut the waiting time short, you will be dis-
appointed. That’s why it is important to do the local injection in a preop-
erative holding area. Make certain you do the injection with the patient
supine. This will help to minimize the vasovagal ( ainting) events. Remem-
ber that the wound will not be completely dry. Although this will not be a
signi cant problem, the wound will ooze somewhat initially.
Do A Sit e v iSit
I you still have doubts about the bene ts o WALANT, schedule a site visit
with someone who is using the technique. I will admit that I was initially
skeptical about this technique. However, once you see how the process
works, including your increased e ciency and patient satis action, you
won’t go back to the old way o per orming hand surgery.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
102
WH Y AN D WH EN I USE TH E WALAN T TECH N IQUE
Günter Germann
I came rom a classical background in hand surgery, with plexus blocks
and general anesthesia with a bloodless tourniquet eld. This and my
work on cytokine release a ter tourniquet ischemia 1 made it almost irri-
tating to see Dr. Lalonde rst promoting the wide awake approach.5
•
WALANT has now become an integral part o our hand surgical prac-
tice. A major advantage o the WALANT technique is that the patient
can actively move his or her ngers so we are able to evaluate the
unctional result intraoperatively.
•
Patient satis action is high, and results with f exor tendon repair and
other operations can be better than with traditional techniques. (See
Chapter 32, f exor tendon repair, Chapter 38, tenolysis, and Chapter
39, tendon trans er.)
•
In the rst cases, we did not wait long enough a ter injection o the
local anesthetic. Patients had residual pain. Since we started waiting
30 minutes, we have not encountered this problem.
•
Initially, we were not generous enough with the amount o local anes-
thetic. Changing that early in our practice eliminated patient discom-
ort.
•
We eel that using a 27-gauge needle helps to decrease the pain o
the injection.
•
Today we use the WALANT approach whenever we think it is appropri-
ate. Our experiences are promising, and the technique has stood the
test o time.6 However, we still have a number o patients who wish to
have some sort o sedation so they will be “detached” rom the surgi-
cal intervention. We provide that or those patients.
WALAN T IS MY METH OD OF CH OICE FOR MUCH
OF MY H AN D SURGERY
Jason Wong
I was an early enthusiast o the WALANT technique because o my inter-
est in improving outcomes in f exor tendon repair. I’ve subsequently ap-
plied the method to most hand procedures that I eel com ortable with
and per orm regularly.
•
For f exor tendon surgery, this is the biggest positive change since the
introduction o early true active motion. It is my method o choice.
•
WALANT is not or the uninitiated, because it requires you to be com-
ortable per orming hand surgery with a small amount o bleeding.
You also have to be amiliar with anatomic variations. Hence this tech-
nique is easier or experienced surgeons.

Ch apt er 13 ° Per f o r min g Yo u r Fir s t Cases Wit h WALAN T
103
•
I eel that the real merits lie in:
–
The ability to assess unction on the table
–
Gaining access to operating rooms without the need or anesthesi-
ology cover
–
The opportunity to communicate with and get to know your pa-
tients
–
Increased patient compliance; patients realize how much time and
e ort you have put into their surgery. They more readily keep their
appointments and per orm their subsequent hand therapy as in-
structed, as they have experienced it with you.
•
I try to avoid WALANT procedures in:
–
Individuals who are very anxious and will undergo complex proce-
dures
–
Patients having secondary or corrective surgery
–
Those with Raynaud’s phenomenon, previous digital ischemia, or
scleroderma
–
Very young children, except or straight orward amputation o ac-
cessory digits
AD D ITION AL CON SID ERATION S
Donald H. Lalonde
The unlikely worst case scenario could be that you need to abandon
WALANT because the patient is unable to tolerate it, or you run into
un oreseen problems intraoperatively. That has never happened to me.
However, i it did, I would simply cover the wound with a bandage or
close the skin and nish the operation later or on another day with the
patient under general anesthesia. This is not a terrible allback position.
t ry t h e t ec h n iq u e f ir St Wit h pAt ien t S ASLeep Bu t Wit h o u t
A t o u r n iq u et
As soon as possible a ter your anesthesiologist has the patient asleep or
sedated, be ore you prepare and drape, inject the tumescent lidocaine
and epinephrine solution as described in Chapter 4. A ter that injection,
apply the sa ety net tourniquet that you will likely not inf ate. By the time
you scrub, prep, and drape the patient, the epinephrine will have had at
least 5 to 10 minutes to work. The e ect will not be as complete as i the
epinephrine had 26 minutes to work, but you will still nd the bleeding
acceptable or good vision.
The wound will bleed a little when you cut the skin, but try to ignore this.
Pull rmly on the Senn retractors and divide the transverse carpal liga-
ment or A1 pulley. By the time you have done that, most o the bleeding
will be drying up, and you will see that you have survived and managed
quite well without a tourniquet. I you are able to wait 26 minutes be ore
you make the rst incision, you will have very little to cauterize at the
end. I have not used cautery or trigger nger and carpal tunnel proce-
dures in Saint John or 25 years.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
104
Wo r kin g Wit h An An eSt h eSio Lo g iSt
•
I you are working with an anesthesiologist, ask him or her to use only
propo ol. Inject the lidocaine with epinephrine as soon as the propo-
ol permits injection o pain- ree local anesthetic. The anesthesiolo-
gist can stop all medication right a ter your injection and wake up the
patient. This will give you the ability to per orm intraoperative patient
teaching (see Chapter 8) with a ully cooperative patient who can per-
orm pain- ree movement.
•
Suggest that the anesthesia provider totally avoid opioids and amnes-
tics to prevent nausea and allow the patient to remember your intra-
operative advice.
•
We try to avoid making an incision immediately a ter injection. We
inject our patients in rooms outside the operating room, such as the
postanesthesia care unit (recovery room). We do this so the wound site
will bleed less when we make the rst incision. It takes an average o
26 minutes or maximal vasoconstriction to peak a ter 1:100,000 epi-
nephrine injection in humans.5 Lidocaine also increases its numbing e -
ect over that time.
•
The numbness provided by lidocaine with epinephrine lasts an average
o 5 hours in the hand4 when we use median and ulnar nerve blocks as
part o the tumescent local anesthesia. Numbness lasts an average o
10 hours as a digital block with epinephrine.6 We inject one or two pa-
tients ahead o the one we are operating on so the lidocaine and epi-
nephrine each have at least 26 minutes to take e ect (see Chapter 14).
Injecting patients outside the main operat-
ing room in the patient holding area or in
the recovery room on a stretcher helps to
decrease the risk of the patient’s fainting
(see Chapter 6) and gives the lidocaine
and epinephrine 26 minutes or more to
work.

Ch apt er 13 ° Per f o r min g Yo u r Fir s t Cases Wit h WALAN T
105
h emo St ASiS
•
We seldom use a cautery or WALANT surgery, but we have it avail-
able. At a concentration o 1:100,000, epinephrine produces very good
hemostasis. Setting up a cautery with every case is a waste o time and
money. I we encounter a larger vein, we clamp it with a hemostat and
leave it to clot or a ew minutes or tie it o .
•
The higher the concentration o epinephrine, the better the hemosta-
sis, and the longer the vasoconstriction will last.7 However, 1:400,000
to 1:1,000,0008 concentrations provide enough hemostasis that cau-
tery is not required or most cases.
•
Simply ignore the small amount o bleeding a ter the incisions and it
will dry up. The time you will save by not having to cauterize bleeders
a ter letting down a tourniquet will be worth it.
References
1. Lalonde DH, Wong A. Dosage of local anesthesia in wide awake hand surgery. J Hand
Surg Am 38:2025, 2013.
2. Lalonde D, Martin A. Tumescent local anesthesia for hand surgery: improved results, cost
effectiveness, and wide-awake patient satisfaction. Arch Plast Surg 41:312, 2014.
3. Lalonde D. Minimally invasive anesthesia in wide awake hand surgery. Hand Clin 30:1,
2014.
4. Chandran GJ, Chung B, Lalonde J, Lalonde DH. The hyperthermic effect of a distal volar
forearm nerve block: a possible treatment of acute digital frostbite injuries? Plast Recon-
str Surg 126:946, 2010.
5. McKee DE, Lalonde DH, Thoma A, Glennie DL, Hayward JE. Optimal time delay between
epinephrine injection and incision to minimize bleeding. Plast Reconstr Surg 131:811,
2013.
6. Thomson CJ, Lalonde DH. Randomized double-blind comparison of duration of anes-
thesia among three commonly used agents in digital nerve block. Plast Reconstr Surg
118:429, 2006.
7. Fitzcharles-Bowe C, Denkler KA, Lalonde DH. Finger injection with high-dose (1:1000)
epinephrine: does it cause finger necrosis and should it be treated? Hand (N Y) 2:5, 2007.
8. Prasetyono TO, Biben JA. One-per-mil tumescent technique for upper extremity surgeries:
broadening the indication. J Hand Surg Am 39:3, 2014.

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107
Ch a P t e r 14
Sc h ed u l in g Fif t een o r Mo r e
H an d Su r g er y Cases per D ay
Donald H. Lalonde
H OW TO BOOK A D AY OF FIFTEEN OR MORE
ELECTIVE CASES
With good planning and coordination with sta , it is possible to sched-
ule 15 or more elective cases per day that one surgeon, one nurse, and
one receptionist can accomplish in the o ce or hospital minor procedure
room in the clinic.
•
For the rst three cases, schedule simple procedures: carpal tunnel or
trigger nger repairs. Ask the patients to come at 7:45 AM, 7:50 AM,
and 7:55 AM.
•
Schedule longer cases and trauma cases with less predictable lengths
later in the day in the event that those procedures run overtime.
•
Inject the rst three patients with local anesthetic.
•
Inject patients while they are lying down on a stretcher. They are less
likely to aint (vasovagal reaction) i they are lying down.
•
As soon as patients eel well a ter the injection, they can be asked to
sit in a chair to liberate the stretcher so you can inject another patient.
Two stretchers and an operating table to inject patients are ideal in
the event you encounter a patient who aints and needs to remain ly-
ing down or a while. However, i necessary, one stretcher and one op-
erating table will su ce or local anesthetic injections.
•
A ter you inject the rst three patients, complete their paperwork.
After we inject patients while they
are lying down on a stretcher in the
office, they sit up and wait at least
30 minutes for the lidocaine and
epinephrine to work optimally. The
setup is the same in the ambulatory
clinic in the hospital. The patients
with their hand up have had their
injection.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
108
•
While you inject the rst three patients and do their paperwork, the
nurse sets up the rst patient on the operating table and opens the
tray o surgical instruments.
•
We per orm most clinic and o ce surgeries sa ely with eld sterility,
which greatly increases e ciency (see Chapter 10).
•
A ter you nish the rst operation, inject the ourth patient and do
paperwork while the nurse sets up the tray or the second case and
brings the second patient into the minor procedure room.
•
The nurse can put on a pair o gloves and per orm retraction i
needed during part o the surgery. The rest o the time, the nurse cir-
culates. You get your own instruments o the tray.
•
Always try to inject one or two patients ahead o the one you are op-
erating on so the lidocaine and epinephrine have at least 30 minutes
to work optimally. It takes an average o 26 minutes or maximal vaso-
constriction to peak a ter 1:100,000 epinephrine injection in humans.1
•
Do not inject the patient and make an incision immediately a ter. The
site will bleed less i you organize your time as described to allow an
adequate interval or the epinephrine to work. The lidocaine compo-
nent also increases its e ect over 30 minutes and lasts over 4 hours in
the hand when you block the median nerve as part o tumescent local
anesthesia 2 (Chapter 18). Numbness in the nger lasts 10 hours when
you inject lidocaine with epinephrine.3 (See Chapter 1, Atlas, or spe-
ci cs on injection placement, timing, and duration.)
•
You can conduct most o your communication with the patient while
you inject the local anesthetic and as you operate (see Chapter 8).
•
I you are working with medical students or residents, rst teach them
how to give local anesthetic injections in a minimally pain ul ashion
(have them read Chapter 5 and look at the videos rst), and have the
patients score their injection technique. When they amaze patients
with minimal pain injections, the patients will be much more com ort-
able about allowing them to participate in the surgery under your di-
rection.
•
Clip 14-1 demonstrates that three carpal tunnel procedures can be per-
ormed per hour at a relaxed pace by one surgeon and one nurse.
Clip 14-1 Three
carpal tunnel
procedures
performed per hour.

Ch apt er 14 ° Sc h ed u l in g Fif t een o r Mo r e H an d Su r g er y Cases per D ay
109
IN TEGRATIN G PATIEN T CON SULTATION S FROM
TH E EMERGEN CY D EPARTMEN T AN D TRAUMA
SURGERY IN A H OSPITAL CLIN IC
•
We schedule our emergency department consultations to come to the
hand surgery clinic in the hospital at 8 AM Mondays and Fridays, where
we triage them and operate on those who need surgery (see hospital
setup clips in Chapter 16).
•
When we see a list o patients who arrive rom the emergency depart-
ment or consultation, we do not know which ones will need surgery.
When we evaluate a patient who needs surgery, we go ahead and in-
ject that patient at the end o the consultation. I necessary, he or she
can wait or 1 or 2 hours a ter we inject the local anesthetic, and it will
not wear o . A ter we nish our nonsurgical consultations, we per-
orm surgeries on those patients who need it.
•
I we know ahead o time that there are trauma patients requiring
surgery who are coming to our clinic, we schedule them to come an
hour be ore the end o the clinic consultation patients. This allows the
surgical patients an hour in which the local anesthetic can take e ect
be ore we per orm their surgery. In the meantime, we can nish see-
ing our clinic consultation patients.
References
1. McKee DE, Lalonde DH, Thoma A, Glennie DL, Hayward JE. Optimal time delay between
epinephrine injection and incision to minimize bleeding. Plast Reconstr Surg 131:811,
2013.
2. Chandran GJ, Chung B, Lalonde J, Lalonde DH. The hyperthermic effect of a distal volar
forearm nerve block: a possible treatment of acute digital frostbite injuries? Plast Recon-
str Surg 126:946, 2010.
3. Thomson CJ, Lalonde DH. Randomized double-blind comparison of duration of anes-
thesia among three commonly used agents in digital nerve block. Plast Reconstr Surg
118:429, 2006.

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111
Ch a P t e r 15
In t eg r at in g H an d Th er apis t s
In t o WALAN T
Susan Kean, Amanda Higgins, Donald H. Lalonde
IN CORPORATIN G H AN D TH ERAPISTS IN TO YOUR
H AN D SURGERY CLIN IC
I you do not presently have hand therapists seeing patients with you
ull time in your hand surgery clinic, you should think about making that
happen or at least a ew hours per week. There are many advantages to
this1:
1. You can educate each other so you both enhance your skills.
2. Verbal communication between you and the hand therapists will
produce better patient outcomes in complex problems such as
f exor tendon repair and reconstruction.
3. The patient will see that you are a team and will want to become
an active participant in your e orts to produce the optimal out-
come.
4. The patient will see that you value the therapist’s opinion and
thus will be more likely to listen to the therapist and comply with
instructions.
5. In some systems such as ours, therapists can take over patient care
rom the surgeon and complete the care or many hand problems.
This rees up the surgeon’s time, and the therapist can provide
excellent ongoing one-on-one care.
6. I you begin per orming WALANT hand surgery in your clinic,
therapists can watch the surgery and assess the patients. In
addition, therapists can educate the patient between the time o
local anesthetic injection and surgery, as well as during the surgery
itsel . Clip 15-1 shows hand therapists engaging in preoperative
therapy consultation between injection o local anesthetic and
surgery or a f exor tendon repair in a 10-year-old girl.
7. Therapists will waste a lot less time and avoid making judgment
errors based on inadequate in ormation because they could not
communicate with the surgeon.
8. It will be easier or you to start doing early protected movement
or nger ractures i the therapists see patients with you in the
clinic (see Chapter 41).
Clip 15-1 Hand
therapists in
preoperative therapy
consultation.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
112
H OW TO IN TEGRATE H AN D TH ERAPISTS IN TO
YOUR CLIN ICS AN D WALAN T PROCED URES
•
The surgeon must initiate the e ort to integrate therapists into the
clinic—because no one else will do it. You can begin by making ap-
pointments with the hospital and therapy administrators to get this
process started.
•
Arrange to talk to the key hospital administrators one at a time. Con-
vince them that you need a hand therapist to come to your clinic or
1 hour once a week so you can see patients with complex hand con-
ditions with him or her. You can schedule complex patients to arrive
when the therapist is there so no time is wasted. We began this in our
hospital 25 years ago. One hour became 2 hours; once a week became
twice a week; one therapist became two therapists. We now have two
or three therapists or 4 hours 3 days a week.
•
We per orm our WALANT hand minor trauma procedures in the clinic
in one room while the therapists are working in another clinic room
where they make orthoses (splints) and see patients (see Chapter 16
or a video o our clinic setup). These are primarily hand ractures and
tendon and nerve lacerations. Major hand trauma is still handled in
the main operating room.
•
We ask the therapists to come into the clinic operating rooms to ob-
serve parts o procedures. They per orm intraoperative patient as-
sessment and education as required (see clips that ollow) in between
their splinting and consultation duties.
•
Point out anatomic structures to the therapists, much as you would do
with a medical student or resident. Demonstrate how reconstructed
tendons and bones move or unction during the surgery.
•
Hand therapists will start to engage with the patient even be ore the
surgery. Therapists can start patient education in the time a ter the lo-
cal anesthetic injection while the surgeon is seeing other patients and
waiting or the local anesthetic to take optimal e ect. When they are
amiliar with your techniques, they can do a better job o educating
your patients about what to expect a ter surgery. This will be even eas-
ier or them i they have seen you per orm the surgery.
•
Do not orget that the hand therapist is in the room! Talk with the
therapist about what you are seeing or doing. This will help him or her
to determine the best postoperative care.

Ch apt er 15 ° In t eg r at in g H an d Th er apis t s In t o WALAN T
113
AD VAN TAGES FOR H AN D TH ERAPISTS IN GEN ERAL
•
They see live tissue and how it unctions with active movement during
surgery.
•
They understand surgical technique because they have seen it rst-
hand, not just rom hearing or reading about it.
•
They can assess patient compliance and reliability be ore, during, and
a ter the operation.
•
There is real-time interaction between the surgeon and therapist,
avoiding miscommunication about the outcome and treatment plan.
•
This establishes the therapist in the “role o coach” to the patient.
AD VAN TAGES FOR TH E PATIEN T
•
An educated patient who has undergone wide awake hand surgery is
aware o what happened during surgery and what he or she needs to
do or a success ul recovery.
•
From the start, the patient becomes an active participant in the reha-
bilitation team with the surgeon and the therapist.
•
The patient’s intraoperative interaction places ownership or postop-
erative care squarely on his or her shoulders.
AD VAN TAGES FOR H AN D TH ERAPY IN FLEXOR
TEN D ON REPAIR
•
See Chapter 32 or extensive discussions in both video and text on
postoperative therapy o f exor tendon repair.
•
In Clip 15-3 the surgeon and therapist teach the patient about the
Saint John postoperative protocol during f exor tendon surgery.
•
Therapists can see intraoperative ull st active f exion and extension
testing o tendon integrity (no gapping) and glide-through pulleys at
the time o surgery.
•
The therapist can initiate communication regarding repair and the
treatment protocol with the surgeon and patient be ore, during, and
immediately a ter the surgery.
Clip 15-2 Patient
watching structures
being repaired.
Clip 15-3
Intraoperatively
the surgeon and
therapist teach
the patient about
postoperative care.
Clip 15-4 Therapist
teaching a patient
during flexor tendon
repair surgery.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
114
•
When therapists see ull st f exion and extension without gapping
at surgery, they know that 3 days later the patient is unlikely to have
gapping and rupture i he or she limits movement to hal a st. This
helps therapists gain the increased con dence to move the repaired
tendon early with true active movement or better results with less po-
tential or rupture and tenolysis.2 (See Chapter 32 or videos o up to
hal a st o active movement.)
AD VAN TAGES FOR H AN D TH ERAPY IN EXTEN SOR
TEN D ON REPAIR
•
Seeing no gap at surgery with intraoperative testing o the repair with
simulated relative motion extension splinting assures the surgeon and
therapist that they can allow the patient an earlier return to work (as
early as 3 to 5 days postoperatively) wearing a relative motion exten-
sion splint.3
•
Watching the repaired hand move during surgery helps therapists de-
cide whether they should incorporate the wrist component o relative
motion extension splinting or not.1
•
Therapists can see and assess the stress placed on the repair when they
start early protected movement (see Chapters 35 and 36).
AD VAN TAGES FOR H AN D TH ERAPY IN FIN GER
FRACTURES
•
Therapists and surgeons are able to see how stable the reduced nger
ractures are when they move a ter K-wire insertion at surgery. This in-
creases con dence or both the surgeon and therapists to begin early
protected active movement protocols a ter xing nger ractures with
K-wires4 (Chapter 41).
•
See Chapter 41 or extensive discussions in videos and text on early
protected movement with hand therapy a ter K-wiring nger rac-
tures. You can move ngers early, as you do with f exor tendon re-
pairs.
•
Watching active movement during surgery lets therapists and sur-
geons know whether K-wire placement inter eres with joint motion.
Clip 15-5 Allowing
wrist extension and
active flexion after
flexor tendon repair.
Clip 15-6 Relative
motion extension
splinting for extensor
tendon repair.
Clip 15-7 Early
protected active
motion after K-wired
repair of finger
fractures decided
with the therapist
during surgery.

Ch apt er 15 ° In t eg r at in g H an d Th er apis t s In t o WALAN T
115
•
Seeing active movement during the surgery helps the surgeons and
therapists decide what kind o splint to use to protect the racture
a ter surgery.
References
1. Lalonde DH. How the wide awake approach is changing hand surgery and hand therapy:
inaugural AAHS sponsored lecture at the ASHT meeting, San Diego, 2012. J Hand Ther-
apy 26:175, 2013.
2. Higgins A, Lalonde DH, Bell M, McKee D, Lalonde JF. Avoiding flexor tendon repair rup-
ture with intraoperative total active movement examination. Plast Reconstr Surg 126:941,
2010.
3. Merritt WH. Relative motion splint: active motion after extensor tendon injury and repair.
J Hand Surg Am 39:1187, 2014.
4. Jones NF, Jupiter JB, Lalonde DH. Common fractures and dislocations of the hand. Plast
Reconstr Surg 130:722e, 2012.
5. Burns MC, Derby B, Neumeister MW. Wyndell Merritt immediate controlled active motion
(ICAM) protocol following extensor tendon repairs in zone IV-VII: review of literature, or-
thosis design, and case study-a multimedia article. Hand (N Y) 8:17, 2013.
Clip 15-8 Therapist
teaching early
movement 3 days
after K-wiring finger
fractures.

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117
Ch a P t e r 1 6
Min o r Pr o c ed u r e Ro o m Set u p
Donald H. Lalonde, Geoff Cook
With the advent o WALANT and eld sterility, we per orm most o our
hand surgery in minor procedure rooms outside o the main operating
room. In this chapter, we provide videos and descriptions o the minor
procedure room setup in two hospitals and one surgeon’s o ce where we
per orm these procedures in Saint John, New Brunswick, Canada.
PH YSICAL SPACE
A reception area with seating and a receptionist to manage this area is
essential. A ter you inject patients with local anesthetic, most can go back
to sit in the reception area to wait or their procedure with their amilies.
This allows a hal hour between injection o the local anesthetic and the
onset o optimal numbing and epinephrine vasoconstriction.1
o u r f Ac iLit ieS in SAin t Jo h n, n eW Br u n SWic k, c An ADA
We have per ormed wide awake hand surgery or more than 30 years in
our acility with a relatively modest investment o money, space, equip-
ment, and sta ng or our accredited minor procedure rooms.
m in o r pr o c eDu r e r o o mS
•
Our o ce minor procedure room in Canada is accredited by the Ca-
nadian Association or Accreditation o Ambulatory Surgical Facilities
(CAAASF), .org, or pure local anesthesia (no sedation).
•
In the United States, as in Canada, you can have a minor procedure
room in your o ce accredited or pure local anesthesia (no sedation)
Clip 16-1 Clinic
consultation and
minor procedure
room setup at the
Saint John Regional
Hospital.
Clip 16-2 Clinic
consultation and
minor procedure
room setup at St.
Joseph’s Hospital.
Clip 16-3 Minor
procedure accredited
operating room at
Dr. Lalonde’s office.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
118
by the American Association or Accreditation o Ambulatory Surgery
Facilities (AAAASF), w w.aaaas .org, more easily and with much
less cost than you would need or accreditation or per orming proce-
dures with sedation or general anesthesia.
•
It is ideal to have two or more stretchers in addition to the procedure
table on which to inject lying-down (supine) patients, but one is su -
cient. We do injections with the patient lying down instead o sitting
up to decrease the risk o ainting (see Chapter 6).
•
In one o our hospitals, we have access to only one procedure room
most o the time. In this situation, we inject patients on stretchers in
other rooms down the hall. A ter we inject the local anesthetic, most
patients can then sit with their relatives or 30 minutes or more be ore
surgery while the local anesthetic achieves optimal numbing and vaso-
constriction. I patients need to remain lying down because o ainting
or other issues, we let them lie on their stretcher until we move them
to the procedure room.
•
All you really need in a procedure room is a stretcher that can be ad-
justed to the Trendelenburg position (head down, eet up), an arm
board, and a good light ( xed or portable). All hospitals have these
acilities.
•
Cleaning sta wash the minor procedure room f oors in the evening,
but not between cases, unless there is an in ection issue such as
abscess drainage or a patient who has been identi ed as having a
methicillin-resistant Staphylococcus aureus (MRSA) in ection.
PERSON N EL
•
In addition to the receptionist, only one nurse is required to help the
surgeon or most simple cases such as carpal tunnels and trigger n-
gers.
•
The nurse both circulates and assists. She puts on gloves only to hold
retractors i and when necessary. The surgeon gets his own instru-
ments o the tray. We get a second assistant or complex cases, such
as racture reduction.
•
No recovery room or recovery personnel are required, since no seda-
tion is given, which would require recovery. Patients just sit up and go
home a ter the surgery.
EQUIPMEN T
Su r g ic AL e q u ipmen t in o u r m in o r pr o c eDu r e r o o m
•
For minor hand surgery procedures such as carpal tunnel surgery, we
use small drapes with a hole, or small sterile towels.

Ch apt er 16 ° Min o r Pr o c ed u r e Ro o m Set u p
119
A typical Canadian minor procedure room setup with field sterility (see Chapter 10) for performing
carpal tunnel surgery with one surgeon and one nurse assistant. The nurse puts on gloves only to
hold retractors if and when necessary. The nurse both circulates and assists. The surgeon takes his
own instruments off the tray. This is the way most Canadian carpal tunnel surgery is performed.2
A basic instrument tray for carpal tunnel surgery
includes scalpel handle, forceps, suture scissors,
dissecting scissors, a needle holder, and a cup to
hold the sterilizing liquid.
Two Senn retractors for carpal tunnel
procedures. We open the Senn retractors
separately.
•
We use Desmarres (vein) retractors wrapped separately or trigger
ngers and De Quervain surgery (see Chapter 21 or a photo o
Desmarres retractors).
•
Also wrapped separately, we keep periosteal elevators, skin hooks,
hemostats, rongeurs, towel clips to reduce ractures, K-wires, curettes,
and army-navy retractors or lacertus tunnel release.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
120
We have a cautery machine available in the minor procedure room but seldom use it. We also have
an electric K-wire driver.
A low-radiation C-arm (such as the
Hologic Fluoroscan InSight-FD
Mini C-arm) is very valuable for
diagnostic and therapeutic proce-
dures. A radiation technologist is not
required because of the low radiation
produced by these types of devices.3
•
We have sterile gowns and large drapes available when we choose to
have augmented eld sterility or cases such as open nger and hand
ractures, and f exor tendon repairs. Sterile C-arm drapes are also
available.
•
We do have a tourniquet but seldom use it. We use a sterile 1⁄4-inch
Penrose drain or a tourniquet or some nger procedures such as nail
bed work, schwannoma, or giant cell tumor excision.
•
An ultrasound machine is also help ul or diagnostic and therapeutic
purposes i possible. Sterile covers can be purchased or the ultrasound
probe or intraoperative use.
H AN D TRAUMA
•
In many Canadian cities, most trauma surgery, such as K-wiring rac-
tures and repairing lacerated tendons and nerves, happens in clinic
minor procedure rooms. We operate at our convenience in daytime
hours with eld sterility (see Chapter 10).

Ch apt er 16 ° Min o r Pr o c ed u r e Ro o m Set u p
121
•
Our typical telephone discussion with the emergentologist is like this:
“Thank you or your (Saturday night) call. I would be so grate ul i you
would kindly wash it out, close the skin, and we will be delighted to
see the patient in the clinic Monday/Friday morning.”
•
It is ideal to have a clinic adjacent to the minor procedure room
where we see most patients re erred rom the emergency department.
Our emergentologists re er most o them to the hand surgery clinics
4 mornings a week. There we triage them into those who need sur-
gery and those who do not. Patients requiring surgery can have it
done right there in the minor procedure rooms the morning we see
them.
OTH ER FACILITIES N EAR TH E MIN OR PROCED URE
ROOMS
•
It is ideal to have the hand therapists working in a room nearby (see
Clip 16-1) so we can invite them into our minor procedure rooms to
witness tendon and racture surgery, educate patients during the sur-
gery, and abricate splints be ore or a ter the surgery (see Chapter 15).
PROCED URES N OT PERFORMED IN MIN OR PROCED URE
ROOMS
•
For some procedures, we pre er doing WALANT in a ormal operat-
ing room environment or ull sterility or vital sign monitoring o the
patient.
•
Full sterility is more desirable when inserting oreign bodies such as
plates or joint implants. We also use main OR ull sterility or long pro-
cedures in relatively avascular areas, such as thumb basal joint arthro-
plasty, extensive tendon trans ers, or secondary tendon reconstruction.
•
I a patient has cardiac issues and monitoring is desirable, we use mon-
itors or WALANT patients in the main operating room. We can also
decrease the concentration o epinephrine to 1:400,000. It washes out
aster and bleeds a little more but still provides excellent visualization.
References
1. McKee DE, Lalonde DH, Thoma A, Glennie DL, Hayward JE. Optimal time delay between
epinephrine injection and incision to minimize bleeding. Plast Reconstr Surg 131:811,
2013.
2. Leblanc MR, Lalonde J, Lalonde DH. A detailed cost and efficiency analysis of performing
carpal tunnel surgery in the main operating room versus the ambulatory setting in Can-
ada. Hand (N Y) 2:173, 2007.
3. Thomson CJ, Lalonde DH. Measurement of radiation exposure over a one-year period
from Fluoroscan mini C-arm imaging unit. Plast Reconstr Surg 119:1147, 2007.

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Part III
Spec if ic d et ail s o f h o w t o Per f o r m
w id e aw ake h an d su r g er y f o r
c o mmo n o per at io n s

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