Hand surgery can raise questions beyond the operation itself. Will it hurt? Will you need put to sleep? How will you feel afterward?

Wide-awake hand surgery — with a technique known as WALANT — offers another option for certain procedures. It can avoid grogginess from sedation and allow you to talk with your surgeon throughout the operation.

“WALANT eliminates many of these fears and inconveniences for people,” says Neil Singh, DO, hand and upper extremity surgeon, UPMC Regional Orthopaedics.

What Is WALANT Surgery?

WALANT stands for "wide awake local anesthesia no tourniquet." It allow certain hand and wrist operations while you remain awake, using medicine to numb the surgical area.

The technique does not require sedation, which makes you relaxed or sleepy, or general anesthesia, which makes you unconscious. It also avoids a tourniquet, a tight band placed around the arm to limit blood flow temporarily.

Staying awake lets you participate when the surgeon needs to check movement. During a tendon repair, for example, your surgeon may ask you to move your fingers to assess the repair before finishing.

“It takes away the guesswork,” Dr. Singh says. “It’s very motivating for patients.”

Seeing their hand move during surgery can give patients more confidence in the repair as they begin recovery.

What Conditions Can WALANT Treat?

Surgeons can use WALANT for several hand and wrist procedures. Your surgeon considers your health and the type of surgery to decide whether it’s appropriate.

  • Arthritis procedures — Addresses arthritic conditions to relieve pain and other symptoms.

  • De Quervain’s release — Relieves pressure on the thumb tendons to address pain and discomfort.

  • Endoscopic carpal tunnel release — Relieves pressure on a nerve at the wrist to address numbness, tingling, and other symptoms. This is a minimally invasive technique that can allow for faster recovery and return to activity compared to a traditional open carpal tunnel release.

  • Finger fracture repair — Repairs fracture using pins, wires, or small plates.

  • Ganglion cyst removal — Removes a fluid-filled lump that may cause pain or limit movement.

  • Mass excision — Removes a lump, cyst, or tumor from the soft tissues or bones of the hand or wrist.

  • Tendon repair — Repairs damaged tissue that connects muscle to bone and helps move your hand or fingers.

  • Trigger finger release — Opens a tight section of tissue around a tendon so the finger can move more freely.

Who Can Have WALANT Surgery?

You can have WALANT surgery if local anesthesia provides enough pain control for your operation and you can remain still while awake. Your surgeon reviews your health, blood flow to your hand, and medication allergies to determine whether it’s safe for you.

Why Does WALANT Use Only Local Anesthesia?

Local anesthesia blocks pain signals in the surgical area. It can provide enough pain control for select procedures without putting you to sleep.

WALANT typically combines a local anesthetic, such as lidocaine, with epinephrine, a medicine that narrows blood vessels to reduce bleeding. The local anesthetic keeps the area numb, while epinephrine helps the surgeon see clearly without a tourniquet.

Avoiding a tourniquet also removes the aching and pressure it can cause, which may otherwise require additional anesthesia or sedation.

What Are the Benefits of WALANT Hand Surgery?

WALANT can improve comfort during surgery, let the surgeon assess movement, and simplify recovery from anesthesia.

Checks movement during surgery

Your surgeon may ask you to move your hand or fingers to check whether a repaired tendon or a treated joint moves as expected. A repair can look secure while the hand is still, but movement may reveal a gap in the repair, tightness, or tissue catching. Your surgeon can address these problems before closing the incision.

The tissue still needs to heal afterward, and you may need hand therapy to restore movement and strength.

Reduces discomfort

A tourniquet’s tight pressure can become uncomfortable as surgery continues, even when the surgical area is numb. WALANT avoids this pressure and aching by using medicine to control bleeding instead.

The local anesthetic also continues to provide pain relief after surgery until it wears off. This reduces early pain and the need for pain medicine, although you may still have soreness from the operation.

Avoids sedation and general anesthesia

Sedation and general anesthesia can leave you sleepy or nauseated after surgery. They can also affect breathing and blood pressure. WALANT avoids these effects because it does not use those medicines, which may benefit patients with certain heart or lung conditions.

Local anesthesia still carries risks, including reactions to the medicines used. Surgical risks, such as bleeding and infection, also remain.

Simplifies the surgical visit

You don’t need to wait for sedation or general anesthesia to wear off before going home. You may also avoid fasting before surgery.

With your surgeon’s approval, you can drive yourself home rather than arrange a ride. This depends on the procedure and whether you can safely use your hand. Numbness, bandages, and pain medicines may limit your ability to drive.

What Should I Expect Before, During, and After WALANT Surgery?

Your care team will prepare you for the procedure, check your comfort during surgery, and explain how to care for your hand afterward.

Before surgery

Your care team reviews your health history, medicines, and allergies. They explain whether you need to stop eating or drinking before surgery and which medicines to take or pause. Tell them if you’re anxious about staying awake or have questions about pain control.

The surgeon injects the numbing medicine near the surgical area. You may feel a brief sting or burning sensation.

“We use different techniques to make the injection fairly painless,” Dr. Singh says.

During surgery

The care team positions your arm, cleans the surgical area, and places sterile drapes around it. A drape can block your view of your hand, although some patients choose to watch.

Once the surgeon confirms the area is numb, they begin. A nurse stays with you, and the team explains what’s happening throughout the procedure.

“The nurses and staff are well trained,” Dr. Singh says. “They communicate with patients about what’s happening the whole time.”

You may feel pressure or movement, but you should not feel sharp pain. Tell the team if you feel discomfort so they can decide if more numbing medicine if needed. Your surgeon may ask you to move your hand or fingers to check the repair.

Simple procedures, such as carpal tunnel or trigger finger release, may take about 15 to 30 minutes. More complex repairs take longer. Your visit also includes time for preparation and for the numbing medicine to work.

After surgery

The incision is covered with a dressing, a protective covering of sterile gauze or a bandage. You may also need a splint to protect the treated area. Before you leave, you receive instructions for wound care, pain relief, and activity.

Numbness may last for several hours. Protect your hand from heat and injury while it is numb. Soreness or swelling may develop as the medicine wears off.

Recovery depends on the operation. A tendon repair may require a splint and a specific hand therapy plan. Other procedures may allow movement sooner. Follow your surgeon’s instructions about lifting, work, driving, and exercise.

At UPMC, our surgeons are experts in advanced surgical techniques, including the WALANT procedure. To learn more about the services we provide, visit our website.