Surgery resources

Resources

Access useful resources about net zero surgery:

Sustainable surgery: the first "net zero" operation in the NHS. 2022.
Watch the NHS surgical team discuss the significance and impact of the first recorded net zero operation in the NHS.

The Royal College of Surgeons of England have released a Sustainability in the operating theatre: A guide to good practice, with practical recommendations for surgeons and members of the surgical team.

The Intercollegiate Green Theatre Checklist and compendium of evidence. Evidence-based recommendations from 3 UK medical colleges for environmentally sustainable practice in operating theatres, recently endorsed by Council of the Royal Australasian College of Surgeons.

Ready references

Carbon footprint of surgery

• The Carbon Footprint of Surgical Operations. Rizan et al. 2020. This systematic review details major carbon hotspots in operating theatres including electricity use and procurement of consumables.
• The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems. MacNeill et al. 2017. Carbon footprinting of 3 hospitals in different countries finds operating theatre greenhouse gas emissions of 3.2-5.2 million kg CO2e per year.
• Introduction of the Surgical Providers Assessment and Response to Climate Change (SPARC2) Tool. Ewbank et al. 2021. Scoring system to assess climate-readiness of hospitals and assist in reducing carbon footprint of surgical care.

Creutzfeldt-Jakob Disease

Reducing the Risk of Transmission of CJD from surgical instruments used for interventional procedures on high-risk tissues. NICE. 2020. Evidence-based recommendations for high-risk tissues (essentially CNS) and cost-effectiveness studies do not support routine use of single-use equipment except in known or suspected cases.

Environmental sustainability in operating theatres

• Empowering Surgeons, Anaesthesiologists, and Obstetricians to Incorporate Environmental Sustainability in the Operating Room. Yates et al. 2021. Importance of reducing energy usage (lighting, air conditioning), practising environmentally preferable purchasing, minimising opening of disposables, using reusables whenever possible, reprocessing of "single-use" items, rationalising waste streams.
• The Green Print: Advancement of Environmental Sustainability in Healthcare. Sherman et al. 2020. Comprehensive review of strategies in healthcare.
• Operating room greening initiatives - the old, the new, and the way forward: A narrative review. Wyssusek et al. 2018. The future of OR greening is intricate and requires multidisciplinary collaboration between all health care personnel and hospital management, adequate leadership and guidance, implementation of an 'environmental greening team', staff education, and a predilection for new and novel environmentally-friendly technologies.

Gowns and drapes

• A comparison of resuable and disposable perioperative textiles: sustainability state-of-the-art. Overcash. 2012. Reusable surgical textiles offer substantial sustainability benefits over disposables, at equivalent cost, protection and comfort.
• Environmental considerations in the selection of isolation gowns: A life cycle assessment of reusable and disposable alternatives. Vozzola et al. 2018. Significant environmental benefits of reusable garment systems.
• Comparative life cycle assessment of reusable and disposable scrub suits used in hospital operating rooms. Burguburu et al. 2022.

Infection control issues

• The carbon footprint of the operating room related to infection prevention measures: a scoping review. Bolten et al. 2022. High carbon footprint of many infection prevention measures that do not reduce infection risk.
• Balancing Infection Control and Environmental Protection as a Matter of Patient Safety: The Case of Laryngoscope Handles. Sherman & Hopf. 2018. An illustration of an overcautious empirical infection control measure leading to environmentally harmful practice (laryngoscope handles).

Laparoscopic surgery

• Environmental impact and life cycle financial cost of hybrid (reusable/single-use) instruments versus single-use equivalents in laparoscopic cholecystectomy. Rizan & Bhutta. 2022. Lower environmental impact and lower overall cost of hybrid instruments.
• Comparison of economic and environmental impacts between disposable and reusable instruments used for laparoscopic cholecystectomy. Adler et al. 2005. Disposable instruments should be used only if they offer clear advantages over reusables.
• Environmental impact of single-use, reusable, and mixed trocar systems used for laparoscopic cholecystectomies. Boberg et al. 2022. Reusable trocar system reduces environmental impact and financial costs.

Minor operations

Carbon footprint of dermatologic surgery. Tan & Lim. 2020. Lower environmental impact of skin lesion surgery when done in outpatient clinic setting.

Opthalmology

• The carbon footprint of cataract surgery. Morris et al. 2013.
• The Cataract surgery and environmental sustainability: Waste and lifecycle assessment of phacoemulsification at a private healthcare facility. Thiel et al. 2017. Carbon footprint of one cataract procedure done in NHS equivalent to 30 procedures done with reusable equipment at Indian clinic, without difference in safety or outcome.
• Ophthalmology Going Greener: A Narrative Review. Wong et al. 2021.

Orthopaedics

• Environmental sustainability in orthopaedic surgery. Phoon et al. 2022. A scoping review examining environmental impact of orthopaedic surgery and methods of reducing this.
• How Can We Make Hand Surgery Carbon Neutral. Borg. 2021.

Recycling of plastics

Recycling of medical plastics. Joseph et al. 2021.

Reflux management

Modelling the carbon footprint of reflux control. Gatenby. 2011. Lower cost and carbon footprint associated with durable anti-reflux surgery.

Reprocessing

Assessing the environmental, human health, and economic impacts of reprocessed medical devices in Phoenix hospital's supply chain. Unger & Landis. 2016. Lower cost of reprocessing disposable devices, but impact on environment and human health dependent on optimising reprocessing inputs and systems.

Reusable versus disposable equipment

• Life cycle assessment of a disposable and a reusable surgery instrument set for spinal fusion surgeries. Leiden et al. 2020. In this analysis of spinal fusion surgery, the carbon footprint of reusable instruments was found to be lower only when amount of instrumentation was rationalised and sterilisation processes were optimised.
• Operating in a Climate Crisis: A State-of-the-Science Review of Life Cycle Assessment within Surgical and Anesthetic Care. Drew et al. 2021. An in-depth look at the importance of life cycle analysis to determine the environmental impact of interventions and equipment.
• How medicine becomes trash: disposability in health care. Greene et al. 2022. A description of how the linear economy of single-use disposable equipment has taken over healthcare.

Robotic surgery

Environmental sustainability in robotic and laparoscopic surgery: systematic review. Papadopoulou et al. 2022. Increased environmental impact of robotic surgery may not be sufficiently offset by any clinical benefit.

Skin preparation solution

Antiseptic Skin Agents to Prevent Surgical Site Infection After Incisional Surgery. Smith et al. 2022. RCT showing alcoholic povidone iodine to be non-inferior to alcoholic chlorhexidine and not superior to aqueous povidone iodine.

Sterilisation

• Steam sterilisation's energy and water footprint. McGain et al. 2017. Minimisation of environmental impact of steam sterilisation by improved efficiencies.
• Minimizing carbon and financial costs of steam sterilisation and packaging of reusable surgical intruments. Rizan et al. 2022. Rationalising make-up of sets, efficient machine loading, renewable energy, recycling.

Theatre caps

Why throw away non-biodegradable theatre caps? Plenty of reusable washable theatre caps available, such as the bandannas from the CANTEEN youth cancer charity.​