Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Br J Surg. 2023 Jun 12;110(7):804-817. doi: 10.1093/bjs/znad092.


Background: Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

Methods: This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

Results: In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

Conclusion: This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Plain language summary

The effects of climate change need urgent action. Most countries and organizations have made commitments to reduce carbon. Healthcare, and especially surgery, is responsible for producing a large amount of carbon and for other behaviours that are harmful to the environment. The aim of this study was to identify the most practical and safe interventions to make surgery more environmentally friendly. Interventions to achieve green surgery were found in the literature and added to a list. The list was ordered and shortened, following advice of doctors and patients. The safest and most practical interventions were at the top. The top three areas for change were to reduce the use of one-use items and energy, recycle, and manage waste appropriately. There are several ways that we can make surgery greener. The list produced gives us practical examples of what can be done.

Publication types

  • Systematic Review

MeSH terms

  • Delivery of Health Care*
  • Developing Countries*
  • Environment
  • Health Personnel
  • Humans