Many hand surgery procedures can be done in the office
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Credit goes to Donald H. LaLonde, MD, FRCSC, at Dalhousie University in Nova Scotia, who helped debunk the idea that epinephrine is unsafe to use in digits and developed more comfortable methods of local anesthesia.
He also popularized the ability to do most hand surgery in the office with local field draping, which uses fewer resources and creates less waste.
Source: David C. Ring, MD, PhD
There is a cost associated with maintaining small sets of instruments and stocking towels, gauze, suture, prep solutions and bandage material. However, the main barrier to doing surgery in the office is financial. Medicare and commercial insurance do not pay for cubital tunnel release and needle fasciotomy or fasciectomy for Dupuytren’s disease when these procedures are done in the office.
Fortunately, our county payer for safety net insurance understands value and our services agreement incentivizes optimizing health while being a good steward of resources. The result is akin to VIP treatment of low-income patients. Office surgery tends to be easier on patients and less intimidating. In many cases, patients can undergo surgery as early as the day after the initial encounter. There are almost no bureaucratic barriers, such as preauthorizations, required electrodiagnostic testing or other similar issues, that are commonly encountered with commercial insurers. The patient’s family is with the patient, comfortably seated in an exam room while we prepare for the procedure, and the patient’s family is waiting there for the patient when we return from the operating suite. I call everyone — the patient and his or her family — the next day and they all get my cell phone number. This is the type of care everyone desires.
Out-of-pocket costs for the patient are one of the fastest-rising areas in health care. Surgery performed in the office is less costly. Not only the uninsured patients, but all patients with a percentage copay for surgery will become more cost-conscious. A patient with a high deductible will usually pay the entire cost of a minor hand surgery.
Day of the procedure
I meet patients in an exam room, answer their questions, confirm that what we planned to do still makes sense and get written informed consent. I write my initials and a “yes” at the exact point on the patient’s skin where I will make the incision, like a bull's-eye directing me to the correct location and helping prevent a wrong site procedure (Figure 1). This process constitutes our “block timeout.”
I then inject a mixture of 1% lidocaine with epinephrine 1:1 with 0.5% bupivacaine without epinephrine, which lasts about 8 to 10 hours, on average. Following Lalonde’s advice, I use a 27-gauge needle (a 30-gauge needle often gets occluded by skin), inject a small amount of anesthetic, wait 10 seconds and then, very slowly, inject the rest of the anesthetic, all in a single site, creating one large, expanding area of anesthetic. During this slow injection time, after the initial period of more intense pain, the patient and I chat about recovery. If you wait 20 to 30 minutes after delivery of the anesthetic, there is almost no bleeding during the case. Therefore, I try to administer a patient’s anesthetic one procedure in advance, so that it sets up while I am doing someone else’s surgery. Often this is not possible. In that case, any bleeding is manageable without a tourniquet after as little as 5 minutes.
I walk the patient across the hall to an operating suite where the patient lies on a table with an arm on a standard arm board. The instruments are on a Mayo stand. After prep and local field drape, we do a safety check. The patient tells us his or her name, date of birth and the surgery he or she wants done while everyone in the room helps confirm what is listed on the consent form and marked on the patient (Figure 2).
Indications
I will perform in the office any surgery that is not at risk for major bleeding, such as a volar wrist ganglion, and does not leave a permanent metal implant, such as a plate and screws (Figure 3). For example, I pin fractures, repair tendons and digital nerves, amputate fingertips, release cubital tunnels, remove lipomas on the shoulder or back, and release Dupuytren’s contractures (Figure 4). Since the start of the COVID-19 pandemic, we mostly use buried 5-0 absorbable suture, such as polydioxanone. The scar might be a little tender as the suture absorbs, and we still get the occasional wound separation and superficial infection. However, the convenience of not returning to the office — a phone or video check-in is done at 2 weeks — for suture removal is appreciated by the patients.
After the surgery, we sit the patient up and make sure the patient is not woozy. Then, we stand the patient up and again check to make sure he or she is not woozy. Then, we walk the patient back to the room and, if the patient is feeling up to it, the patient can leave immediately.
At-home care
The dressing can come off at any time and the wound can get wet and soapy in the shower. I often recommend waiting 2 days before showering to allow a scab to form. They use over-the-counter pain medication (acetaminophen and ibuprofen), and I recommend they start taking this as soon as they get home, long before the anesthetic wears off. Pain can signal danger, so I prepare patients for that feeling of, “There’s my surgery pain ... my body needs time to heal.” This is partly why I give patients my cell phone number and call them the next day. I have not prescribed opioids for any of these procedures in about 6 years. The next-day call is also so I can remind patients and their families that “movers recover quicker. You want to be a mover.”
I encourage patients to get into their daily routines. Recovery after injury and surgery is all about feeling healthy and moving, even when that movement is painful. It is counter-intuitive, which is why patients benefit from our guidance.
My hope in writing this article is that patients, surgeons, payers and policymakers might see that office surgery is best for the patient, the surgeon, society and the environment. We need to move the culture on this. It feels like the right thing to do.
- References:
- Joukhadar N, et al. Plast Reconstr Surg Glob Open. 2021;doi:10.1097/GOX.0000000000003730.
- Thiel CL, et al. Hand (N Y). 2019;doi:10.1177/1558944717743595.
- For more information:
- David C. Ring, MD, PhD, is associate dean for comprehensive care, professor of surgery and courtesy professor of psychiatry and health social work. He can be reached at Dell Medical School — The University of Texas at Austin, 1701 Trinity St., Austin, TX 78712; email: david.ring@austin.utexas.edu.
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