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Wide Awake, Local Anaesthetic, No Tourniquet


A technique for using local anaesthetic, where patients remain awake, rather than general anaesthetic, during some surgeries has meant that over 60 patients across County Durham and Darlington were able to undergo surgical procedures that might have otherwise been delayed during the Covid-19 pandemic.   

During spring and early summer County Durham and Darlington NHS Foundation Trust, like Trusts across the NHS, focused on caring for patients with Covid-19 and being prepared for potentially even larger number of these patients.  This meant that some services, including some surgical procedures, had to be reduced both to keep patients safe and as staff were re-deployed to areas where their skills were most needed. 


Plastic surgeons based at University Hospital of North Durham, recognised that a local anaesthetic technique, popular in the USA, but little used in the UK, could be offered to certain groups of patient so their procedures could go ahead.   Luckily, several of them were fully trained in using the technique - known as WALANT. 

Haitham Khashaba, speciality doctor in plastic surgery, explains, "Using WALANT, which stands for 'Wide Awake, Local Anaesthetic, No Tourniquet' , is  particularly ideal for some finger, hand and lower arm injuries and can also be used for planned surgeries such as carpal tunnel syndrome and some complications of arthritis in the hand and fingers. 

"The procedure involves an injection containing a local anaesthetic and adrenaline - which causes the artery to constrict so that it doesn't bleed - usually a tourniquet and a general anaesthetic is needed to achieve this.  The surgeon is then able to undertake the procedure. 

"We found that during lockdown, more people presented to our emergency departments with hand injuries than we would usually see - possibly due to DIY or gardening accidents.    

"We were able to review them in our outpatient department and those patients whose injury was appropriate for WALANT and who were happy to go ahead, had their procedure there and then.  Some patients are understandably concerned about being awake during the procedure, preferring to wait and have a general anaesthetic. We understand these concerns and there is no pressure to opt for WALANT.  Patients having a planned procedure, with whom we can discuss the WALANT option in advance, are more likely to go ahead''.

 "With a general anaesthetic, patients need to starve beforehand and stay in hospital for at least a few hours afterwards.  If the procedure takes place in the afternoon this can mean an overnight stay in hospital, both for observation and to be reviewed by a physiotherapist''.  

"With WALANT, patients can usually be seen more or less straight away by one of our physio team and given advice on do's and don'ts as well as some exercises. It's natural for the area operated on to swell afterwards, but the speed of this review means that, if a splint is needed, it can be applied before the area starts to swell.  The patient can then go home, often having only been in hospital for a few hours. It's that simple''  

"The feedback we've had has been tremendously positive with many patients saying they found it really interesting being awake during the procedure'' 

"Of course, WALANT isn't suitable for every injury or condition, but we assess patients and offer it where possible.  Patients who present at Darlington Memorial Hospital with an injury are referred to University Hospital of North Durham, which is where the Plastics service is based and, where appropriate, have the procedure on the same day.  For more complex surgeries, where WALANT is appropriate, we'll use one of our theatres''   

Gemma Morris, 26, had surgery on her thumb in July, using the WALANT technique, and can't speak highly enough of her experience.

Gemma, who lives in Crook, explains, "I snapped a tendon in my thumb which meant it didn't work at all.  Mr Khashaba explained that the first finger actually has two tendons, so he could transplant one of them into my thumb which sounded like an amazing, and straightforward, solution - however, when he suggested doing it using only local anaesthetic, I admit I was terrified''.   

"He gently explained what would happen and all the benefits compared with having a general anaesthetic, including that we could go ahead there and then - so I decided to give it a go''.

"We were in an operating theatre and Mr Khashaba talked to me from the start, explaining what he was doing.  After the first few minutes, I was relaxed enough to watch - it was fascinating and the time flew by!  A temporary cast was put on to protect my thumb and because I didn't need time to come around I was able to see a physio immediately after the procedure.  Then I went home''.

"If I'd had a general anaesthetic, I may have had to stay in hospital overnight which would have been fine, but so much nicer to at home''.

"My thumb was back to normal really quickly.  I work in a nursery and didn't appreciate how much we use our thumbs until I couldn't use one of mine''. 

"We're very lucky having this option available, making the whole process quicker and easier.  I'm very grateful and glad I agreed to it.  I would encourage others to consider WALANT if they're offered it."


Published 9th November 2020



'As I was very, very nervous, I must have been the worst patient ever and they were brilliant with me and I can't thank them enough - could you please pass on my sincere thanks.'

Patient, Hysteroscopy Unit, Chester-le-Street Community Hospital