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Wide Awake Hand Surgery

Park, Eugene, M.D.; Ko, Jason H., M.D.

Plastic and Reconstructive Surgery: October 2018 - Volume 142 - Issue 4 - p 1101-1102
doi: 10.1097/PRS.0000000000004821
Book and Media Reviews

Disclosure:The authors have no financial interest to declare in relation to the content of this review.

As a service to our readers, Plastic and Reconstructive Surgery® reviews books, DVDs, practice management software, and electronic media items of educational interest to reconstructive and aesthetic surgeons. All items are copyrighted and available commercially. The Journal actively solicits information in digital format for review.

Reviewers are selected on the basis of relevant interest. Reviews are solely the opinion of the reviewer; they are usually published as submitted, with only copy editing. Plastic and Reconstructive Surgery® does not endorse or recommend any review so published. Send books, DVDs, and any other material for consideration to: Arun K. Gosain, M.D., Review Editor, Plastic and Reconstructive Surgery, Brookriver Executive Center, 8150 Brookriver Drive, Suite S-415, Dallas, Texas 75247.

Arun K. Gosain, M.D.

Review Editor

Wide Awake Hand Surgery, edited and written primarily by Donald H. Lalonde, is a manual on how to perform “wide-awake local anesthesia no-tourniquet surgery” for a wide array of hand and upper extremity problems. Designed to be a “cookbook,” the text takes the reader through each step of wide-awake local anesthesia no-tourniquet surgery in detail, from preparation of the optimal local anesthetic mixture to the setup of an ideal procedure room. The book contains contributions from several well-known hand surgeons who have adopted the wide-awake local anesthesia no-tourniquet surgery technique and provides their varied perspectives on the benefits of this system, and some of the barriers to getting started. However, the voice and vision of this textbook belongs to Dr. Lalonde himself, and it is a testament to how he has dedicated his career to pioneering new ways to perform hand surgery. Over the years, Dr. Lalonde has successfully challenged dogma that used to make hand surgeons afraid to use epinephrine in the fingers—one of the highlights of the e-book is the video entitled, “History of the Rise and Fall of the Epinephrine Danger Myth,” which every hand surgeon should view. Dr. Lalonde also opened our eyes to using simpler methods of operative sterility (without higher infection rates), which simultaneously helped to spark the increasingly important dialogue regarding efforts to decrease surgical waste.

Wide Awake Hand Surgery is primarily a manual on local anesthesia techniques that allow hand surgeons to perform cases using Dr. Lalonde’s now well-known wide-awake local anesthesia no-tourniquet surgery method. By design, the text does not go into the actual steps of the operations. As such, it is most appropriate for fully trained surgeons who are looking to incorporate the wide-awake technique into their current practice. This is not to say that trainees and students would not benefit from reading it as well. The text contains a thorough description of injection techniques that minimize patient discomfort, and foundational knowledge about local anesthesia drugs with which everyone should become familiar.

The book is divided into three broad categories: (1) an atlas of local anesthetic diffusion in the hand, (2) principles of starting and running a practice that incorporates wide-awake local anesthesia no-tourniquet surgery, and (3) instructions for using wide-awake local anesthesia no-tourniquet surgery in specific operations. The early chapters provide evidence-based statements on the safety of wide-awake local anesthesia no-tourniquet surgery, data regarding the cost savings and risk reduction associated with the technique, and pointers on how surgeons can work with their hospital and colleagues to establish a wide-awake local anesthesia no-tourniquet surgery–ready clinic. Achieving “institutional buy-in” to begin performing wide-awake local anesthesia no-tourniquet surgery is a potential barrier for any U.S. surgeon (especially in a large institution); thus, it is helpful that Dr. Lalonde specifically addresses strategies to help the reader in this regard. In terms of specific types of operations, the textbook covers a variety of procedures, including nerve decompression, arthritis surgery, tendon repairs, tendon transfers, Dupuytren’s procedures, and fracture fixation. Each chapter provides easy-to-understand diagrams that illustrate optimal injection points and the area that typically becomes anesthetized. This is supplemented by a thorough description of postoperative therapy protocols, including the incorporation of early active motion and relative motion splints.

Perhaps the most valuable component of Wide Awake Hand Surgery is the attached e-book, which provides a searchable digital copy of the entire text, and over 150 videos showing injection techniques, patient counseling strategies, and other visual aids to supplement the text. A unique benefit of wide-awake surgery is the ability to have patients actively participate in aspects of the surgery. This is useful when setting the tension during a tendon transfer, evaluating for gap formation after flexor tendon repair, or checking stability after fracture fixation. Videos of these interactions help the reader understand the power of wide-awake surgery and demonstrate how both surgeons and patients might feel more reassured about postoperative outcomes. The videos are further useful in that they show how Dr. Lalonde counsels, educates, and comforts his patients both before and during surgery. Dr. Lalonde’s bedside manner is second to none, and the opportunity to witness and learn from his patient encounters is a resource that would otherwise be available only by visiting him.

Overall, Wide Awake Hand Surgery is an excellent resource for hand surgeons interested in learning wide-awake local anesthesia no-tourniquet surgery. Some criticism can be given regarding the repetition of information from chapter to chapter, and a few videos that do not supplement but rather duplicate the information in the text. All proceeds from sales of the book go to the American Association for Hand Surgery’s Lean and Green project, which aims to reduce the amount of waste produced in hand surgery. This is an extremely informative book by a pioneering surgeon who has dedicated his career to challenging dogma, decreasing surgical waste, and pushing the boundaries of what we can do in hand surgery with just some local anesthesia with epinephrine, sterile gloves and towels, and an open mind.

Copyright © 2018 by the American Society of Plastic Surgeons