Gone are the days of a paternalistic approach to medicine. Patients need to be at the centre of their care and being awake during surgery allows us, as surgeons, to educate and reassure them and build a rapport with them.

Educating patients about the diagnosis and operation during surgery can help to begin laying the responsibility for their rehabilitation, wound care etc. in their court thereby empowering them with a degree of autonomy for their own outcome. Better informed patients are less likely to litigate, are more likely to perform their rehabilitation more accurately and potentially have a better outcome.

Being able to inform and educate during surgery also negates the need to see patients in between cases once they wake from a GA thereby improving efficiency of the list.

"Wrong site surgery" is almost unheard of when the patient is Wide Awake. The WHO checklist can be performed by asking the patient what operation they want on which part of the body. (Most reply "liposuction" or "a facelift" but I do gently remind them that this is out of my skill set!) They can however confirm that what we are about to do is correct.

We know that communication is the root of the vast majority of complaints and litigations so using the time in theatre to inform and communicate with ones patient can only be a good thing.

The local anaesthesia used is mostly 1% lignocaine/lidocaine with adrenaline/epinephrine. This has a fast onset of action, within a few minutes but can last several hours.

The adrenaline/epinephrine is 1:100 000 in the USA and Canada and 1:200 000 in Europe/UK. ​

The Xylocaine has a pH of between 4 & 5 (roughly 4.7). This can be corrected to 7.4 by adding 2mls of 8.4% bicarbonate to a 20ml vial of Xylocaine. Buffered Xylocaine hurts less (see section on how to give an almost painless injection).

Another local anaesthetic (Bupivicaine) can be used alone (with adrenaline) or be added to a lignocaine/adrenaline mix to prolong its activity from 4 to roughly 15 hours. This does however allow return of pain sensation before protective sensation which some patients do not like. It is certainly recommended for any bony work (trapeziectomy/scaphoid etc.) as these can be more painful post-operatively.

The local anaesthesia is injected in a tumescent technique to assist with haemostasis, injecting large volumes under the skin that then dissipates to all the areas that need to be numbed before surgery starts! We can use up to 50mls of 1% for an average patient but if you need more we can simply dilute by half and the adrenaline will still provide enough haemostasis to perform the surgery safely. An example would be 30-40mls for an tendon (e.g. EIP to EPL) transfer. It sounds a lot but it will disperse very quickly.

I would suggest any surgeon apply a tourniquet to their own arm for 15 minutes and see how comfortable/tolerable it is...I can vouch for the fact that it is not! I do appreciate that newcomers to the technique may wish to have one applied for the first few case but not inflated, just in case but you will not need it.

The principle is simple really:
With adrenaline in the local anaesthetic mixture = you don't need a tourniquet (which hurts!)
Without a tourniquet = you don't need a regional anaesthetic (to stop the pain of the tourniquet)
Without a regional anaesthetic = you don't need an anaesthetist
Without an anaesthetist / ODP = vastly reduced cost
Fewer people involved = leaner and more efficient process
Better processes = more patients treated, more efficiently in a more patient-centred manner
So it all starts with the local anaesthetic...

It is a more moist wound than when using a tourniquet but one quickly gets used to it and using more gauze swabs is now very routine. Firmly pressing on the wound to absorb the fluid is a good technique rather than rubbing the wound as the former does not displace the tiny clots that have formed and pressing for a second or so will allow the excess fluid/LA to be absorbed into the gauze.

There is no question that the main benefit of not having a tourniquet and a regional or general anaesthetic is that the patient can move their digits to test your repair/reconstruction. This is a very powerful message to the patient that their hand/fingers can move and should be moved. With awake patients, moving their fixed digits, they can rehabilitate earlier with more conviction and potentially get better results. We await the results of larger, multi-centre studies in the future to prove this is the case!