WALANT stands for Wide Awake Local Anesthetic No Tourniquet.
A surgery where you are fully awake, the hand is numb, there is no tight band squeezing your arm, and you can move your fingers during the operation.
That last part is not a quirk.
It is the entire point.
How it works
Two drugs mixed together and injected into the surgical area.
- Local anesthetic to numb the area
- Adrenaline to constrict the small blood vessels, which controls bleeding without a tourniquet
The adrenaline part was considered dangerous in fingers for most of the twentieth century, based on a handful of old case reports involving a different, degraded anesthetic. That teaching has been overturned by a large body of work since, and adrenaline in the finger is now routine in units that have adopted this.
The injection takes effect over roughly 20 to 30 minutes, which is why you may wait between being injected and being operated on.
Why being awake improves the result
Under general anesthetic, the surgeon repairs the tendon, closes up, and finds out how it moves weeks later.
Awake, they ask you to bend the finger on the table. If the repair catches, or the release is incomplete, or the tension is wrong, they fix it there and then.
- Trigger finger release — you demonstrate that the catching is gone before they close
- Flexor tendon repair — the repair is tested under active movement, which catches gapping and bunching
- Tendon transfers, where tension is the entire game
- Carpal tunnel release and Dupuytren’s surgery
- Many finger and metacarpal fractures
You cannot test a tendon repair on a sleeping patient. That is the case in one sentence.
Being awake is not the compromise. It is the quality control.
The practical advantages
- No fasting. Eat breakfast, take your usual medication
- No general anesthetic risks — no nausea, no grogginess, no anesthetic recovery period
- No tourniquet. A tourniquet is a blood pressure cuff at 250mmHg for up to two hours, and it is one of the least pleasant parts of awake hand surgery done the old way
- Shorter day. Often in and out in a couple of hours, walking out unaided
- Cheaper, and safer for people with heart or lung disease who would be poor candidates for a general
- You get taught during the operation. Surgeons routinely show patients their own repaired tendon moving. People remember that
What it feels like
The injection stings for 20 to 60 seconds. That is the worst of it, and a good injector buffers the solution and goes slowly, which reduces it considerably.
After that, nothing sharp. You will feel pressure, pulling and movement. You will hear instruments. There is a drape, so you see the field only if you want to.
People talk throughout. Most report it is far less alarming than they expected.
The most common comment afterwards is that the anticipation was worse than the event. The second most common is surprise at how ordinary it felt.
Who it suits less well
- People with significant needle phobia or anxiety, where the stress outweighs the benefit
- Children, generally
- Very long or complex reconstructions, or surgery involving several areas
- Cases needing a bone graft from elsewhere
- Anyone who genuinely does not want to be awake. That is a legitimate preference and a reasonable thing to say out loud
Worth asking
- Is my operation suitable for WALANT?
- Will you ask me to move during it, and what will you be checking?
- How long between injection and start?
- Can I drive home? Usually no, even without sedation
- When does the numbness wear off, and what pain relief do I take before it does?
That last one matters. The adrenaline keeps the area numb for hours, and pain arrives suddenly when it wears off. Take the first dose of pain relief before that happens rather than after.
If your surgeon can watch the hand work before closing it, the problem gets solved in theatre rather than discovered in therapy.
See also what to ask before hand surgery.
Every article on this site is written using the Closing Window Method: name the window your condition runs on, find where you are in it, and act while it’s still open.