Essentials of Hand and Upper Extremity Surgery
Chapter 69: Procedure Room or Office Hand Surgery with Field Sterility
Donald Lalonde, James Clarkson
Sometimes, you’re asked to do something you love, but you realize you can never fully do it justice. That’s exactly what happened when Dr. Don Lalonde, the father of awake hand surgery, invited me to coauthor his chapter in the upcoming edition of Essentials of Hand and Upper Extremity Surgery. The chapter focuses on his groundbreaking WALANT (Wide Awake Local Anesthesia No Tourniquet) surgical technique—a method that harkens back to the era before general anesthesia, when surgeons and patients navigated the challenges of awake surgery, working together towards their goal in authentic, almost artisanal relationships. Now we can offer this painlessly, using local anesthesia and where desired distractive technologies such as Immersive VR. The world has changed, and as we all grow old together, we must find a neurologically safer alternative to general anesthesia.
Dr. Lalonde’s inimitable style, directness, and meticulous attention to detail have made this chapter a comprehensive guide for surgeons looking to establish an office-based practice for awake hand surgery, just as I’ve done at Heritage Hand and Plastic Surgery. Much of the chapter is reflected in a podcast we recorded for the American Society for Surgery of the Hand at their annual meeting in Minneapolis in September.
Episode 26: WALANT, In-Office Surgery, and More with Drs. Donald Lalonde and James Clarkson. You can listen to it here.
As medicine becomes increasingly influenced by industry, patients and doctors alike are recognizing the value of simpler, more personalized care. This is an exciting time to explore how we can treat patients with greater efficiency and humanity. Since opening my private practice two months ago after leaving Michigan State University, I’ve had dozens of patients seek me out for individualized treatment. They want care that prioritizes their convenience and experience as much as the technical outcomes, and it gives me a chance to get to know them, and they I, as we share stories together.
Remarkably, while awake hand surgery can be performed in an office setting, less than 3% of suitable hand cases in the United States are offered this option annually. When I first learned about Dr. Lalonde’s work in Canada, in 2005 as a plastic surgery trainee in Dundee, Scotland, I knew it was something extraordinary but It wasn’t until well after I became an attending at Michigan State University in 2010 that I began offering awake surgery in the office in 2016. It took time for me to escape the inertia of the 20th century, and realize we might be on the wrong track. The complexity of hospital-based care had started to feel overwhelming, and, in conversations with my patients, I realized I wasn’t alone in this sentiment.
Hand clinic patients often present with pain-related issues, and the most elegant solutions are those that deliver the greatest benefit with the least intervention. Every patient’s goals are unique, as is their experience of pain. WALANT surgery embodies this simplicity, aligning with Hippocrates’ oath: First, do no harm.
When you encounter someone like Dr. Don Lalonde, you’re reminded of why you entered medicine in the first place. He stands against the tide of corporatized healthcare, championing a philosophy that prioritizes patients over processes. His work not only reshapes the practice of hand surgery but also rekindles my passion for personalized patient-centered care.
