What’s in a Name?

Is it time for a change in terminology?

Why not call this site "Wide Awake Hand Surgery"? After all the definitive book on Walant (Wide Awake Local Anaesthetic No Tourniquet - or "Walnut" as my kids call it!) by one of the co-founders of this site is called Wide Awake Hand Surgery!

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Well, there has been some debate over the years since Walant has been popular as to what to call it. Initially it was called Wide Awake Hand Surgery as the patients were…wide awake. The problem was that this also included those patients that had no sedation admittedly but they did have a more invasive and proximal nerve block, such as an axillary or supra-clavicular block. This gave them a wonderful sensory block at the expense of a motor block as well. This is not what hand surgeons mean by Wide Awake Hand Surgery. This is traditional hand surgery just omitting the sedation (or general anaesthetic) but nothing else. It's no different from normal.

Walant is a more radical departure from traditional practices of using a tourniquet, anaesthetist/anesthesiologist and having a "nice, dry" surgical field. The critical change when using Walant is the addition of adrenaline/epinephrine to the local anaesthetic (LA). Adding this negates the need for the tourniquet and the cascading benefits follow from there (see "benefits of Walant"). With no tourniquet, we don't need a regional or general anaesthetic to cover the pain that the tourniquet causes. With no more formal anaesthetic we don't need an anaesthetist (and the expensive paraphernalia that accompanies them!) and this opens the door for us to reduce costs, improve efficiency within the theatre system and importantly frees us from the shackle of using the main operating theatre. So Walant is different from Wide Awake Hand Surgery.

The term Walant was first introduced by Dr. Jerry Rubin on ASSH List Serv. in July 2011. It is a rather inelegant term but it certainly describes the technique better. In Indonesia, Dr. Theddeus Prasetyono refers to Walant in one his publications on this matter as "Tourniquet-free Hand Surgery" which is a somewhat simpler but all-encompassing term, implying the use of adrenaline/epinephrine.

So why not call the site Wide Awake Hand Surgery? This site is dedicated to extolling the virtues of Walant and we do not cover or intend to cover surgery using more proximal "regional" anaesthetic techniques. These are well described in Green's or other reference hand surgery textbooks. We will only be describing, promoting and teaching the use of adrenaline/epinephrine mixed with the LA that we inject.

Does using a tourniquet for a short time mean we are not using Walant? Certainly not, as I can testify to in my own surgery (radial sagittal band repair). I had a forearm tourniquet on for 20 minutes and it was a great deal less painful than I expected. I had scar tissue present from previous surgery so to delineate the layers more easily, my surgeon applied a tourniquet briefly but took it off once the dissection had been completed. Once the tourniquet was off I was able to fully flex and extend and the repair had been well and truly tested!

Adrenaline/EPINEPHRINE does not penetrate scar tissue and this is why Dupuytren's disease surgery is more difficult; because there are very small things in our surgical field that we don't want to damage, but there is also more fluid oozing from very small vessels that penetrate the diseased tissue that have not been constricted by the adrenaline. Adrenaline does not differentiate between scar and Dupuytren's disease; the adrenaline still cannot penetrate it. This is why Dupuytren's surgery is in the advanced section of the Walant University and we would certainly not recommend using Walant techniques (without a tourniquet, however briefly) when there is extensive scar tissue present, such as in some tendon surgery. Once you are more used to the surgical field being more moist, you can start to be bolder in the presence of scar but it is not for the uninitiated!

So is Walant the right term? I'm not sure about that either but it's the best we have, as they say! The issue I have is that the term "Walant" omits adrenaline/epinephrine from the description. I would argue that it is not the fact that we do not routinely use a tourniquet that sets this technique apart and it is not the same as the routine use of LA. We have shown that just being "wide awake" does not distinguish this technique from more traditional hand surgery. It is the addition of adrenaline/epinephrine to the LA that sparks the cascade of changes that benefit us when using this technique.

Perhaps we should call it "Surgery of the Hand with Active Movements" but I'm not sure the acronym will catch on (!) so for now we're stuck with Walant (or Wide Awake Hand Surgery). Any suggestions for other acronyms please leave in the comments section below.

About the Author

Don Lalonde and Ali Phillips are hand surgeons in Canada and the UK respectively. They are co-founders of Walant.Surgery and are helping the world adopt WALANT. Get in touch HERE

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