Step-By-Step Guide to the WALANT Technique

What Is the Walant Procedure?

Wide-awake local anesthesia with no tourniquet (WALANT) is a common alternative approach for hand surgery around the globe. As the name suggests, it involves performing surgery while the patient is fully awake, using only local anesthesia injected into the surgical site without using a tourniquet for hemostasis.

WALANT was founded in Canada in the early 2000s. The goal was to improve the experience, safety, and accessibility of hand surgery. WALANT enables surgery in a clinic or office rather than the main operating room. The benefits of WALANT include lower costs because no operating room or anesthesia is required, faster recovery for patients, and the ability for the patient to provide input during sensitive repairs. It also prevents difficulties associated with tourniquet use. WALANT can be performed in the clinic, allowing more people to get hand surgery.

WALANT was created out of a desire to improve access to hand surgery treatments. With an insufficient amount of operating rooms and anesthesiologists to fulfill demand, Dr. Lalonde pioneered a method for doing surgeries in the clinic without relying on primary operating room resources. Patients enjoyed the quick access to surgery and minimal downtime. Orthopedic and plastic surgery groups adopted WALANT globally over the next decade as an efficient way to treat hand injuries and chronic conditions.

Specific training is needed to learn the WALANT technique since it differs from typical operating room cases. Practice on cadavers allows trainees to get used to doing injections and surgery in an awake patient without a tourniquet. Simulation training also helps acquire the skills. Strong communication ability is important for interacting with awake patients. When first implementing WALANT, having dedicated staff for patient coaching is crucial.

What Are the Indications and Contraindications of the WALANT Procedure?

WALANT can be used for a variety of hand-surgical operations. The most common operations performed using WALANT are:

• Trigger Finger Release: This surgery fixes a finger that is stuck in a bent position.

• Removal of Cysts or Masses: WALANT can remove benign tumors from the hand.

• Pinning Finger Fractures: WALANT enables surgeons to repair damaged finger bones with pins.

• Tendon Repair: Damaged tendons in the hand can be repaired using WALANT.

• Distal Radius Fractures: WALANT can be used to repair a shattered wrist bone.

• Dupuytren’s Contracture: This condition that bends the fingers can be treated with WALANT.

• Carpal Tunnel Release: Surgical procedure releasing the carpal tunnel in the wrist to alleviate nerve compression.

• De Quervain’s Release: Surgical intervention to treat De Quervain's tenosynovitis, a condition causing inflammation of tendons in the thumb.

• Metacarpal Fractures: Treatment involving the use of WALANT for repairing fractures in the metacarpal bones of the hand.

• Arthroscopy: Minimally invasive surgical technique using a camera to visualize and treat joint-related issues in the hand.

WALANT is not suggested for young children, uncooperative adults, persons with circulatory difficulties, or those who are allergic to lidocaine. Patients with coagulation issues, cardiac disorders, or kidney/liver disease should proceed with caution, although it is normally highly safe if the patient is carefully chosen.

What Are the Preoperative and Post-operative Procedures for the WALANT Procedure?

Before Surgery:

• Patients can eat and drink normally before the surgery, unlike with other surgeries.

• They come 30 minutes early for check-in.

• The surgeon discusses the next operation.

• Numbing medication is injected into the hand and allowed time to take effect.

During Surgery:

• The surgery is done using sterile techniques like in the operating room.

• The patient remains awake and able to communicate with the surgeon.

• During tendon repairs, the patient can move their hand to check for adequate tension.

• This feedback enables the surgeon to improve the repair quality.

• The patient is awake yet comfortable because only one hand is numb.

After Surgery:

• The dressings are applied, and the instructions are reviewed.

• The procedure is carried out using standard techniques.

• Patients can go home 30 minutes after finishing.

• No lengthy recovery room stay is needed.

What Are the Benefits of WALANT Surgery?

There are numerous potential benefits associated with the WALANT technique:

1. Patient Experience:

• Avoid risks of sedation, such as nausea or respiratory depression

• A decreased anxiety while awake without medication.

• Enhanced understanding and participation in surgery.

• Quicker recovery and discharge after the procedure.

• With high satisfaction rates, most would choose WALANT again.

2. Safety:

• Eliminates risks of tourniquet use, like nerve palsy.

• Allows better intraoperative repairs with patient feedback.

• Reduced infection risks by minimizing OR exposures.

3. Convenience:

• Able to drive self to and from the procedure.

• No fasting is required before surgery.

• More flexible scheduling of cases.

• Procedures performed during regular clinic hours.

• Less time off work for patients can be explained in simple terms.

What Is the Future of the WALANT Procedure?

WALANT was originally created for hand surgery, but it has since been expanded to include additional extremities. Lower leg and foot surgeries, arthroplasty cases, and elbow fracture repairs have all been described using the WALANT method. This certainly broadens the potential possibilities.

The COVID-19 pandemic also shed light on the need for creative solutions to continue providing essential surgical care when hospital resources are constrained. WALANT allows for procedures without the close proximity required for intubations, minimizing virus transmission risks. Further research into angiography in WALANT will assist in broadening its use in trauma surgery.

Conclusion

In conclusion, WALANT is an innovative anesthetic technique that enhances the patient experience and access to hand surgery. It offers a safe and well-tolerated alternative to traditional techniques that need sedation or general anesthesia. With adequate patient selection and training, WALANT offers considerable therapeutic and economic benefits. Further study and instruction will be critical in broadening its applications beyond hand surgery and incorporating it into more surgical practices worldwide. WALANT symbolizes a shift in surgical care delivery aimed at improving results and the patient experience.