If the global healthcare sector were a country, it would rank as the fifth-largest greenhouse gas emitter on the planet. The operating room (OR) stands out as the primary energy consumer and waste producer, consuming up to six times more energy than other hospital areas and generating over half of the hospital's waste. As sustainability takes centre stage in the industry agenda, green surgery is emerging as a vital component in reducing hospitals' carbon impact worldwide. Carbon hotspots in the operating theatre include anaesthetic gases, energy, and single-use products.
Surgeons can lead the charge
“Surgeons have an opportunity to be leaders in this space, mainly because the single biggest producer of waste is indeed the operating room,” says Dr. Mehul V. Raval, a paediatric surgeon at the Ann & Robert H. Lurie Children's Hospital in Chicago. Dr. Raval co-authored a 2022 report in the Journal of the American College of Surgeons (JACS) based on a study on how sustainability interventions in surgical care could reduce hospital costs and decrease their carbon footprint. The study design was a retrospective review of 23 studies involving 28 quality improvement initiatives that incorporate what is known as the “triple bottom line” framework into operating room management. This framework considers the combined impact of environmental, financial, and social interventions.
Dr. Mehul V. Raval, Paediatric Surgeon at Ann & Robert H. Lurie Children's Hospital
“The opportunity to reduce our carbon footprint falls squarely on us, and I see surgeons taking a prominent role in leading efforts, not just locally with their green implementation teams, but in setting national standards and policies that will move this effort forward for an overall sustainable way of approaching healthcare delivery,” he adds. “At the end of every day and every case, it’s disturbing how many bags of trash we are throwing away, especially with the use of disposables and plastics that we see growing in use as time goes on,” Dr. Raval says.
Surgeons can advocate for change to move the needed across the entire OR value chain, from ensuring proper waste disposal to implementing recycling programmes. “If we can come together just to think about what we are using, we can lower the amount of waste that we are producing overall, and reduce our emissions,” says Dr. Gwyneth Sullivan, the lead study author and a surgical resident at Rush University and a research fellow at Northwestern University Surgical Outcomes and Quality Improvement Center, both in Chicago.
Dr. Gwyneth Sullivan, surgical resident at Rush University, and research fellow at Northwestern University Surgical Outcomes and Quality Improvement Center
Sustainability in practice
The research delved into five sustainability approaches — refuse, reduce, reuse, repurpose, and recycle — and their impacts on operating room costs and the environment. All interventions demonstrated cost savings. For instance, a quality improvement initiative at a hospital saved US$2,233 annually by transitioning to a waterless surgical scrub, conserving 2.7 million litres of water annually.
The most impactful intervention was a straightforward educational initiative, resulting in US$694,141 in annual savings by educating staff on proper medical waste disposal. This effort also led to a 30 per cent reduction in medical waste.
Other cost-saving measures included powering down lights and equipment overnight and reducing the frequency of washing non-contaminated anaesthetic equipment. Over a third of the studies focused on the "refuse" category, where surgical teams minimised the use of certain supplies or opted for alternative items. For example, surgeons often use premade packs of gowns, gloves, and surgical equipment for cases. Interventions in this category involved modifying practices and eliminating unnecessary disposable items from these packs.
The DRAGON trial: a new milestone
In 2023, surgical teams worldwide were invited by the University of Birmingham to participate in a groundbreaking trial, named DRAGON, to assess the effectiveness of reusable gowns and drapes in reducing surgical site infections (SSIs) compared to disposable ones. The trial is being rolled out across 134 operating theatres globally, with an estimated recruitment of approximately 27,000 participants. The primary objective is to measure the difference in SSIs between reusable and disposable surgical drapes and gowns.
“The DRAGON trial will provide us with a unique opportunity to consider whether assumptions that are made about the clinical superiority of disposable gowns and drapes hold up,” says Dr. Aneel Bhangu, Professor of Global Surgery, NIHR Lead Clinician Scientist in the NIHR Global Surgery Unit at the University of Birmingham, who is the chief investigator of the project. "We need to make sure that we're negotiating with industry partners to try and enable reusable equipment, that we're only opening things that we need to use,” he says. “We can comfortably expect to deliver policy-changing data on those three topics within the next three years."
Dr. Aneel Bhangu, Professor of Global Surgery and NIHR Lead Clinician Scientist in the NIHR Global Surgery Unit, University of Birmingham
The global randomised trial marks a milestone as the first surgical trial with a triple endpoint, evaluating the clinical, financial, and environmental impacts of different surgical gowns and drapes. This holistic approach underscores the importance of sustainability alongside clinical efficacy and cost-effectiveness in healthcare practices.
An innovative approach to anaesthetics
The initiative’s focus is across three key pillars. In addition to the DRAGON trial on reusable drapes and gowns and focusing on improving waste management to enhance both segregation and recycling at the end of each surgery, Dr. Bhangu stresses the role of collaborating with anaesthetists to explore ways to reduce the use of environmentally harmful gases during anaesthesia.
Anaesthetic gases make up about half of greenhouse gas emissions of operating rooms; studies evaluating interventions that reduce these and other sources of emissions could make a substantial impact. In 2021, Pedro Hispano Hospital in Portugal partnered with Baxter-ZeoSys to trial an innovative gas capture system to reduce emissions from anaesthetic gases. Operating on the principle of a circular economy, wherein materials are reused to minimise waste, this system intercepts waste gases before they are released into the atmosphere. These captured gases can then be reused in future anaesthetic procedures.
The hospital utilised gas canisters containing highly porous adsorbent granules to capture waste gases from four anaesthesia machines. These canisters successfully collected 99 per cent of waste anaesthetic gases and once full, were transported to an industrial unit where the captured gases were extracted and purified. The purified sevoflurane, one of the captured gases, has received approval for use in new anaesthetics in Germany and Austria.
A model for a collaborative approach
Dr. Bhangu emphasises the diverse composition of their team, which includes health economists, statisticians, trial managers, patient representatives, and individuals from various countries such as India, Nigeria, Ghana, Benin, Rwanda, and South Africa. This global representation underscores their commitment to generating universally applicable data. “This level of diversity is important. It's not just a few surgeons in England trying to tell everyone what to do. It's representing a global, multidisciplinary community to tackle one of the biggest challenges of our time.”
This collaborative model suggests a future where operating rooms will have dedicated green teams comprising surgeons, nurses, anaesthesiologists, supply chain personnel, environmental services staff, and hospital management. Together, they can adopt a sustainability-first approach to reducing the environmental footprint of healthcare facilities and protect communities from climate threats.
