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The idea of remaining “wide awake” during any kind of surgery might sound terrifying, but there are many benefits for patients when general anesthesia is not used.

Wide awake surgery is known as WALANT, which stands for Wide Awake Local Anesthesia, No Tourniquet. At Vail-Summit Orthopaedics and Neurosurgery (VSON), Drs. Erik Dorf and Terrell Joseph are performing wide awake hand surgeries, and Dr. Ernest Braxton is doing wide awake spine surgeries.

Dr. Dorf has been doing wide awake hand surgeries for 18 months now and says it’s particularly useful for hand procedures such as tendon repair, carpal tunnel release, trigger finger release or mass removal. Dr. Dorf has done more than 200 wide awake hand surgeries at Peak One Surgery Center in Frisco, and has recently been approved to perform wide awake surgeries at the Edwards Surgery Center as well.

Here’s what Dr. Dorf had to say about this relatively new technique.

Is this the future of surgery? Is wide awake surgery an option across multiple specialties or is it only appropriate for certain procedures?

Dr. Dorf: I do believe that this is the direction that many surgical procedures are headed. Wide awake surgery offers advantages over surgeries that are performed under general anesthetics with significantly lower risk. Other subspecialties, like foot and ankle surgery, and even some spine surgeries can be done awake with minimal discomfort and decreased risk. 

How do you control pain during a wide awake surgery?

The key to performing WALANT surgery is lidocaine with epinephrine. Lidocaine is the same drug that dentists use in their office to control pain. With enough lidocaine, procedures can be performed without the patient experiencing any pain. When we mix epinephrine with the lidocaine, the pain relief lasts even longer, and the epinephrine constricts the surrounding blood vessels and thus controls bleeding. Because there is very little bleeding, we don’t need to use a tourniquet which can be uncomfortable for the patient.

What are the advantages of wide awake vs. general anesthesia?

Dr. Dorf: The advantages of this technique are really now starting to become clear. I waited until the evidence demonstrated significant benefits, without compromising patient safety.

Beyond the benefits of avoiding anesthesia, I feel that I can offer better surgical outcomes with this technique. We are able to test patients’ response to surgery intraoperatively by asking patients to move their hand in the operating room (OR). This allows me to check our work and make adjustments if needed. I can honestly say that I have had patients who have achieved a better surgical result because we were able to do their surgery wide awake and test the tendon repair or release in the operating suite.

What do you talk about with patients prior to the procedure?

Dr. Dorf: I of course discuss the procedure in detail. I ask my patients about how they would like to participate in the surgery, and I prepare them for questions that I might ask them once we have begun. I want to make sure the patient is comfortable being awake during their operation. I want our patients to have a great experience so that they will go out and tell their friends about this as an option. I think this approach has been very successful, and many of our patients have had WALANT surgery on one side, and then chosen to do the same on the other side.

Do you offer patients any other options should they not feel comfortable with this one?

Dr. Dorf: Of course! If a patient is not comfortable with having a wide awake procedure, we will consult with the anesthesia team and they can offer any level of sedation for any procedure. This can range from a little relaxation medication to full general anesthesia. We still use these options for many of our patients.