COMMENTARY

Operation Sustainable Surgery: Saving Lives Must Not Be to the Detriment of the Planet

Evangelos Xynos, MD, PhD; Antonino Spinelli, MD, PhD

Disclosures

August 27, 2021

The sustainability of surgical procedures is perhaps not something the wider population often questions. After all, we're the trusted professionals who carry their lives in our hands. In times of bad health, it's unlikely that thoughts will turn to the carbon footprint of the operation that the patient or a loved one is about to undergo. But upon deeper reflection, we within the sector have woken up to the fact that sustainability in surgery requires urgent attention.

The healthcare sector is significantly resource-intensive, with operating rooms being one of the biggest perpetrators. Despite its admirable ambition to become net zero carbon by 2040, the National Health Service (NHS) in England has an annual carbon footprint of 24.9 million tons of CO2e. Meanwhile, the carbon footprint of an operating department in a large hospital in the United Kingdom is estimated at 5000 tons CO2e annually, with a single operation estimated at 173 kg CO2e. A report in The Lancet estimated that the healthcare sector is responsible for 4.6% of global carbon emissions.

Many of us are acutely aware of the unsustainability of our practice, but surgeons are notoriously time-poor and their priorities often fall elsewhere. Patient safety and protocol must always come first, and lifesaving procedures quite naturally rise to the top of our to-do lists. When we're not with our patients, our time is dedicated to carrying out research and sharing learnings, as we strive to improve patient outcomes worldwide.

This is by no means a dismissal of our personal responsibility for achieving greater sustainability in surgery. Quite the opposite — the European Society of Coloproctology is campaigning to improve practices and better understand the obstacles colorectal surgeons are facing. Nonetheless, many of the changes that need to be made are not within a surgeon's remit of authority, no matter their seniority. The sector is in desperate need of greater collaboration, at the organizational, national, and international levels.

How Surgeons Can Begin to Make a Difference

Working to improve sustainability within our multidisciplinary teams is, of course, crucial. There are many small changes we can make, such as only opening instruments in the operating room that we are certain we will use, leveraging new telehealth technologies where prudent, and working with patients to prevent unnecessary surgeries. However, it is imperative that we also achieve wider participation and a concerted effort from hospital boards, medical device manufacturers, and healthcare policy makers.

Single-use products, meant to prevent risk for infection during operations, are one of the key contributors to a surgical procedure's carbon footprint. But reusing certain pieces of equipment does not need to affect patient safety. We must establish an evidence-based and widely agreed-upon list of items that are safe and feasible to be used more than once with appropriate decontamination. Nearly 10 years, ago the Association of Surgeons of Great Britain and Ireland released a consensus statement on cost-effective surgery in which the authors stated that the risk for cross-infection with single-use surgical instruments is "infinitesimally small," but that "hysteria leads to colossal waste." Since then, progress has been slow. Indeed, our research suggests some hospitals do reuse "single-use" items, whereas others do not. A well-communicated and joined-up approach is surely all that is needed to prevent tons upon tons of surgical waste.

The financial interests of medical device manufacturers' should also be further scrutinized as we promote more sustainable ways of practicing surgery. The more we buy single-use products, the greater their profits. We should therefore question the industry's insistence that certain items must be single-use. If and when we discover otherwise, these large corporations should be held to account. To instill wider industry change, hospital management must use their agency to procure reusable tools, and partner with manufacturers to find new and innovative solutions.

Water consumption in operating rooms is another issue that must be addressed. Recent studies suggest that there is no significant difference between the antiseptic efficacies of traditional scrubbing practices and a waterless hand scrub.[1,2,3] An average of 60.2 liters of water per procedure could be saved if alcohol-based agents were used instead.

Similarly, we are seeing increasing awareness of the detrimental effects of anesthesia. Exhaled anesthetic gases are recognized greenhouse gases and contribute to 5% of the NHS footprint in the United Kingdom. Alternatives such as low-flow anesthesia; "blue-zone technologies" that capture, reclaim, and purify halogenated agents; and total intravenous anesthesia, which avoids their use completely, should be considered for all surgeries on a case-by-case basis.

There's No Effective Healthcare Without a Healthy Planet

Climate change is one of the greatest threats to mankind, and as surgeons we cannot forget how closely the health of our patients is intertwined with the health of our planet. Surgical care that consumes resources at a rate that exceeds available supplies is no longer acceptable. We must no longer focus solely on the health of our patient as an indicator of success, but also on that of the environment, global populations, and future generations.

The onus of sustainable surgery should not fall on surgeons alone. Internationally, we need reviews of the processes by which hospitals are managing resources. At a national level, we need updated protocols and systemwide change. Hospital management must consider the existing culture and practices and support all staff to deliver more sustainable healthcare.

The United Nations and other organizations have targeted 2030 as the year by which we need to achieve several sustainable development goals. With less than a decade to go, it's time for a united approach, and greater accountability at all levels to make sustainable surgery a reality.

Evangelos Xynos, MD, PhD, is president of the European Society of Coloproctology and professor of surgery at the University of Crete, Greece. His clinical and research interests include colorectal cancer, the pelvic floor, and functional coloproctology.

Antonino Spinelli, MD, PhD, is general secretary of the European Society of Coloproctology; director of the Colon and Rectal Surgery Unit at Humanitas Research Hospital in Milan, Italy; and full professor of surgery at Humanitas University. Professor Spinelli's specialist interests include minimally invasive techniques, enhanced postoperative patient recovery, rectal cancer, and inflammatory bowel disease.

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