Carbon footprint of robotically-assisted laparoscopy, laparoscopy and laparotomy: a comparison

Reusable surgical headwear has a reduced carbon footprint and matches disposables regarding surgical site infection: a systematic review and meta-analysis

Surgical headwear is designed to maintain sterility and prevent microbial contamination. However, the environmental impact of the healthcare industry carries an obligation to develop sustainable alternatives. We aim to explore the environmental impact and safety of reusable surgical headwear. A systematic review and meta-analysis were performed using MEDLINE, Embase, Scopus, Google Scholar, PubMed, and the Cochrane Library until December 10, 2023. Studies were reviewed for suitability and risk of bias using the ROBINS-I tool, with the results aggregated using Review Manager Version 5.4 for odds ratios (ORs) and 95% confidence intervals (CIs), and the I2 was used to assess heterogeneity. This systematic review included nine studies, and the meta-analysis included six studies involving 45,708 procedural cases. There was no significant difference in surgical site infection (SSI) rates between the reusable and disposable groups (OR: 0.79; 95% CI: 0.59-1.07; P=0.13). Policy implementation did not affect SSI rates (OR: 1.21; 95% CI: 0.85-1.73; P=0.30). Reusable surgical head covers demonstrated a significantly lower carbon footprint (P<0.001), ozone depletion (P<0.005), fossil fuel depletion (P<0.005), terrestrial acidification (P<0.005), and fine particulate matter formation (P<0.005) than disposable alternatives. Reusable surgical headwear matches disposable options for SSI incidence and offers environmental advantages. These findings support a shift towards reusable alternatives in healthcare, aligning patient safety with ecological responsibility. By adopting reusable alternatives, healthcare systems can actively contribute to planetary health, thereby highlighting the significant role of sustainable practices in modern medical settings.

Environmental sustainability in gynecologic oncology

Climate change is a complex, global issue that is impacting human health in various ways, with healthcare being a significant contributor to carbon emissions in the United States. This review discusses the environmental impact of important aspects of gynecologic oncology care, including surgery, anesthesia care, radiology, chemotherapy, and radiation oncology. Operating room energy and material use is highlighted, with a focus on the environmental impact of robotic surgery. The contribution of certain anesthetic gases in increasing greenhouse gas emissions is addressed. Additionally, the environmental impacts of radiologic imaging, chemotherapy, and radiation oncology are also discussed. Despite the complexity of climate change, there are multiple strategies on the individual and institutional level that can help mitigate the environmental impact of gynecologic oncology care. Individual efforts include practicing red bag stewardship, limiting single use-supplies, decreasing the use of potentially deleterious anesthetics, and supporting research into alternative dosing for chemotherapy and radiation which requires less patient travel. Institutional strategies include investing in efficient HVAC systems, utilizing reusable and reprocessed materials and devices, and purchasing renewable energy sources. Both individuals and institutions can advocate with industry and government at all levels for practices and policies that support lower carbon emissions. By recognizing our role in reducing carbon emissions, we can work towards improving the well-being of our patients and the larger community.

Patient perspectives on climate friendly healthcare: an exploratory study in obstetrics and gynaecology

OBJECTIVE

To investigate patient perspectives on climate change and climate change mitigation strategies in healthcare.

METHODS

A cross-sectional survey among gynaecological patients from two Dutch outpatient clinics. Main outcomes included patients' climate-related knowledge and worry, climate friendly healthcare perspectives and willingness to opt for climate friendly treatment alternatives. Multivariable linear regression analyses were performed to explore patient characteristics associated with climate friendly healthcare perspectives.

RESULTS

274 surveys were included. Most patients (79 %) were worried about climate change. Although almost all (91 %) found it important to contribute to climate protection, patients showed hesitance regarding healthcare measures that would impinge on individual choices. 62 % was willing to opt for climate friendly treatments, but this proportion varied by medical condition. Climate-related knowledge and worry were both positively associated with climate friendly healthcare perspectives.

CONCLUSION

Gynaecological patients are concerned about climate change and possess substantial self-reported climate-related knowledge. Patients vary in their support of climate action that involves individual patient care, but the majority is open to choose climate friendly treatment alternatives for certain medical conditions.

PRACTICE IMPLICATIONS

This exploratory study holds implications for the feasibility of integrating climate impact into clinical decision-making and provides a foundation for normative evidence for decarbonizing healthcare.

Improving sustainability and mitigating the environmental impacts of anaesthesia and surgery: a narrative review

Climate change, environmental degradation, and biodiversity loss are adversely affecting human health and exacerbating existing inequities, intensifying pressures on already strained health systems. Paradoxically, healthcare is a high-polluting industry, responsible for 4.6% of global greenhouse gas emissions and a similar proportion of air pollutants. Perioperative services are among the most resource-intensive healthcare services and are responsible for some unique pollutants. Opportunities exist to mitigate pollution throughout the entire continuum of perioperative care, including those that occur upstream of the operating room in the process of patient selection and optimisation, delivery of anaesthesia and surgery, and the postoperative recovery period. Within a patient-centred, holistic approach, clinicians can advocate for healthy public policies that modify the determinants of surgical illness, can engage in shared decision-making to ensure appropriate clinical decisions, and can be stewards of healthcare resources. Innovation and collaboration are required to redesign clinical care pathways and processes, optimise logistical systems, and address facility emissions. The results will extend beyond the reduction of public health damages from healthcare pollution to the provision of higher value, higher quality, patient-centred care.

Interventions to Reduce Surgical Waste Burden: A Systematic Review

Background

Operating suites are significant drivers of waste, pollution, and costs. Surgeons can help fight the climate crisis by implementing innovative strategies aimed at mitigating the environmental impact of surgical procedures and decreasing operational costs, and moving toward a more sustainable healthcare system. This study aims to review the literature describing interventions that reduce surgical waste.

Methods

PubMed, Cochrane, and Embase were searched. Studies reporting interventions to reduce operative waste, including emissions, energy, trash, and other, were included. Case reports, opinion-based reports, reviews, and meta-analyses were excluded. Study quality was rated using MINORS and Jadad scales. Data were extracted from each study to calculate waste on a per case basis. Narrative review of studies was performed rather than meta-analysis.

Results

The search yielded 675 unique hits, of which 13 (level of evidence: I-III) met inclusion criteria. Included studies were categorized by intervention type in relation to the operating and procedure room. Three studies evaluated provider education initiatives, three evaluated setup of instruments, two evaluated single-use items, four evaluated technique changes, and one evaluated surgical venue. Seven studies reported significant reductions in disposable surgical waste throughput, and seven reported significant reductions in cost.

Conclusions

The results of this systemic review demonstrated the effectiveness of surgical waste reduction initiatives in reducing waste volume, cost, and carbon emissions. Within plastic surgery, minimal surgical packs resulted in reduced gross waste and cost while promoting patient satisfaction in hand surgery, supporting the continued development and implementation of such initiatives in a surgical context.

Excess use of surgical supplies in minimally invasive benign gynecology surgery: an observational study

BACKGROUND

Single-use materials and equipment are regularly opened by the surgical team during procedures but left unused, potentially resulting in superfluous costs and excess environmental waste.

OBJECTIVE

This study aimed to estimate the excess use of surgical supplies in minimally invasive benign gynecologic surgeries.

STUDY DESIGN

This is a prospective observational study conducted at a university-affiliated single tertiary medical center. Designated study personnel were assigned to observe surgical procedures performed during July to September 2022. Surgical teams were observed while performing surgeries for benign indications. The teams were not informed of the purpose of the observation to avoid potential bias. Disposable materials and equipment opened during the procedure were documented. Excess supplies were defined as those opened but left unused before being discarded. Costs per item of the excess supplies were estimated on the basis of material and equipment costs provided by the hospital.

RESULTS

A total of 99 surgeries were observed, including laparoscopic (32%), robotic (39%), hysteroscopic (14%), vaginal (11%), and laparotomy procedures (3%). Excess use of surgical supplies was documented in all but one procedure. The total cost across all surgeries reached $6357. The contained tissue extraction bag was the most expensive item not used (Applied Medical, Rancho Santa Margarita, CA; $390 per unit) in 4 procedures, contributing 25.54% to the total cost. Raytec was the most common surgical waste, with a total of n=583 opened but unused (average n=5.95 per surgery). A significant difference was found in the rate of excess supplies across the surgical approaches, with robotic surgery contributing 52.19% of the total cost (P=.01).

CONCLUSION

Excess use of disposable materials and equipment is common in minimally invasive benign gynecologic surgeries and contributes to superfluous costs and excess environmental waste. It is predominantly attributed to the opening of inexpensive materials that are left unused during the procedure. Increased awareness of costs and generated waste may reduce excess use of surgical supplies and should be further explored in future research.

Making minimally invasive procedures more sustainable: A systematic review comparing the environmental footprint of single-use versus multi-use instruments

BACKGROUND

Healthcare systems contribute 5%-10% of the global carbon footprint. Given the detrimental impact of climate change on population health, health systems must seek to address this environmental responsibility. This is especially relevant in the modern era of minimally invasive procedures (MIP) where single-use instruments are increasingly popular. We compared the environmental footprint of single-use versus multi-use instruments in MIP.

METHODS

We conducted a systematic review across five databases to identify relevant original studies, following the PRISMA guidelines. We extracted environmental impact data and performed a quality assessment of included studies.

RESULTS

We included 13 studies published between 2005 and 2024. Eight employed Life Cycle Analysis (LCAs), which is the gold standard methodology for studies evaluating environmental impact. The instruments studied included laparoscopy systems, endoscopes, cystoscopes, bronchoscopes, duodenoscopes, and ureteroscopes. Six studies, including three high quality LCAs and one fair quality LCA, showed that single-use instruments have a significantly higher environmental footprint than their multi-use counterparts. Six studies suggested a lower environmental footprint for single-use instruments, and one study presented comparable results. However, these studies were of poor/fair quality.

CONCLUSION

Although our systematic review yielded mixed results, all high quality LCAs suggested multi-use instruments may be more environmentally friendly than their single-use counterparts. Our findings are limited by inter-study heterogeneity and methodological quality. There is an urgent need for additional research employing gold standard methodologies to explore the interplay between environmental impact and operational factors such as workflow efficiency and cost-benefit ratio to allow health systems to make more informed decisions.

The role of planetary health in urologic oncology

INTRODUCTION

Climate change and global warming are an omnipresent topic in our daily lives. Planetary health and oncology represent two critical domains within the broader spectrum of healthcare, each addressing distinct yet interconnected aspects of human well-being. We are encouraged to do our part in saving our planet. This should include the decisions we make in our professional life, especially in uro-oncology, as the healthcare sector significantly contributes to environmental pollution.

AREAS COVERED

There are many aspects that can be addressed in the healthcare sector in general, as there are structural problems in terms of energy consumption, water waste, therapeutic techniques, transportation and drug manufacturing, as well as in uro-oncology specific areas. For example, the use of different surgical techniques, forms of anesthesia and the use of disposable or reusable instruments, each has a different impact on our environment. The literature search was carried out using PubMed, a medical database.

EXPERT OPINION

We are used to making decisions based on the best outcome for patients without considering the impact that each decision can have on the environment. In the present article, we outline options and choices for a more climate-friendly approach in urologic oncology.

What Is the Carbon Footprint of Adult Spinal Deformity Surgery?

Background/Objectives: While the economic cost of adult spinal deformity (ASD) surgery has been studied extensively, its environmental impact is unknown. The aim of this study is to determine the carbon footprint (CF) associated with ASD surgery. Methods: ASD patients who underwent > four levels of corrective surgery between 2017 and 2021 were included. The open group included a posterior-only, single-stage technique, while the minimally invasive surgery (MIS) group was defined as the use of lateral interbody fusion and percutaneous posterior screw fixation. The two groups were propensity-score matched to adjust for baseline demographic, surgical, and radiographic characteristics. Data on all disposables and reusable instruments, anesthetic gas, and non-gas medications used during surgery were collected from medical records. The CF of transporting, using, and disposing of each product and the footprint of energy use in operating rooms were calculated. The CF produced was evaluated using the carbon dioxide equivalent (CO2e), which is relative to the amount of CO2 with an equivalent global warming potential. Results: Of the 175 eligible patients, 15 pairs (65 ± 9 years, 47% female) were properly matched and analyzed for all variables. The average CF generated per case was 147.7 ± 37.3 kg-CO2e, of which 54% was attributable to energy used to sterilize reusable instruments, followed by anesthetic gas released into the environment (17%) and operating room air conditioning (15%). Conclusions: The CF generated during ASD surgery should be reduced using a multidisciplinary approach, taking into account that different surgical procedures have different impacts on carbon emission sources.

Ecogastroenterology: cultivating sustainable clinical excellence in an environmentally conscious landscape

Gastrointestinal practices, especially endoscopy, have a substantial environmental impact, marked by notable greenhouse gas emissions and waste generation. As the world struggles with climate change, there emerges a pressing need to re-evaluate and reform the environmental footprint within gastrointestinal medicine. The challenge lies in finding a harmonious balance between ensuring clinical effectiveness and upholding environmental responsibility. This task involves recognising that the most significant reduction in the carbon footprint of endoscopy is achieved by avoiding unnecessary procedures; addressing the use of single-use endoscopes and accessories; and extending beyond the procedural suites to include clinics, virtual care, and conferences, among other aspects of gastrointestinal practice. The emerging digital realm in health care is crucial, given the potential environmental advantages of virtual gastroenterological care. Through an in-depth analysis, this review presents a path towards sustainable gastrointestinal practices, emphasising integrated strategies that prioritise both patient care and environmental stewardship.

Healthcare sustainability in cardiothoracic surgery

BACKGROUND

Climate change is the greatest threat to human health. Cardiothoracic patients suffer direct consequences from poor environmental health and we have a vested interest to address this in our practice. As leaders of complex high-end surgery, we are uniquely positioned to effect practical and immediate changes to significantly pare down emissions within the operating theatre, outside the operating theatre and beyond the confines of the hospital.

METHODS

We aim to spotlight this pressing issue, take stock of our current efforts, and encourage fellow specialists to drive this agenda.

RESULTS

Sustainability in healthcare needs to be formalized as part of the core curriculum in surgical training and awareness generated via carbon audits and life cycle analyses. Practical actions such as reducing unnecessary equipment usage, choosing reusable equipment over single use disposables, judicious use of investigations rooted in clinical reasoning and sharing of resources across services and health systems help reduce the carbon output of our specialty.

CONCLUSION

The 'Triple Bottom Line' serves as a good template to calibrate efforts that balance quality against environmental costs. More can be done to advocate for and find solutions for sustainable healthcare with cardiothoracic surgery.

Environmental impact of hybrid (reusable/single-use) ports versus single-use equivalents in robotic surgery

Given the rise in robotic surgery, and parallel movement towards net zero carbon, sustainable healthcare systems, it is important that the environmental impact of robotic approaches is minimised. The majority of greenhouse gas emissions associated with robotic surgery have previously been associated with single-use items. Whilst switching from single-use products to hybrid equivalents (predominantly reusable, with a small single-use component) has previously been found to reduce the environmental impact of a range of products used for laparoscopic surgery, the generalisability of this to robotic surgery has not previously been demonstrated. In this life cycle assessment, use of hybrid 5 mm ports compatible with emerging robotic systems (143 g CO2e) was found to reduce the carbon footprint by 83% compared with using single-use equivalents (816 g CO2e), accompanied by reductions in fifteen out of eighteen midpoint environmental impact categories. For endpoint categories, there was an 81% reduction in impact on human health and species loss, and 82% reductions in resource depletion associated with using hybrid robotic 5 mm ports. Whilst the carbon footprint of 5 mm hybrid ports compatible with emerging robotic equipment was 70% higher than previous estimates of ports appropriate for conventional laparoscopic approaches, the six-fold reductions seen with hybrids in this analysis point to the generalisability of the finding that reusable or hybrid products have a lower carbon footprint when compared with single-use equivalents. Surgeons, procurement teams, and policy makers should encourage innovation towards clinically safe and effective robotic instruments with maximal reusable components.

Is a care pathway for enhanced recovery after colorectal surgery environmentally responsible?

INTRODUCTION

Above and beyond the environmentally responsible operating theater, the environmental impact of the pathways of surgically treated patients seems essential but has seldom been considered in the literature. On a parallel track, enhanced recovery programmes (ERP) programs are presently deemed a standard of care. The objective of this review is to determine the carbon footprint of the ERP approach in colorectal surgery.

METHOD

This a narrative review based on articles referenced in PubMed. Our search was centered on the environmental impact of an ERP in the context of colorectal surgery. A number of measures included in the national and international guidelines were studied. We utilized the terms "carbon footprint", "sustainability", "energy cost", "environmental footprint", "life cycle assessment" AND a key word for each subject found in the ERP recommendations.

RESULTS

Most ERP measures in the context of colorectal surgery are factually or intuitively virtuous from an ecological standpoint. With a 3-day reduction in average hospital stay resulting from ERP, the program permits a reduction of at least 375kg CO2e/patient (Appendices 1 and 2). The most substantial part of this reduction is achieved during the perioperative period. While some measures, such as short fasting, are ecologically neutral, others (treatment of comorbidities, smoking cessation, hypothermia prevention, antibiotic prophylaxis, laparoscopy, absence of drains or probes, thromboprophylaxis, early feeding and mobilization…) lead to fewer postoperative complications, and can consequently be considered as environmentally responsible. Conversely, other measures, one example being robotic surgery, leave a substantial carbon footprint.

CONCLUSION

ERP is congruent with two pillars of sustainable development: the social pillar (improved patient recovery, and better caregiver working conditions fostered by team spirit), and the economic pillar (decreased healthcare expenses). While the third, environmental pillar is intuitively present, the low number of published studies remains a limitation to be overcome in future qualitative studies.

Healthcare in the era of climate change and the need for environmental sustainability

ABSTRACT

Climate change is an existential threat to humanity. While the healthcare sector must manage the health-related consequences of climate change, it is a significant contributor to greenhouse gas emissions, responsible for up to 4.6% of global emission, aggravating global warming. Within the hospital environment, the three largest contributors to greenhouse gas emissions are the operating theatre, intensive care unit and gastrointestinal endoscopy. Knowledge of the health-related burden of climate change and the potential transformative health benefits of climate action is important to all health professionals, as they play crucial roles in effecting change. This article summarises the available literature on the impact of healthcare on climate change and efforts in mitigation, focusing on the intrinsic differences and similarities across the operating theatre complex, intensive care unit and gastrointestinal endoscopy unit. It also discusses strategies to reduce carbon footprint.

User experience of wearing comfort of reusable versus disposable surgical gowns and environmental perspectives: A cross-sectional survey

OBJECTIVE

To determine the user experience of wearing comfort of reusable sterile surgical gowns and compare these gowns with conventional disposable surgical gowns.

DESIGN

Cross-sectional survey.

SETTING

An academic hospital in the Netherlands.

POPULATION

Gynaecologists, surgeons, residents and operating room assistants (n=80).

METHODS

Quantitative and qualitative data were obtained via a written questionnaire. Participants provided subjective comments and scored the reusable gown on each individual topic with a score from 1 to 5 (1 = unsatisfactory, 2 = moderate, 3 = good, 4 = very good, 5 = excellent) and compared the reusable gown with the conventional disposable alternative (better, equal or worse).

MAIN OUTCOME MEASURES

Wearing comfort: ventilation and temperature regulation, fit and length, functionality, barrier function and ease of use.

RESULTS

The results of the overall scores of the reusable gown are scored as 'very good' (mean 4.3, SD ± 0.5) by its users. Regarding comparison of the gowns, more than 79% (lowest score 79%, highest score 95%) of the participants scored the reusable gown equal or higher on six of seven topics. The topic 'ease of use' was scored equal or higher by 59% of the participants. Subjective comments provided information on possible improvements.

CONCLUSIONS

The findings of this study demonstrate that there is professional acceptance regarding the utilisation of reusable surgical gowns. To facilitate broader adoption, it is imperative to foster collaboration among suppliers and healthcare institutions. The reusable surgical gown is an environmentally sustainable, safe and comfortable alternative in the operating room.

Systematic review of carbon footprint of surgical procedures

The ecological sustainability of the operating room (OR) is a matter of recent interest. The present systematic review aimed to review the current literature assessing the carbon footprint of surgical procedures in different surgical fields. Following to the PRISMA statement checklist, three databases (MEDLINE, EMBASE, Cochrane Library) were searched by independent reviewers, who screened records on title and abstract first, and then on the full text. Risk of bias was evaluated using the MINORS system. Over the 878 articles initially identified, 36 original studies were included. They considered ophthalmologic surgical procedures (30.5%), general/digestive surgery (19.4%), gynecologic procedures (13.9%), orthopedic procedures (8.3%), neurosurgery (5.5%), otolaryngology/head and neck surgery (5.5%), plastic/dermatological surgery (5.5%), and cardiac surgery (2.8%). Despite a great methodological heterogeneity, data showed that a single surgical procedure emits 4-814 kgCO2e, with anesthetic gases and energy consumption representing the largest sources of greenhouse gas emission. Minimally invasive surgical techniques may require more resources than conventional open surgery, particularly for packaging and plastics, energy use, and waste production. Each OR has the potential to produce from 0.2 to 4kg of waste per case with substantial differences depending on the type of intervention, hospital setting, and geographic area. Overall, the selected studies were found to be of moderate quality. Based on a qualitative synthesis of the available literature, the OR can be targeted by programs and protocols implemented to reduce the carbon footprint and improve the waste stream of the OR.

Meta-analysis of randomized clinical trials comparing robotic versus laparoscopic surgery for mid-low rectal cancers

INTRODUCTION

Robotic surgery (RS) is experiencing major development, particularly in the context of rectal cancer. The aim of this meta-analysis was to summarize data from the literature, focusing specifically on the safety and effectiveness of robotic surgery in mid-low rectal cancers, based on the hypothesis that that robotic surgery can find its most rational indication in this anatomical location.

METHOD

The meta-analysis was conducted according to the PRISMA 2000 recommendations, including all randomized trials that compared robotic surgery versus laparoscopic surgery (LS) that were found in the Medline-PICO, Cochrane Database, Scopus and Google databases. Data were extracted independently by two reviewers. The risk of bias was analyzed according to the Cochrane Handbook method and the certainty of the evidence according to the GRADE method. The analysis was carried out with R software Version 4.2-3 using the Package for Meta-Analysis "meta" version 6.5-0.

RESULTS

Eight randomized trials were included (with a total of 2342 patients), including four that focused specifically on mid-low rectal cancer (n=1,734 patients). No statistically significant difference was found for overall morbidity, intra-operative morbidity, anastomotic leakage, post-operative mortality, quality of mesorectal specimen, and resection margins. The main differences identified were a lower conversion rate for RS (RR=0.48 [0.24-0.95], p=0.04, I2=0%), and a longer operative time for RS (mean difference=39.11min [9.39-68.83], p<0.01, I2=96%). The other differences had no real clinical relevance, i.e., resumption of flatus passage (5hours earlier after RS), and lymph node dissection (one more lymph node for LS).

CONCLUSION

This meta-analysis does not confirm the initial hypothesis and does not show a statistically significant or clinically relevant benefit of RS compared to LS for mid-low rectal cancer.

Environmental sustainability in obstetrics and gynaecology: A systematic review

BACKGROUND

The healthcare sector is responsible for 4%-10% of global greenhouse gas emissions. Considering the broad range of care that obstetricians and gynaecologists provide, mitigation strategies within this specialty could result in significant reductions of the environmental footprint across the whole healthcare industry.

OBJECTIVES

The aim of this review was to identify for what services, procedures and products within obstetric and gynaecological care the environmental impact has been studied, to assess the magnitude of such impact and to identify mitigation strategies to diminish it.

SEARCH STRATEGY

The search strategy combined terms related to environmental impact, sustainability, climate change or carbon footprint, with the field of obstetrics and gynaecology.

SELECTION CRITERIA

Articles reporting on the environmental impact of any service, procedure or product within the field of obstetrics and gynaecology were included. Included outcomes covered midpoint impact categories, CO2 emissions, waste generation and energy consumption.

DATA COLLECTION AND ANALYSIS

A systematic literature search was conducted in the databases of MEDLINE (Ovid), Embase (Ovid) and Scopus, and a grey literature search was performed on Google Scholar and two websites of gynaecological associations.

MAIN RESULTS

The scope of the investigated studies encompassed vaginal births, obstetric and gynaecological surgical procedures, menstrual products, vaginal specula and transportation to gynaecological oncologic consultations. Among the highest yielding mitigation strategies were displacing disposable with reusable materials and minimising content of surgical custom packs. The lowest yielding mitigation strategy was waste optimisation, including recycling.

CONCLUSIONS

This systematic review highlights opportunities for obstetricians and gynaecologists to decrease their environmental footprint in many ways. More high-quality studies are needed to investigate the environmental impact of other aspects of women's and reproductive health care.

Surgery, innovation, research and sustainable development

In the healthcare sector, surgery (especially in the operating theatre) is responsible for emission of greenhouse gases, which is a source of global warming. The goal of this largely quantitative assessment is to address three questions on carbon footprint associated with surgery, the role of primary and secondary prevention prior to surgical procedures, and incorporation of the carbon footprint into judgment criteria in research and surgical innovations. It appears that while the impact of surgery on global warming is undeniable, its extent depends on means of treatment and geographical location. Before and after an operation, primary, secondary and tertiary prevention accompanied by surgical sobriety (avoiding unnecessary or unjustified actions) can be virtuous in terms of sustainable development. However, the sanitary benefits of these actions are often opposed to environmental benefit, which has yet to be satisfactorily assessed. Lastly, the carbon footprint has yet to be incorporated into research protocols or the innovations under development. This should impel us not only to sensitize the different healthcare actors to relevant issues, but also to improve working conditions.

Robotic-assisted vs. open ureteral reimplantation: a multicentre comparison

PURPOSE

Open ureteral reimplantation is considered the standard surgical approach to treat distal ureteral strictures or injuries. These procedures are increasingly performed in a minimally invasive and robotic-assisted manner. Notably, no series comparing perioperative outcomes and safety of the open vs. robotic approach are available so far.

METHODS

In this retrospective multi-center study, we compared data from 51 robotic ureteral reimplantations (RUR) with 79 open ureteral reimplantations (OUR). Both cohorts were comparatively assessed using different baseline characteristics and perioperative outcomes. Moreover, a multivariate logistic regression for independent predictors was performed.

RESULTS

Surgery time, length of hospital stay and dwell time of bladder catheter were shorter in the robotic cohort, whereas estimated blood loss, postoperative blood transfusion rate and postoperative complications were lower than in the open cohort. In the multivariate linear regression analysis, robotic approach was an independent predictor for a shorter operation time (coefficient - 0.254, 95% confidence interval [CI] - 0.342 to - 0.166; p < 0.001), a lower estimated blood loss (coefficient - 0.390, 95% CI - 0.549 to - 0.231, p < 0.001) and a shorter length of hospital stay (coefficient - 0.455, 95% CI - 0.552 to - 0.358, p < 0.001). Moreover, robotic surgery was an independent predictor for a shorter dwell time of bladder catheter (coefficient - 0.210, 95% CI - 0.278 to - 0.142, p < 0.001).

CONCLUSION

RUR represents a safe alternative to OUR, with a shorter operative time, decreased blood loss and length of hospital stay. Prospective research are needed to further define the extent of the advantages of the robotic approach over open surgery.

Robot-assisted surgery in thoracic and visceral indications: an updated systematic review

BACKGROUND

In surgical advancements, robot-assisted surgery (RAS) holds several promises like shorter hospital stays, reduced complications, and improved technical capabilities over standard care. Despite extensive evidence, the actual patient benefits of RAS remain unclear. Thus, our systematic review aimed to assess the effectiveness and safety of RAS in visceral and thoracic surgery compared to laparoscopic or open surgery.

METHODS

We performed a systematic literature search in two databases (Medline via Ovid and The Cochrane Library) in April 2023. The search was restricted to 14 predefined thoracic and visceral procedures and randomized controlled trials (RCTs). Synthesis of data on critical outcomes followed the Grading of Recommendations, Assessment, Development, and Evaluation methodology, and the risk of bias was evaluated using the Cochrane Collaboration's Tool Version 1.

RESULTS

For five out of 14 procedures, no evidence could be identified. A total of 20 RCTs and five follow-up publications met the inclusion criteria. Overall, most studies had either not reported or measured patient-relevant endpoints. The majority of outcomes showed comparable results between study groups. However, RAS demonstrated potential advantages in specific endpoints (e.g., blood loss), yet these findings relied on a limited number of low-quality studies. Statistically significant RAS benefits were also noted in some outcomes for certain indications-recurrence, quality of life, transfusions, and hospitalisation. Safety outcomes were improved for patients undergoing robot-assisted gastrectomy, as well as rectal and liver resection. Regarding operation time, results were contradicting.

CONCLUSION

In summary, conclusive assertions on RAS superiority are impeded by inconsistent and insufficient low-quality evidence across various outcomes and procedures. While RAS may offer potential advantages in some surgical areas, healthcare decisions should also take into account the limited quality of evidence, financial implications, and environmental factors. Furthermore, considerations should extend to the ergonomic aspects for maintaining a healthy surgical environment.

Environmental Impact of Adult Tonsillectomy: Life Cycle Assessment and Cost Comparison of Techniques

OBJECTIVES

To quantify and compare the cost and environmental impact of different techniques for adult tonsillectomy surgery, and to identify target areas for impact reduction.

METHODS

Fifteen consecutive adult tonsillectomy surgeries were prospectively randomized to one of three tonsillectomy techniques: cold, monopolar electrocautery, or low-temperature radiofrequency ablation (Coblation). Life cycle assessment was used to comprehensively evaluate the environmental impact of study surgeries. Outcomes assessed included multiple measures of environmental impact, including greenhouse gas (GHG) emissions, and cost. Environmental impact measures were analyzed to identify highest-yield areas for improvement, and outcomes were compared between surgical techniques using statistical analysis.

RESULTS

GHG emissions for cold, monopolar electrocautery, and Coblation techniques were 157.6, 184.5, and 204.7 kilograms of carbon dioxide equivalents (kgCO2 -eq) per surgery, respectively, with costs totaling $472.51, $619.10, and $715.53 per surgery, respectively. Regardless of surgery technique, anesthesia medications and disposable equipment contributed most to environmental harm. Cold technique demonstrated reduced environmental impact related to disposable surgical equipment in the categories of greenhouse gas emissions, acidification of soil and water, eutrophication of air, ozone depletion, release of carcinogenic, and non-carcinogenic toxic substances, and respiratory pollutant production (p < 0.05 for all comparisons with other techniques).

CONCLUSION

Within the boundaries of operating room processes, cold technique minimizes cost and environmental impact of adult tonsillectomy surgery, with statistical significance noted in the impact of disposable surgical equipment. Areas of highest potential for improvement identified include reducing use of disposable equipment and collaboration with the Anesthesiology care team to streamline medication use.

LEVEL OF EVIDENCE

2, randomized trial Laryngoscope, 134:622-628, 2024.

Reducing greenhouse gas emissions in a bariatric surgical unit is a complex but feasible project

Obesity is a growing issue worldwide, whose causes and consequences are linked to the environment and which therefore has a high carbon footprint. On the other hand, obesity surgery, along with other procedures in surgical suites, entails environmental consequences and responsibilities. We conducted a prospective comparative study on two groups of bariatric interventions (N = 59 and 56, respectively) during two consecutive periods of time (Oct 2021-March 2022), first without and then with specific measures aimed at reducing greenhouse gas emissions related to bariatric procedures by approximately 18%. These measures included recycling of disposable surgical equipment, minimizing its use, and curbing anesthetic gas emissions. Further and continuous efforts/incentives are warranted, including reframing the surgical strategies. Instead of comparing measurements, which is difficult at the present time, we suggest defining an ECO-SCORE in operating rooms, among other healthcare facilities.

Perspectives on technology: to use or to reuse, that is the endoscopic question-a systematic review of single-use endoscopes

OBJECTIVE

To compare clinical outcomes of single-use endoscopes with those of reusable endoscopes to better define their role within urology.

METHODS

A systematic search of electronic databases was performed. All studies comparing the clinical outcomes of participants undergoing urological procedures with single-use endoscopes to those of participants treated with reusable endoscopes were included. Results are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement.

RESULTS

Twenty-one studies in 3943 participants were identified. Six different single-use flexible ureteroscopes and two different single-use flexible cystoscopes were assessed. There were no differences in mean postoperative infection rates (4.0% vs 4.4%; P = 0.87) or overall complication rates (11.5% vs 11.9%; P = 0.88) between single-use and reusable endoscopes. For patients undergoing flexible ureteroscopy there were no differences in operating time (mean difference -0.05 min; P = 0.96), length of hospital stay (LOS; mean difference 0.06 days; P = 0.18) or stone-free rate (SFR; 74% vs 74.3%; P = 0.54) between the single-use and reusable flexible ureteroscope groups.

CONCLUSION

This study is the largest to compare the clinical outcomes of single-use endoscopes to those of reusable endoscopes within urology, and demonstrated no difference in LOS, complication rate or SFR, with a shorter operating time associated with single-use flexible cystoscope use. It also highlights that the cost efficiency and environmental impact of single-use endoscopes is largely dependent on the caseload and reprocessing facilities available within a given institution. Urologists can therefore feel confident that whether they choose to 'use' or to 'reuse' based on the financial and environmental implications, they can do so without negatively impacting patient outcomes.

Carbon footprints in minimally invasive surgery: Good patient outcomes, but costly for the environment

Advancements in technology and surgical training programs have increased the adaptability of minimally invasive surgery (MIS). Gastrointestinal MIS is superior to its open counterparts regarding post-operative morbidity and mortality. MIS has become the first-line surgical intervention for some types of gastrointestinal surgery, such as laparoscopic cholecystectomy and appendicectomy. Carbon dioxide (CO2) is the main gas used for insufflation in MIS. CO2 contributes 9%-26% of the greenhouse effect, resulting in global warming. The rise in global CO2 concentration since 2000 is about 20 ppm per decade, up to 10 times faster than any sustained rise in CO2 during the past 800000 years. Since 1970, there has been a steady yet worrying increase in average global temperature by 1.7 °C per century. A recent systematic review of the carbon footprint in MIS showed a range of 6-814 kg of CO2 emission per surgery, with higher CO2 emission following robotic compared to laparoscopic surgery. However, with superior benefits of MIS over open surgery, this poses an ethical dilemma to surgeons. A recent survey in the United Kingdom of 130 surgeons showed that the majority (94%) were concerned with climate change but felt that the lack of leadership was a barrier to improving environmental sustainability. Given the deleterious environmental effects of MIS, this study aims to summarize the trends of MIS and its carbon footprint, awareness and attitudes towards this issue, and efforts and challenges to ensuring environmental sustainability.

Environmental effects of surgical procedures and strategies for sustainable surgery

There is a bidirectional relationship between climate change and health care. Climate change threatens public health, and health care contributes to climate change. For example, surgery is the most energy-intensive practice in the health-care sector, and gastrointestinal conditions are responsible for a substantial environmental burden. However, environmental costs associated with health care are often overlooked. This issue has been examined more closely in current times. Emerging data are mainly focused on surgery, as the most resource-intensive practice. However, there is still a lack of global awareness and guidance on sustainable surgical practices. This Perspective aims to reassess the evidence on health care and surgery carbon footprints, focusing on gastrointestinal conditions, identify issues that need to be addressed to achieve a more sustainable practice and develop perspectives for future surgical procedures. The proposed framework to mitigate the environmental effects of surgery could be translated to other health-care sectors.

Innovations towards achieving environmentally sustainable operating theatres: A systematic review

INTRODUCTION

The NHS accounts for 5.4% of the UK's total carbon footprint, with the perioperative environment being the most resource hungry aspect of the hospital. The aim of this systematic review was to assimilate the published studies concerning the sustainability of the perioperative environment, focussing on the impact of implemented interventions.

METHODS

A systematic review was performed using Pubmed, OVID, Embase, Cochrane database of systematic reviews and Medline. Original manuscripts describing interventions aimed at improving operating theatre environmental sustainability were included.

RESULTS

675 abstracts were screened with 34 manuscripts included. Studies were divided into broad themes; recycling and waste management, waste reduction, reuse, reprocessing or life cycle analysis, energy and resource reduction and anaesthetic gases. This review summarises the interventions identified and their resulting effects on theatre sustainability.

DISCUSSION

This systematic review has identified simple, yet highly effective interventions across a variety of themes that can lead to improved environmental sustainability of surgical operating theatres. Combining these interventions will likely result in a synergistic improvement to the environmental impact of surgery.

Targeted intervention to achieve waste reduction in gastrointestinal endoscopy

OBJECTIVE

Endoscopy is healthcare's third largest generator of medical waste in hospitals. This prospective study aimed to measure a single unit's waste carbon footprint and perform a pioneer intervention towards a more sustainable endoscopy practice. The relation of regulated medical waste (RMW; material fully contaminated with blood or body fluids or containing infectious agents) versus landfill waste (non-recyclable material not fully contaminated) may play a critical role.

DESIGN

In a four-stage prospective study, following a 4-week observational audit with daily weighing of both waste types (stage 1), stage 2 consisted of a 1-week intervention with team education of waste handling. Recycling bins were placed in endoscopy rooms, landfill and RMW bins were relocated. During stages 3 (1 month after intervention) and 4 (4 months after intervention), daily endoscopic waste was weighed. Equivalence of 1 kg of landfill waste to 1 kg carbon dioxide equivalent (CO_2e) and 1 kg of RMW to 3kgCO_2e was assumed. Paired samples t-tests for comparisons.

RESULTS

From stage 1 to stage 3, mean total waste and RMW were reduced by 12.9% (p=0.155) and 41.4% (p=0.010), respectively, whereas landfill (p=0.059) and recycling waste increased (paper: p=0.001; plastic: p=0.007). While mean endoscopy load was similar (46.2 vs 44.5, p=0.275), a total decrease of CO_2e by 31.6% (138.8kgCO_2e) was found (mean kgCO_2e109.7 vs 74.9, p=0.018). The annual reduction was calculated at 1665.6kgCO_2e. All these effects were sustained 4 months after the intervention (stage 4) without objections by responsible endoscopy personnel.

CONCLUSION

In this interventional study, applying sustainability measures to a real-world scenario, RMW reduction and daily recycling were achieved and sustained over time, without compromising endoscopy productivity.

The Environmental Impact of Open Versus Endoscopic Carpal Tunnel Release

PURPOSE

The environmental impact of common ambulatory hand surgeries has been an area of growing interest in recent years. There were 2 objectives of this study: (1) to quantify the carbon footprint of carpal tunnel surgery and its principal driving components; and (2) to compare the carbon footprints of open carpal tunnel release (oCTR) and endoscopic carpal tunnel release (eCTR).

METHODS

We performed a life cycle assessment to quantify the environmental impacts of 2 surgical procedures: oCTR and eCTR. Patients were retrospectively identified by querying the Mass General Brigham institutional billing database. Fourteen oCTR procedures and 14 eCTR procedures in 28 patients were included in the life cycle assessment. The boundaries of the life cycle assessment were the start and end times of the procedures. The environmental impacts were estimated using the carbon footprint, expressed in the equivalent mass of carbon dioxide released into the atmosphere (kgCO₂-eq). The facility-related, processing-related, solid waste-related, and total kgCO₂-eq were calculated.

RESULTS

The average carbon footprint of carpal tunnel release was 83.1 kgCO₂-eq and was dominated by processing-related and facilities-related factors. The average carbon footprint of eCTR (106.5 kgCO₂-eq) was significantly greater than that of oCTR (59.6 kgCO₂-eq).

CONCLUSIONS

Endoscopic carpal tunnel release leaves a greater carbon footprint than oCTR, and its environmental impact is dominated by facility-related and central processing-related factors.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic and Decision Analyses IV.

HealthcareLCA: an open-access living database of health-care environmental impact assessments

Anthropogenic environmental change negatively effects human health and is increasing health-care system demand. Paradoxically, the provision of health care, which itself is a substantial contributor to environmental degradation, is compounding this problem. There is increasing willingness to transition towards sustainable health-care systems globally and ensuring that strategy and action are informed by best available evidence is imperative. In this Personal View, we present an interactive, open-access database designed to support this effort. Functioning as a living repository of environmental impact assessments within health care, the HealthcareLCA database collates 152 studies, predominantly peer-reviewed journal articles, into one centralised and publicly accessible location, providing impact estimates (currently totalling 3671 numerical values) across 1288 health-care products and processes. The database brings together research generated over the past two decades and indicates exponential field growth.

The environmental impact of health care for musculoskeletal conditions: A scoping review

BACKGROUND

Health care has significant environmental impact. We performed a scoping review to map what is known about the environmental impact of health care for musculoskeletal conditions.

METHODS

We included published papers of any design that measured or discussed environmental impact of health care or health support services for any musculoskeletal condition in terms of climate change or global warming (e.g., greenhouse gas emissions it produces). We searched MEDLINE and Embase from inception to 2 May 2022 using keywords for environmental health and musculoskeletal conditions, and performed keyword searches using Google and Google Scholar. Two independent reviewers screened studies. One author independently charted data, verified by a second author. A narrative synthesis was performed.

RESULTS

Of 12,302 publications screened and 73 identified from other searches, 122 full-text articles were assessed for eligibility, and 49 were included (published 1994 to 2022). Of 24 original research studies, 11 measured environmental impact relating to climate change in orthopaedics (n = 10), and medical aids for the knee (n = 1), one measured energy expenditure of laminar versus turbulent airflow ventilation systems in operating rooms during simulated hip replacements and 12 measured waste associated with orthopaedic surgery but did not relate waste to greenhouse gas emissions or environmental effects. Twenty-one editorials described a need to reduce environmental impact of orthopaedic surgery (n = 9), physiotherapy (n = 9), podiatry (n = 2) or occupational therapy (n = 1). Four narrative reviews discussed sustainability relating to hand surgery (n = 2), orthopaedic surgery (n = 1) and orthopaedic implants (n = 1).

CONCLUSION

Despite an established link between health care and greenhouse gas emissions we found limited empirical data estimating the impact of musculoskeletal health care on the environment. These data are needed to determine whether actions to lower the carbon footprint of musculoskeletal health care should be a priority and to identify those aspects of care that should be prioritised.

Assessing the carbon footprint of digital health interventions: a scoping review

OBJECTIVE

Integration of environmentally sustainable digital health interventions requires robust evaluation of their carbon emission life-cycle before implementation in healthcare. This scoping review surveys the evidence on available environmental assessment frameworks, methods, and tools to evaluate the carbon footprint of digital health interventions for environmentally sustainable healthcare.

MATERIALS AND METHODS

Medline (Ovid), Embase (Ovid). PsycINFO (Ovid), CINAHL, Web of Science, Scopus (which indexes IEEE Xplore, Springer Lecture Notes in Computer Science and ACM databases), Compendex, and Inspec databases were searched with no time or language constraints. The Systematic Reviews and Meta-analyses Extension for Scoping Reviews (PRISMA_SCR), Joanna Briggs Scoping Review Framework, and template for intervention description and replication (TiDiER) checklist were used to structure and report the findings.

RESULTS

From 3299 studies screened, data was extracted from 13 full-text studies. No standardised methods or validated tools were identified to systematically determine the environmental sustainability of a digital health intervention over its full life-cycle from conception to realisation. Most studies (n = 8) adapted publicly available carbon calculators to estimate telehealth travel-related emissions. Others adapted these tools to examine the environmental impact of electronic health records (n = 2), e-prescriptions and e-referrals (n = 1), and robotic surgery (n = 1). One study explored optimising the information system electricity consumption of telemedicine. No validated systems-based approach to evaluation and validation of digital health interventions could be identified.

CONCLUSION

There is a need to develop standardised, validated methods and tools for healthcare environments to assist stakeholders to make informed decisions about reduction of carbon emissions from digital health interventions.

Environmental sustainability in robotic and laparoscopic surgery: systematic review

BACKGROUND

Minimally invasive surgical (MIS) techniques are considered the gold standard of surgical interventions, but they have a high environmental cost. With global temperatures rising and unmet surgical needs persisting, this review investigates the carbon and material footprint of MIS and summarizes strategies to make MIS greener.

METHODS

The MEDLINE, Embase, and Web of Science databases were interrogated between 1974 and July 2021. The search strategy encompassed surgical setting, waste, carbon footprint, environmental sustainability, and MIS. Two investigators independently performed abstract/full-text reviews. An analysis of disability-adjusted life years (DALYs) averted per ton of carbon dioxide equivalents (CO2e) or waste produced was generated.

RESULTS

From the 2456 abstracts identified, 16 studies were selected reporting on 5203 MIS procedures. Greenhouse gas (GHG) emissions ranged from 6 kg to 814 kg CO2e per case. Carbon footprint hotspots included production of disposables and anaesthetics. The material footprint of MIS ranged from 0.25 kg to 14.3 kg per case. Waste-reduction strategies included repackaging disposables, limiting open and unused instruments, and educational interventions. Robotic procedures result in 43.5 per cent higher GHG emissions, 24 per cent higher waste production, fewer DALYs averted per ton of CO2, and less waste than laparoscopic alternatives.

CONCLUSION

The increased environmental impact of robotic surgery may not sufficiently offset the clinical benefit. Utilizing alternative surgical approaches, reusable equipment, repackaging, surgeon preference cards, and increasing staff awareness on open and unused equipment and desflurane avoidance can reduce GHG emissions and waste.

The environmental impact of surgery: A systematic review

BACKGROUND

Climate change is a significant public health threat. Health care comprises 10% of greenhouse gas emissions in the United States, where surgery is especially resource intensive. We did a systematic review to assess and summarize the published evidence of the environmental impact of surgery.

METHODS

We searched Medline, Embase, Web of Science, and GreenFILE databases for publications that report any environmental impact measure by all surgical subspecialties, including anesthesia. Inclusion criteria were published in English, original research, and passed peer review. Because data were heterogeneous and the aim was broad, we conducted a qualitative summary of data. Where possible, we compare impact measures.

RESULTS

In the study, 167 articles were identified by our search strategy and reviewed, of which 55 studies met criteria. Eight were about anesthesia, 27 about operating room waste, and 6 were life cycle assessments. Other topics include carbon footprint and greenhouse gas emissions. Nine papers fell into 2 or more categories. Overall, the operating room is a significant source of emissions and waste. Using anesthetic gases with low global warming potential reduces operating room emissions without compromising patient safety. Operating room waste is often disposed of improperly, often due to convenience or knowledge gaps. There are environmental benefits to replacing disposable materials with reusable equivalents, and to proper recycling. Surgeons can help implement these changes at their institution.

CONCLUSION

Although there is a clear need to lower the carbon footprint of surgery, the quality of research with which to inform protocol changes is deficient overall. Our attempt to quantify surgery's carbon footprint yielded heterogeneous data and few standardized, actionable recommendations. However, this data serves as a starting point for important future initiatives to decrease the environmental impact of surgery.

Assessment of the Versius Robotic Surgical System in Minimal Access Surgery: A Systematic Review

Background: Despite the superiority of minimal access surgery (MAS) over open surgery, MAS is difficult to perform and has a demanding learning curve. Robot-assisted surgery is an advanced form of MAS. The Versius® surgical robot system was developed with the aim of overcoming some of the challenges associated with existing surgical robots. The present study was designed to investigate the feasibility, clinical safety, and effectiveness of the Versius system in MAS. Materials and Methods: A comprehensive search was carried out in the Medline, Web of Science Core Collection (Indexes = SCI-EXPANDED, SSCI, A & HCI Timespan), and Scopus databases for articles published until February 2022. The keywords used were Versius robot, visceral, colorectal, gynecology, and urologic surgeries. Articles on the use of the Versius robot in minimal access surgery (MAS) were included in the review. Results: Seventeen articles were reviewed for the study. The investigation comprised a total of 328 patients who had been operated on with this robot system, of which 48.3%, 14.2%, and 37.5% underwent colorectal, visceral, and gynecological procedures, respectively. Postoperative and major complications within 30 days varied from 7.4% to 39%. No major complications and no readmissions or reoperations were reported in visceral and gynecological surgeries. Readmission and reoperation rates in colorectal surgeries were 0–9%. Some procedures required conversion to conventional laparoscopic surgery (CLS) or open surgery, and all procedures were completed successfully. Based on the studies reviewed in the present report, we conclude that the Versius robot can be used safely and effectively in MAS. Conclusions: A review of the published literature revealed that the Versius system is safe and effective in minimal access surgery. However, the data should be viewed with caution until randomized controlled trials (RCTs) have been performed. Studies on the use of this robotic system in oncological surgery must include survival as one of the addressed outcomes.

How can we address the ever-pressing need to 'green up' surgical practice in the National Health Service?

Clinical practice has inadvertently changed after the COVID-19 pandemic and currently the need to provide sustainable surgical services is more pressing than ever. The National Health Service has committed to a long-term efficient plan to reduce carbon footprint but there is no detailed plan for surgical practice, the domain that contributes the most to hospital-derived pollution. A series of consecutive steps and measures ought to be taken, starting from a hybrid approach quantifying surgically attributed carbon footprint. Then, a variety of suggested measures can be widely discussed and accordingly applied on a wider or more local level. Appropriate training should always precede implementing new practices to ensure that staff is familiar with these. These measures cover a broad range and should be arranged on a patient-centred basis from preoperative preconditioning to an effective follow-up. The need for more intense research and implementation of enhanced recovery protocols is widely discussed. Also, the necessity of green research and reinvestment of materials and resources is highlighted. A change of philosophy from a cradle-to-grave approach to a repurposing approach is suggested. We are confident that a new era is dawning in surgical practice and teamwork is the key for providing greener surgical services.

Building sustainable and resilient surgical systems: A narrative review of opportunities to integrate climate change into national surgical planning in the Western Pacific region

Five billion people lack access to surgical care worldwide; climate change is the biggest threat to human health in the 21st century. This review studies how climate change could be integrated into national surgical planning in the Western Pacific region. We searched databases (PubMed, Web of Science, and Global Health) for articles on climate change and surgical care. Findings were categorised using the modified World Health Organisation Health System Building Blocks Framework. 220 out of 2577 records were included. Infrastructure: Operating theatres are highly resource-intensive. Their carbon footprint could be reduced by maximising equipment longevity, improving energy efficiency, and renewable energy use. Service delivery Tele-medicine, outreaches, and avoiding desflurane could reduce emissions. Robust surgical systems are required to adapt to the increasing burden of surgically treated diseases, such as injuries from natural disasters. Finance: Climate change adaptation funds could be mobilised for surgical system strengthening. Information systems: Sustainability should be a key performance indicator for surgical systems. Workforce: Surgical providers could change clinical, institutional, and societal practices. Governance: Planning in surgical care and climate change should be aligned. Climate change mitigation is essential in the regional surgical care scale-up; surgical system strengthening is also necessary for adaptation to climate change.

[Climate change: how surgery contributes to global warming]

BACKGROUND

Surgery as an important part of the healthcare sector contributes to environmental pollution and therefore to the climate crisis. The aim of this review is to create an overview of the current data situation and possibilities for improvement.

METHODS

A literature search was performed in PubMed/MEDLINE using the following five terms: "carbon footprint and surgery", "climate change and surgery", "waste and surgery" and "greening the operating room" focusing on energy, waste, water and anesthesia.

RESULTS

The greatest part of emissions in surgery is generated by the use of energy. The operating rooms (OR) need 3-6 times more energy than the other hospital rooms. Of the total hospital waste 20-30% is produced during operations, which is particularly due to the increasing use of disposable articles and 50-90% of waste classified as hazardous is incorrectly sorted. The disposal of this waste is not only more environmentally harmful but also much more expensive. The processing of surgical items by autoclaving consumes large amounts of water. Modern sterilization methods, for example using plasma could be future alternatives. Up to 20% of volatile nonmetabolized anesthetic agents are vented into the stratosphere and destroy the ozone layer. Intravenous anesthetic drugs should be used whenever possible instead. The choice of operating method can also contribute to the environmental impact of an operation.

CONCLUSION

The surgical disciplines are a relevant producer of environmental pollutants. Through diverse interdisciplinary approaches surgery can also contribute to protecting the environment.

Environmental impact and life cycle financial cost of hybrid (reusable/single-use) instruments versus single-use equivalents in laparoscopic cholecystectomy

BACKGROUND

Hybrid surgical instruments contain both single-use and reusable components, potentially bringing together advantages from both approaches. The environmental and financial costs of such instruments have not previously been evaluated.

METHODS

We used Life Cycle Assessment to evaluate the environmental impact of hybrid laparoscopic clip appliers, scissors, and ports used for a laparoscopic cholecystectomy, comparing these with single-use equivalents. We modelled this using SimaPro and ReCiPe midpoint and endpoint methods to determine 18 midpoint environmental impacts including the carbon footprint, and three aggregated endpoint impacts. We also conducted life cycle cost analysis of products, taking into account unit cost, decontamination, and disposal costs.

RESULTS

The environmental impact of using hybrid instruments for a laparoscopic cholecystectomy was lower than single-use equivalents across 17 midpoint environmental impacts, with mean average reductions of 60%. The carbon footprint of using hybrid versions of all three instruments was around one-quarter of single-use equivalents (1756 g vs 7194 g CO₂e per operation) and saved an estimated 1.13 e^-5 DALYs (disability adjusted life years, 74% reduction), 2.37 e^-8 species.year (loss of local species per year, 76% reduction), and US $ 0.6 in impact on resource depletion (78% reduction). Scenario modelling indicated that environmental performance of hybrid instruments was better even if there was low number of reuses of instruments, decontamination with separate packaging of certain instruments, decontamination using fossil-fuel-rich energy sources, or changing carbon intensity of instrument transportation. Total financial cost of using a combination of hybrid laparoscopic instruments was less than half that of single-use equivalents (GBP £131 vs £282).

CONCLUSION

Adoption of hybrid laparoscopic instruments could play an important role in meeting carbon reduction targets for surgery and also save money.

Disposable Ureteroscopes in Urology: Current State and Future Prospects

Ureteroscopy is the most common surgical modality for stone treatment. Reusable flexible ureteroscopes are delicate instruments that require expensive maintenance and repairs. Multiple single use ureteroscopes have been developed recently to combat the expensive and time-intensive sterilization and repair of ureteroscopes. Although multiple studies have looked at different aspects of reusable and single use ureteroscopes, there is significant heterogeneity in performance measures and cost between the 2 categories, and neither has a clear advantage. Both can be used successfully, and individual and institution level factors should be considered when deciding which ureteroscope to use.

Assessment of environmental sustainability in renal healthcare

The health effects of climate change are becoming increasingly important; there are direct effects from heatwaves and floods, and indirect effects from the altered distribution of infectious diseases and changes in crop yield. Ironically, the healthcare system itself carries an environmental burden, contributing to environmental health impacts. Life cycle assessment is a widely accepted and well-established method that quantitatively evaluates environmental impact. Given that monetary evaluations have the potential to motivate private companies and societies to reduce greenhouse gas emissions using market mechanisms, instead of assessing the carbon footprint alone, we previously developed a life cycle impact assessment method based on an endpoint that integrates comprehensive environmental burdens into a single index-the monetary cost. Previous investigations estimated that therapy for chronic kidney disease had a significant carbon footprint in the healthcare sector. We have been aiming to investigate on the environmental impact of chronic kidney disease based on field surveys from the renal department in a hospital and several health clinics in Japan. To live sustainably, it is necessary to establish cultures, practices, and research that aims to conserve resources to provide environmentally friendly healthcare in Japan.

Operating in a Climate Crisis: A State-of-the-Science Review of Life Cycle Assessment within Surgical and Anesthetic Care

BACKGROUND

Both human health and the health systems we depend on are increasingly threatened by a range of environmental crises, including climate change. Paradoxically, health care provision is a significant driver of environmental pollution, with surgical and anesthetic services among the most resource-intensive components of the health system.

OBJECTIVES

This analysis aimed to summarize the state of life cycle assessment (LCA) practice as applied to surgical and anesthetic care via review of extant literature assessing environmental impacts of related services, procedures, equipment, and pharmaceuticals.

METHODS

A state-of-the-science review was undertaken following a registered protocol and a standardized, LCA-specific reporting framework. Three bibliographic databases (Scopus®, PubMed, and Embase®) and the gray literature were searched. Inclusion criteria were applied, eligible entries critically appraised, and key methodological data and results extracted.

RESULTS

From 1,316 identified records, 44 studies were eligible for inclusion. The annual climate impact of operating surgical suites ranged between 3,200,000 and 5,200,000 kg CO2e. The climate impact of individual surgical procedures varied considerably, with estimates ranging from 6 to 1,007 kg CO2e. Anesthetic gases; single-use equipment; and heating, ventilation, and air conditioning system operation were the main emissions hot spots identified among operating room- and procedure-specific analyses. Single-use equipment used in surgical settings was generally more harmful than equivalent reusable items across a range of environmental parameters. Life cycle inventories have been assembled and associated climate impacts calculated for three anesthetic gases (2-85 kg CO2e/MAC-h) and 20 injectable anesthetic drugs (0.01-3.0 kg CO2e/gAPI).

DISCUSSION

Despite the recent proliferation of surgical and anesthesiology-related LCAs, extant studies address a miniscule fraction of the numerous services, procedures, and products available today. Methodological heterogeneity, external validity, and a lack of background life cycle inventory data related to many essential surgical and anesthetic inputs are key limitations of the current evidence base. This review provides an indication of the spectrum of environmental impacts associated with surgical and anesthetic care at various scales. https://doi.org/10.1289/EHP8666.