What is WALANT? Mike Hayton explains all...  

Wide Awake hand surgery under Local Anaesthesia with No Tourniquet (WALANT) is becoming increasingly popular in North America due to the influences  of Don LaLonde in Canada. The uptake in the UK has been less enthusiastic and the reasons for this are as yet unclear.


The WALANT technique uses local anaesthetic mixed with adrenaline to cause vasoconstriction, thereby reduce bleeding and avoid the need for a painful torniquet. Historically surgeons were all taught to avoid the use of adrenaline in end arteries, such as the fingers, for fear of 'digital ischaemia' and eventual digit loss. However, the literature does not support this effect and the effects of adrenaline can be rapidly reversed using phentolamine.



There are many advantages to all parties in using the WALANT technique including the surgeon, the hospital and of course the most important party the patient.


Advantages to the patient


  • The obvious advantage is the avoidance of a general anaesthetic with all its associated risks and side effects including nausea, hangover, thromboembolic disease (DVT, PE) 
  • Post operative controlled pain
  • Rapid discharge mean patients are free to leave the hospital once back from theatre and on average saves the usual 3-4-hour recovery before discharge.
  • Real time feedback to the surgeon during the operation. This will be covered below but also the patient will understand the surgery, and even watch the procedure and will therefore know what exactly has been done which clearly will help with post operative rehabilitation.

 

Advantages to the surgeon


Surgery is performed with real time active feedback from the patient. This is particularly important for procedures that involve obtaining movement as an outcome.

 

Here are a few common examples.

  • Finger joint replacements can be inserted, and the stability and range of movement may be assessed with active movement on table to ensure adequate soft tissue balance and movement is achieved. If the joint feels stiff, then further bony resection can be performed and movement reassessed and improved. 
  • Tendon transfers performed with the patient asleep are often difficult to gauge tension in the reconstruction. With wide awake feedback the perfect tensioning can be obtained by asking the patient to move the joints. If inadequate tension has been created the transfer can be tightened to optimise function.
  • Acute tendon repairs are particularly benefit from this technique. The repair can be cycled under active (rather than passive) load and assessed for gapping which is known to lead to early rupture. Active movement can also identify catching of the repair through the narrow fibrosseous tunnels in the hand and wrist. In such cases the repair is tidied up with small buried sutures to create a smooth repair site.

 

Disadvantages


As with any surgery, there are a few risks associated. The procedure does involve in introduction of local anaesthetic and therefore the soft tissues can become a little “boggy”. However appropriate timings of wound infiltration of the wound can minimise this and allow for a perfectly adequate surgical field that is relatively dry and well anaesthetised.


The adrenaline significantly reduces blood loss but some oozing is inevitable. However, a surgeon will be able to obtain haemostasis and achieve a satisfactory bloodless field in order to visualise the important structures.

 

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In Summary, WALANT is a very powerful tool that is safe, effective and well tolerated by patients. It has become a major method of providing anaesthesia and my indications for its use are always widening and recently have included trapeziectomies and wrist arthroscopy. 

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