How to Start WALANT Procedure Room Surgery Like Ghana to Improve Access and Affordability

GOAL OF THIS VIDEO ARTICLE A wide-awake local anesthesia no tourniquet (WALANT) procedure room is where sedation-free WALANT minor surgical procedures are performed with evidence-based field sterility1 and minimally painful tumescent local anesthesia2 outside of the main operating room. Lidocaine and epinephrine are the only 2 medications given to the patients, like at a dentist’s office. Following the Canadian model, the first WALANT room was started in Ghana in 2017. (See Video 1 [online], which shows the first WALANT procedure room in Ghana in Kumasi in 2017. This began the process of introducing affordable, more accessible surgery to northern Ghanaian patients. This is “the recipe” for how we did it.) (See Video 2 [online], which displays how the WALANT room in Kumasi, Ghana, improved over its first 7 y.) {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"shows the first WALANT procedure room in Ghana in Kumasi in 2017. This began the process of introducing affordable, more accessible surgery to northern Ghanaian patients. This is “the recipe” for how we did it.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_t1apf7e7"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2","caption":"displays how the WALANT room in Kumasi, Ghana, improved over its first 7 y.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_f95ky7ft"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Patients in Ghana now have new access to surgery at less than half the cost with no increase in infection rates.3 Since then, WALANT has developed in 75 hospitals in 8 East African countries to decrease costs and increase access to surgery in sub-Saharan East Africa as well.4 The WALANT technique and procedure rooms have increased access to surgical care for patients, care that they would not otherwise have been able to receive. In addition, the WALANT procedure rooms have freed up the main operating room and general anesthesia to do other cases, resulting in capacity building around surgical care. The purpose of this short article and its videos is to provide surgeons from other countries with a “quick recipe” for how they can start WALANT minor procedure rooms in their own hospitals. (See Video 3 [online], which displays the first WALANT room in Accra, Ghana, which started in 2022. This began the process of introducing affordable, more accessible surgery to southern Ghanaian patients.) (See Video 4 [online], which displays how and why the WALANT room in Accra is helping patients get affordable, accessible surgery.) {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 3","caption":"displays the first WALANT room in Accra, Ghana, which started in 2022. This began the process of introducing affordable, more accessible surgery to southern Ghanaian patients.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_8mgjcdkb"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 4","caption":"displays how and why the WALANT room in Accra is helping patients get affordable, accessible surgery.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_nw35pnew"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} ADVANCES THAT ENABLED MOVING SOME SURGICAL PROCEDURES TO MINOR PROCEDURE ROOMS Evidence-based field sterility in minor procedure rooms has been shown to have the same infection rates as the main operating room for many operations.1 The reduced usage of draping, gowning, and consumables is allowing our hospitals to more wisely use our resources to perform more surgery in the WALANT rooms. Sedation is no longer required for many operations because epinephrine hemostasis has eliminated the need for the tourniquet and because properly injected tumescent local anesthesia is minimally painful, even for larger procedures in the main operating rooms.2 THE VALUE OF WALANT MINOR PROCEDURE ROOM SURGERY Decreasing the need for formal operating theaters or anesthesiologists, WALANT minor procedure room surgery is possible in locations where these expensive resources are lacking. In both Accra and Kumasi, our surgical numbers greatly increased compared with the previous years where all cases had to be done in the main operating rooms. The number of WALANT cases and the number and specialties of surgeons using the WALANT rooms continue to increase. Moving minor procedures out of the main operating room allows better access there for major surgery that really needs general anesthesia and full sterility. In Ghana, main operating room time is often impossible to get. With WALANT, all that is needed is any room with a bed. There is no need for elaborate expensive ventilation systems.1 Very basic instruments are all that is required. Expensive ceiling-mounted lights are not necessary. Standing floor lamps or headlights are sufficient. Multiple studies have shown that WALANT surgery is consistently cheaper and more efficient.5 With WALANT surgery, a perioperative workup for sedation is not required. This saves our patients even more money and time. Because we do not use sedation with WALANT, most patients get up and go home from the operating table, like in a dentist office. Costs for recovery room personnel and equipment to recover from sedation and general anesthesia are reduced or eliminated. There is no postoperative nausea and vomiting. The patients are able to come for their surgery alone without needing a companion on the day of surgery. Access to operating room personnel was a major challenge in Ghana. This has been reduced with WALANT rooms, which require fewer nurses and do not require anesthesiology teams or hospital admissions to recover from general anesthesia. Although it is available, monitoring is not required in the sedation-free WALANT room, as in emergency department procedure rooms. Our surgeons have more flexibility in booking cases and have more time to properly teach the trainees. Our residents and trainees are able to do cases at their own pace without restrictions from anesthesia or nursing teams, or from the tourniquet time. Patient interaction is an invaluable advantage of WALANT. We are able to test repairs of tendons and bones during the surgery. We educate patients about postoperative care during the surgery to reduce postoperative complications. We find this makes them more cooperative during the postoperative course because they have a better understanding of what has been done for them. In Ghana, we have used the WALANT room for hand cases such as fracture fixation, nerve and tendon repairs, and release of burn contractures. In addition, we have used it for facial reconstruction, mass excisions, acute traumatic wound management, and so on. The WALANT rooms were started by plastic surgeons but are now also used by other specialties, such as general surgery, urology, orthopedic surgery, and dermatology. They also use the WALANT room for minor procedures which they used to take to the main operating room. Working closely with our hospital management team has been very important in providing administrative endorsement and support for logistics, human resources, and daily planning of activities in the WALANT rooms. CONCLUSIONS The WALANT rooms have been beneficial to us in Ghana in the 7 years since their inception. The WALANT technique and procedure rooms have increased access to surgical care for patients, care that they would not otherwise have been able to receive. In addition, the WALANT procedure rooms have freed up the main operating room and general anesthesia to do other cases, resulting in capacity building around surgical care. We recommend that every hospital should start minor procedure room surgery to make surgery more affordable and more accessible. It can be set up with minimal cost and logistics. All that is required is a change of mindset. DISCLOSURES Dr. Lalonde receives royalties from Thieme Medical Publishers and serves as a consultant for ASSI, Corp. The other authors have no financial interest to declare in relation to the content of this article.

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