Dr. Lalonde is a Professor of Surgery at Dalhousie University, Saint John, New Brunswick, Canada. He is the Past President of the Canadian Society for Surgery of the Hand, Past Chairman of the American Board of Plastic Surgery, Past President of the American Association for Hand Surgery, Past President of the Canadian Society of Plastic Surgeons, and an Honorary Member of the American Society of Hand Therapists.

Wide awake surgery advances three disruptive changes that affect all surgical specialties: 1) Replacing sedation with minimally painful tumescent local anesthesia injection to numb large body areas in patients who stay comfortably wide awake for their operations. 2) The tourniquet is no longer needed for many upper and lower limb procedures, further enabling sedation-free surgery. 3) Evidence-based sterility permits many wide-awake operations out of the main operating room without increasing the risk of infection.

Injecting local anesthesia should no longer be painful in 2024. Surgeons who are still hurting people with numbing medicine should look at the videos on the minimally painful injection of tumescent local anesthesia.1 It is easy to teach and learn.1 Patients barely feel the first poke of a tiny 30-gauge needle, then no more pain during the rest of the injections or the surgery. This enables surgeons of many specialties to perform many large operations without any sedation whatsoever.2 This eliminates all nausea and vomiting, as well as all the safety issues of sedating ASA4 patients with medical morbidities.3

Eliminating the tourniquet in favor of epinephrine vasoconstriction has been a major advance in upper4 and lower extremity5 surgery. A PubMed search of the word WALANT (Wide Awake Local Anesthesia No Tourniquet) on July 27, 2024, produced 316 papers.6 Epinephrine safety in the fingers and toes is now well established.7 No tourniquet means patients do not need intravenous or oral sedation to tolerate unnecessary tourniquet pain. The only two medications used in wide-awake surgery are lidocaine and epinephrine in extremely safe dosages, like at the dentist.8 Eliminating the sedation removes the need for preoperative tests, intravenous insertion, monitoring, and “clearing for surgery” consultations. We do not need these for wide-awake surgery any more than we need them to go to the dentist for a filling.

Avoiding unnecessary sedation importantly means we can move many operations to minor procedure rooms with field sterility, while maintaining the same infection risk seen in the main operating rooms. The new field of evidence-based sterility9 studies the rates of infection resulting from differing levels of sterility used to perform the same procedures. Eliminating the unnecessary solid waste10 used in unnecessary main operating room sterility greatly decreases surgical costs11 and the carbon footprint12 for surgery. It is also increasing surgical availability in under-resourced nations where many patients could not previously afford to have surgery because they were unable to pay for unnecessary sedation and main operating room sterility.13

Patients love the wide-awake surgical experience because they avoid intravenous needles, getting undressed, nausea and vomiting, and wasting time having tests and seeing specialists. They just sit right up and go home pain-free after a pleasant, educational experience with their surgeon.14 The wide-awake approach has changed surgery from something that had to be endured into something that can be enjoyed.