Same-Day Hand Surgery - No Hospital, No General Anaesthesia, No Tourniquet, Home Today

Most lumps and lesions on the upper limb are straightforward to treat. What is not always straightforward is the choice of anaesthetic technique. That choice has real world consequences for what a surgeon can assess, confirm, and correct before the wound is closed. In my practice, as much as possible, my preference in hand surgery procedures is to use wide awake local anaesthesia no tourniquet (WALANT).

Case 1 - A Dorsal Finger Tumour

A patient presented with a firm, well-defined swelling on the dorsum of the right middle finger at the proximal interphalangeal joint (PIPJ), affecting his ability to play badminton. The working diagnosis was tenosynovial giant cell tumour (TSGCT).

The tumour was excised via a dorsal approach under WALANT. It was well-encapsulated with no macroscopic tendon involvement. With the patient awake, active range of motion was tested immediately after excision and full active extension at the PIPJ was confirmed before wound closure.

The specimen was sent for histology as a matter of routine. It returned as fibroma of tendon sheath, which is a much less common entity, rather than TSGCT. This was an incidental finding, as the two are clinically indistinguishable and the treatment is identical. The only reason the correct diagnosis exists on record is because the specimen was sent.

The patient maintained full active range of motion throughout recovery and has returned to playing badminton. He has been counselled on the recurrence risk of up to 24% reported in the literature.

Case 2 - A Viral Wart Over the Elbow

A patient was referred after failed cryotherapy by his GP for a lesion over the elbow, clinically consistent with a viral wart. When cryotherapy has failed over a bony prominence with thick overlying skin, surgical excision is the appropriate next step.

The procedure was again performed under WALANT in a clinic procedure room. Closure over the elbow requires careful thought and planning for joint mechanics as every flexion and extension places the wound under tension. A layered closure was used: interrupted sutures to the deep dermis and mattress sutures to the skin to evert and hold the wound edges together. Active bending and straightening of the elbow was tested after closure, confirming the wound would remain closed before the patient left. It healed without complication and stitches were removed 2 weeks later.

Why WALANT Works: The Two Advantages That Matter

WALANT offers two distinct intra-operative advantages that apply across both cases.

The first is the cooperative awake patient. Active (meaning the patient moving himself, rather than the doctor making the hand move ie passive) range of motion can be tested in real time, such as finger extension after tumour excision (as it was growing from the covering of the tendon) in Case 1, and elbow flexion and extension after wound closure in Case 2. These are functional confirmations that no other anaesthetic technique (general or regional) can provide at the time of surgery. In hand surgery, it is the active range of motion that actually matters.

The second is the bloodless field. The adrenaline in the WALANT solution produces vasoconstriction that gives clear operative visibility without the discomfort of a tourniquet. This is the constricting bandage used to exsanguinate a limb, which is why in awake patients, the limit is around 15 to 20 minutes whereas it is up to 2 hours when under general or regional anaesthesia. In Case 1 this was particularly important: the tumour arose adjacent to the extensor mechanism, and incomplete excision at the margins increases recurrence risk. A field obscured by bleeding would compromise the ability to assess excision completeness. In Case 2 it allowed clear visualisation of tissue planes for layered closure. In both cases, WALANT eliminated the discomfort and time pressure of tourniquet use entirely as its effect has been reported to last for 4 to 5 hours.

Both procedures were also performed in a clinic procedure room rather than an operating theatre. For appropriate cases, this is entirely safe and eliminates the additional costs of theatre staff, facility fees, and anaesthetic charges. WALANT makes this possible. Without general anaesthesia or a tourniquet, the infrastructure requirements are minimal. The patient walks in, has the procedure done under local anaesthetic, walks out and goes home after. The financial savings are real and meaningful, and the clinical results are no different, or arguably superior as the functional outcome can be tested on table, with the patient "participating" in his own surgery.

For patients considering hand surgery, you can read more about my WALANT approach, and hand and wrist conditions this is suitable for.

Written by Dr Ng Zhi Yang, UK & Singapore accredited Plastic Surgeon.

References

• Chung EB, Enzinger FM. Fibroma of tendon sheath. Cancer. 1979 Nov;44(5):1945-54. doi: 10.1002/1097-0142(197911)44:5<1945::aid-cncr2820440558>3.0.co;2-t. PMID: 91424.

• British Society for Surgery of the Hand. Wide Awake Hand Surgery Handbook. https://www.bssh.ac.uk/_userfiles/pages/files/COVID/Wide%20Awake%20Hand%20Surgery%20Handbook%20v2.pdf

• Satkunabalan M, Khan R, Ng ZY. UK Trainee Experience with WALANT - An Audit of 102 Cases. J Hand Surg Asian Pac Vol. 2024 Oct;29(5):458-466. doi: 10.1142/S2424835524500449. Epub 2024 Aug 30. PMID: 39205528.