Tourniquet-Free Hand Surgery Using the One-per-Mil Tumescent Technique

Abstract

Background: A pneumatic tourniquet is generally used to achieve a bloodless operation field in hand surgery. However, this has changed with tumescent solution-based wide-awake surgery. This study is a preliminary prospective case series study to elaborate the formula and indications of the tumescent technique in hand surgery without a tourniquet.

Methods: Seven patients (age range, 4 months to 37 years) underwent hand or upper extremity surgery for conditions such as nerve palsy, electric burn defect, fingertip injury, contracture, constriction ring syndrome, or acrosyndactyly. A "one-per-mil" tumescent solution (epinephrine 1:1,000,000+20 mg lidocaine/50 mL saline) was used to create a bloodless operating field without a tourniquet. Observation was performed to document the amount of solution injected, the operation field clarity, and the postoperative pain.

Results: The "one per mil" epinephrine solution showed an effective hemostatic effect. The tumescent technique resulted in an almost bloodless operation field in the tendon and in the constriction ring syndrome surgeries, minimal bleeding in the flap and contracture release surgeries, and acceptable bleeding in acrosyndactyly surgery. The amount of solution injected ranged from 5.3 to 60 mL. No patient expressed significant postoperative pain. Flap surgeries showed mixed results. One flap was lost, while the others survived.

Conclusions: Epinephrine 1:1,000,000 in saline solution is a potential replacement for a tourniquet in hand surgery. Further studies are needed to delineate its safety for flap survival.

Keywords: Epinephrine; Lidocaine; Upper extremity.

Conflict of interest statement

No potential conflict of interest relevant to this article was reported.

Figures

Fig. 1

Injection to a burn hand contracture in a child In case 3, a 12-month-old baby presented with four-finger flexion contracture due to a burn. Injection of the tumescent solution was performed, reaching a total of 5.3 mL, to create a clear operation field without a tourniquet.

Fig. 2

A totally bloodless operation in an arm of a baby In case 4, as shown in Fig. 2, (A) a totally bloodless operation field was successfully made using 17 mL of "one-per-mil" tumescent solution during 140 minutes of constriction release. (B) The results after constriction release postoperative day 12.

Fig. 3

A totally bloodless operation in an arm of a baby In case 4, a 4-month-old male presented with a circumferential constriction ring in his left proximal upper arm. In this case, we determined that it would be almost impossible to set the tourniquet without hindering the operation.