Would You Choose to Stay Awake During Your Surgery?

Surgeons are increasingly offering patients the option to stay awake during surgery, using only local anesthetic instead of general anesthesia.

STORY AT-A-GLANCE

• Orthopedic procedures, such as hand, knee or wrist surgery, are among the most common procedures now performed with patients awake, but heart surgery and many others are following suit

• Using only local anesthetics during surgery eliminates the risks associated with general anesthesia, shortens recovery time and costs considerably less

• Some people may feel overly stressed or anxious during awake surgery, or may be unable to stay still in one position for the duration of surgery

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Editor's Note: This article is a reprint. It was originally published April 15, 2017.

Staying awake during surgery is the norm for certain procedures, like some cesarean sections and brain surgeries. However, most people expect that they'll be under general anesthesia should they require surgery.

This may soon change, as increasing numbers of patients are opting to take control of their surgical experience and stay awake during the procedure.

It's a decision that comes with both benefits and risks — to the patient and the surgeon. Not every surgery is appropriate for staying awake, but if you're given the option, here's what you should consider.

During Which Types of Surgery Can Patients Stay Awake?

Not every hospital offers patients the "awake" option, even in surgeries for which it's conducive, because it requires a customized experience. The surgeon must also be willing and the patient must be able to handle the procedure without becoming overly stressed or anxious.

Assuming all of this lines up, orthopedic procedures, such as hand, knee or wrist surgery, are among the most common procedures now performed with patients awake but, as reported by The New York Times, "surgery in breast, colorectal, thoracic, vascular, otolaryngological, urological, ophthalmological and cosmetic specialties is also moving in this direction."¹

Research suggests many patients have a favorable experience with the "wide awake approach." In a study of the use of local anesthetics in hand surgery, 83% said they would choose this form of anesthesia again if they needed another operation.² In another study, patients were equally satisfied on average whether they received local anesthesia or sedation.³

What Are the Benefits of Staying Awake During Surgery?

One of the primary benefits is avoiding the risks that come along with general anesthesia, which can be significant. Research published in the journal Anesthesiology compared the effectiveness of local versus general anesthesia for hip fracture surgery and found that local anesthesia was associated with better outcomes.

"Regional anesthesia is associated with a lower odds of inpatient mortality and pulmonary complications among all hip fracture patients compared with general anesthesia," the researchers wrote.⁴

Further, with local anesthesia recovery time is reduced, as is the cost of surgery. Patients who undergo sedation spend more time at the hospital, require more pre-operative testing and report greater anxiety prior to surgery.⁵

An analysis of 100 wide awake hand surgery procedures performed at a military medical center also revealed significant cost savings compared to general anesthesia. For two procedures (carpal tunnel release and A1 pulley release), an 85% and 70% cost savings were reported, respectively.⁶

Some Patients Get to Take an Active Role in Surgery

In some cases, another major advantage is that a surgeon can assess a patient's mobility during surgery, which can help to improve outcomes. As noted in the Bulletin of the Hospital for Joint Disease:⁷

"This confers particular advantage in surgeries such as tendon repairs, tendon transfers and soft tissue releases in which intraoperative active motion can [be] used to optimize outcomes.

The wide awake approach also confers significant benefit to patients, providers and health care systems alike due to efficiencies and cost savings."

The Journal of Hand Surgery also reported on the use of local anesthesia for finger tendon transfer, with favorable results in part because the patients get to move their digits during surgery. The researchers explained:⁸

"Wide awake patients are comfortable, cooperative and educable, and are able to help the surgeon set the correct tension for the transfer.

They flex and extend the thumb before the skin is closed to make sure the transfer is not too tight or too loose. It helps that they remember seeing the thumb move nicely during the surgery when they are in postoperative hand therapy."

A Swedish study similarly concluded that, compared to general anesthesia, awake hand surgery reduces patient discomfort, allows the patient to participate in the surgery, improves safe outcomes and greatly reduces the cost of medical care.⁹ "Furthermore, patients regarded as high-risk can be safely treated without risk of cardiac or pulmonary side effects," the researchers wrote.¹⁰

Staying awake during surgery also provides a level of patient involvement that was previously not attainable. For people interested in taking an active role in their health care, awake surgery allows patients to watch the surgical procedure and even ask questions while it's ongoing. As the Times put it:¹¹

"Choosing to watch your own surgery is one more manifestation of the patient autonomy movement, in which patients, pushing back against physician paternalism, are eager to involve themselves more deeply in their own medical treatment."

Wide Awake Surgery May Not Be for Everyone

There are some additional considerations to take into account when considering staying awake during surgery. Practical issues, like staying in one position for hours at a time, with nothing to keep you occupied, should not be ignored.

Also consider how you'll react if you can feel pressure and vibrations from cutting or even smell burning flesh during the surgery. It's a good idea to ask your surgical team what to expect so you can be mentally as well as physically prepared.

This realm of surgery is also changing the ways surgical teams communicate, as they must be careful not to alarm or offend the patient.

One 2016 study published in The American Journal of Surgery looked into surgeons' approaches to communication during awake procedures and many reported challenges, especially in balancing teaching responsibilities with the needs and comfort of the patient.¹²

"Rather than risk unsettling the patient with what might be a typical instruction to a resident — 'See if you can find your way through it' — Dr. [Michael] Marin, [professor and chairman of the surgery department at Mount Sinai Medical Center] may be more circumspect: 'We need to adjust this piece over here,'" the Times reported.¹³

It's important to keep in mind that, even without general anesthesia, surgery still carries risks, including infection. You'll want to explore all of your potential treatment options prior to deciding on surgery of any kind. In the case of knee surgery, for instance, the benefit may be comparable to that received by a sham surgery.

Patients Are Even Undergoing Heart Surgery While Awake

It's one thing to consider staying awake while your thumb is being operated on, but quite another to consider staying awake during open heart surgery. This, too, is increasingly being done, however, with a range of benefits. Doctors can, for instance, monitor the patient's brain during the surgery in case of a stroke.¹⁴

In Canada, surgeons are able to perform heart valve replacements while patients are awake. Medical director at the New Brunswick Heart Centre in Saint John, Dr. Vernon Paddock, told CBC News:¹⁵

"What we have found is that if we do them while they're awake, the patients are much more stable and they recover much more quickly … Patients spend less time in the intensive care unit recovering because they don't have the anesthetic to recover from.

… In fact, some of the patients — now we've started to bypass the intensive care unit and recover them in the cardiac [catheterization] lab."

The awake procedure is also being used for people whom surgery is too risky — like 104-year-old Pat Marble. She received a valve replacement while awake at the Minneapolis Heart Institute at Abbott Northwestern in 2017.¹⁶

Be Sure the Surgery Is Necessary First

If you do, in fact, need surgery, the awake options, which allow you to avoid the many pitfalls of general anesthesia, are likely to be beneficial. However, if your physician tells you that you need surgery, unless it is an emergency, I would strongly recommend you get a second opinion first.

In many cases, you may find that you don't need surgery after all, saving not only a considerable amount of money, but also avoiding the potentially deadly risks that any surgery carries. Tens of thousands of patients undergo unnecessary surgery each and every year, and you don't want to be one of them.¹⁷

There are multiple reasons why unnecessary surgeries take place. In some cases they're the result of criminal acts, in which surgeons intentionally prey on patients, performing surgeries even though they know they are not medically justified.

Far more often, however, are the physicians who perform unnecessary surgeries out of incompetence or a lack of training in less-invasive alternatives. Many health care providers may believe that surgery is the only answer, even when the success rates are minimal and better non-surgical treatment options exist.

Then there are those providers who perform the surgery simply because the profit will increase their income, and they can justify them as medically "necessary."

If you're considering surgery — even awake surgery — it's always a good idea to get a second opinion — and possibly a third and fourth. The other key is to be proactive and start pursuing a healthy lifestyle today, so you don't become a victim of an unnecessary medical procedure.

As much as possible, be proactive in using a healthy lifestyle to support and protect your health and, if illness or injury does occur, use natural methods that will allow your body to heal itself without the need for unnecessary surgery, drugs or other invasive medical procedures.

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1. The New York Times March 25, 2017

2. Handchir Mikrochir Plast Chir. 2011 Jun;43(3):175-80

3. Hand (N Y). 2014 Dec;9(4):399-405

4. Anesthesiology. 2012 Jul;117(1):72-92

5. Hand (N Y). 2013 Mar; 8(1): 47–53

6. J Hand Surg Am. 2017 Mar;42(3):e139-e147

7. Bull Hosp Jt Dis (2013). 2017 Jan;75(1):47-51

8. J Hand Surg Am. 2014 Nov;39(11):2297-9

9. Lakartidningen. 2015 Feb 3;112

10. Lakartidningen. 2015 Feb 3;112

11. The New York Times March 25, 2017

12. Am J Surg. 2016 Jul 29

13. The New York Times March 25, 2017

14. Fox News December 13, 2010

15. CBC News December 19, 2016

16. U.S. News and World Report, September 18, 2017

17. USA Today June 20, 2013