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Doctors Applauding Wide Awake Hand Surgery


SurgenUntil recently, most people who required minor hand surgery faced a “traditional” surgery experience: sedation or general anesthesia; no eating or drinking beforehand; pre-op tests such as blood work and EKGs; painful recovery from incisions and the use of a tourniquet; and hours in the hospital or surgery center before, during and after surgery.

Fortunately, for many patients, the above scenario is no longer the case, as traditional surgery is making room for the WALANT – wide awake, local anesthesia, no tourniquet – procedure. WALANT allows a surgeon to perform the operation while the patient is awake. The surgeon uses a combination of medications – lidocaine and epinephrine – injected locally at the surgical site to numb the site and decrease blood flow to the area. After the procedure, the patient is able to go home immediately after.

The combination of medications means a there is no need for a tourniquet to be placed above the surgical site or sedation to counteract the pain caused by the tourniquet. Traditionally, tourniquets were used to restrict blood flow. Now, epinephrine, which is used to decrease or stop blood flow, is injected into the area.

Orthopaedic surgeons Mark Mellinger, M.D., and John “Bull” Durham, M.D., perform minor hand surgeries using WALANT techniques and protocols. Both physicians are part of Northern Arizona Orthopaedics – with locations in Prescott Valley, Sedona, the Village of Oak Creek, Flagstaff and Page – and both specialize in treating people who have hand and upper-extremity conditions.

“Any time you can reduce the need for sedation, medications and hours in the hospital or surgery center, it is a good thing to do,” said Dr. Durham. “The WALANT technique for hand surgery is a win-win for everyone because it reduces the need of medications, decreases the cost of the procedure and allows the patient to recover faster with less pain.”


WALANT: Less is More

  • No anesthesia: Surgery is performed without sedation or general anesthesia; therefore, the risks and side effects associated with “medically induced relaxation or sleep” are eliminated. And, patients do not experience the side effects that come with anesthesia such as grogginess, nausea or vomiting.
  • No anesthesiologist: Anesthesiologists are doctors and like with any service, they charge for their time. Not needing this service equates to a procedure with significantly lower costs and time.
  • No overnight fasting: Since patients are not “put under,” they are able to eat the day of surgery. This is especially important for those who have diabetes and other health conditions.
  • No pre-surgery tests: Before having surgery that requires anesthesia, most patients must undergo a series of tests. These tests are necessary to rule out health-related complications that could occur when sedation or general anesthesia is required. Since there is no need for sedation, there is no need for pre-op tests. Fewer tests saves time and money.
  • No IV: Unless a patient needs antibiotics before surgery or they are extremely dehydrated, there is no need for an IV.
  • No tourniquet: Tourniquets can cause temporary or permanent nerve, muscle and skin injury. Patients often report more residual pain from the tourniquet than from the surgery. No tourniquet equals less pain.
  • Shortened recovery: Like dental work, once the procedure is complete, the patient simply gets up and goes home.


New Studies; New Protocols

It seems this approach to minor hand and foot surgeries is a “no brainer.” Yet, until recently, wide-awake surgery on the extremities has not been a best practice or widely accepted procedure. So, what changed? According to Dr. Mellinger, the transition started about 10 years ago.

“We were taught in medical school that injecting epinephrine into the hands and feet could cause devastating results such as necrosis or gangrene. This line of thought can be traced back to the 1950s when this drug was wrongly implicated as the cause of gangrene in a number of patients. However, studies now show that it wasn’t the epinephrine that caused the problem, it was the local anesthetic, procainamide, that was the culprit. A review of previous studies by Canadian surgeon Donald Lalonde shows there are absolutely no reported signs of complications from epinephrine use in surgery. Today, we combine lidocaine as the numbing agent and epinephrine to decrease blood flow in the area.

“As physicians, we are always looking for ways to provide better care to our patients. New surgical options such as WALANT is a great example of how medicine is continuing to progress. It is wonderful to be able to treat patients with as little pain and risks as possible; decreasing costs for everyone is an added bonus.”

Additionally, new surgical protocols such as WALANT open the door for more and more procedures to be performed in physician offices or outpatient surgery centers.

“The next step is for minimally invasive procedures to take place in procedure rooms in physician offices,” said Dr. Mellinger. “Being able to perform minor surgeries without the need for anesthesia and/or surgery room expenses will significantly decrease costs and create a better experience for patients.”

Reducing the need for hospital resources benefits patients, physicians and hospitals. Dr. Durham explained, “Physicians are able to treat more patients because overall each procedure takes less time. They also are able to talk with their patient during the actual surgery and even show them what is happening, if the patient is interested. Having the ability to talk with patients before, during and immediately following the procedure, rather than wait for them to awaken from anesthesia, is valuable to both patient and the surgeon.”

Hospitals and surgery centers also benefit because they are able to direct their resources such as operating rooms, nurses and other support staff toward patients who are acutely ill who need to be hospitalized. Not only does this allow hospitals to focus on the sickest and most in need patients, but it also increases a hospital’s bottom line because they receive higher payments and reimbursements for patients who need more aggressive care.

Like all surgical and medical procedures, not all patients are candidates for the WALANT approach to minimally invasive surgery. For those who may experience drug interactions or other possible complications, traditional surgery including sedation may be the best option. Regardless of which techniques and procedures are used, patients have more and more options than ever before. FBN

By Starla Collins

For more information, visit or call 800-773-2553.


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