1. WIDE AWAKE SURGERY
SCOPE IN HAND SURGERY USING
SURGEON ADMINISTERED LOCAL/REGIONAL ANAESTHESIA
(SALoRA)
Wei Ping Sim1, Shoun Tan1, Vaikunthan Rajaratnam1
1Hand and Reconstructive Microsurgery Service,
Department of Orthopaedic Surgery, KTPH

2. Introduction
 Hand surgeries
local/regional anaesthesia
 Popularity of WALANT D
Lalonde - 2015
 Our experience of Surgeon
Administered
Local/Regional Anaesthesia
(SALoRA) without sedation

4. Methodology
 Retrospective analysis of all Hand surgeries performed under
SALoRA from 2013 to 2016
 Single center – KTPH, Singapore
 All cases performed or supervised by the senior author
 Exclusion:
 Surgeries performed by KTPH Hand service on areas other then
the hand, wrist, forearm and elbows

5.  Elective single trigger finger release
 71, Chinese, Male
 Chronic medical issues: well controlled DM, HTN, HLD, Brachiofacial
stroke >10years ago, grade II chronic renal impairment
 Total Mepivacaine 88mg with adrenaline 44mcg injected (max
recommended dose 7 mg/kg mepivacaine)
 Developed tachycardia 150-200 intraoperatively
 Required anaesthetist intervention with IV metoprolol
 Operation time – 15 min
Negative Experience with WALANT

6. SALoRA
 Surgeon Administered
Local/Regional
Anaesthesia
 Local anaesthetic
infiltration without
adrenaline use
 Tourniquet use as
required
 No sedation

7. Study Population
Female, 36%
(719)
Male, 64%
(1275)
Gender
Other
Surgeries,
34% (1022)
Surgeries done
under SALoRA ,
66% (1994)
Surgeries during Time Period
Total: 3016
 1994 surgeries (66%) performed using SALoRA
 Mean age 45.78 years (SD = 16)
 96% unilateral limb, 4% bilateral upper limbs
Elective, 61%
(1217)
Emergency,
39% (777)
Elective vs Emergency Surgery

8. Study Population - Nationality
Singapore, 68%
(1354)
India, 8% (158)
Malaysia, 7% (139)
Bangladesh,
7% (135)
China, 6% (130)
Others, 1% (24)
Myammar, 1% (21)
Indonesia, 1% (19)
Philippines, 1% (14)

9. Region of Surgery
Elbow 0% (5)
Forearm 1% (14) >1 Region 1% (21)
>1 Fingers 4% (80)
Wrist 5% (104)
Hand 44% (883)
1 Finger 45% (887)

10. Types of Surgeries
 Trigger finger, soft
tissue debridement,
soft tissue excision,
carpal tunnel
release, surgical
fixation and soft
tissue
reconstruction/repair
made up >80% of
total cases
performed under
SALoRA

11. Types of Surgeries - Elective
 Trigger finger, soft
tissue excision and
carpal tunnel release
made up >80% of
Elective cases

12. Types of Surgeries - Emergency
 Soft tissue
debridement,
surgical fixation and
soft tissue
reconstruction made
up >80% of
Emergent cases

13. Types of Surgery by Gender
 Male dominance in most surgery
types
 Female dominance is found in
patients with carpal tunnel
release and other
enthesopathies
 Equal distribution is seen in
patients with trigger fingers

14. Arm Tourniquet Use
Bilateral, 3% (66)
Right, 35% (693)
Left, 30% (598)
No Tourniquet, 32%
(637)
 68% of patients tolerated arm
tourniquet use with no issues
 Longest tourniquet duration: 104min
 Shortest tourniquet duration: 2min
 Median arm tourniquet duration: 20min
 Mean: 24min (SD = 15)

15. Types of Surgeries
 Distal radius fixation performed
using Bier’s block
 6 cases
 Mean operative duration 63min (SD
= 27)
 Complex reconstruction
 Cases involving complex repair of
tendons, neurological and vascular
structures
 3 cases

16. Complex Reconstruction Cases
SN Diagnosis Operative Description SALoRA Type Duration
of Surgery
(min)
Tourniquet
Time (min)
1 Multiple
forearm
lacerations
- Ulnar and median nerve repair
- Ulnar artery repair
- FCR, FDS to MF and RF, FDP to
RF and LF, FPL, FCU, BR repair
Bier’s Block 135 39 + 28
2 Wrist
laceration
- Ulnar nerve repair
- Ulnar artery repair
- FCU
Cubital ulnar block, medial
cutaneous branch block,
ulnar block at wrist,
median nerve block
65 28
3 Wrist
laceration
- Median nerve repair
- Ulnar artery repair
- FCU, FCR, FDP to MF RF and
LF, FDS to IF MF and RF
Wrist and field block 85 88

17.  3 cases of SALoRA failure cases (0.001%)
SALoRA Failure Cases
SN Diagnosis Operative
Description
SALoRA Tyoe Duration
of Surgery
(min)
Tourniquet
Time (min)
1 Neglected felon
with OM of distal
phalanx
Incision, drainage and
debridement
Ring Block
- Midazolam given intra-
operatively, op completed
30 Arm - 20
2 Hand laceration Re-look debridement Field Block
- Patient not keen to continue
with SALoRA
5 Nil
3 Foreign body in
Hand
Removal of foreign
body
Field Block
- Fentanyl given intra-operatively,
op completed
70 Arm - 70

18. Conclusion
SALoRA with tourniquet
 Wide spectrum
 Effective
 Productive
 Optimum resource
management
 Inclusion in curriculum of hand
surgery training

19. THANK YOU