Introduction

Surgical site infections (SSI) are the most common healthcare-associated infection however access to healthcare services, lack of patient awareness of signs, and inadequate wound surveillance may limit timely diagnosis. Telemedicine as a method for postoperative follow-up has been shown to reduce time, travel, and cost, without compromising clinical outcomes. Furthermore, a significant contributor of CO₂e is attributable to patient travel, therefore the NHS must adopt innovative approaches to meet its net zero target by 2024.

Aims & Methods

This study aimed to provide a comprehensive analysis of the feasibility and sustainability of telemedicine post-operative follow-up for remote diagnosis of SSI.
Patients were reviewed remotely at 30 days with a combined outcome measure (photographs and validated questionnaire). A hybrid life-cycle assessment approach to carbon footprint analysis was used. The kgCO₂e associated with remote methods was mapped prospectively. A simple outpatient clinic review, i.e. no further investigations or management required, was modelled for comparison. DEFRA conversion factors amongst healthcare specific sources were used to ascertain kgCO₂e. Patient postcodes were applied to conversion factors based upon mode of travel to calculate kgCO₂e for patient travel. Total and Median (IQR) carbon emissions saved were presented for both patients with and without SSI.

Results

31 patients (M:F 2.4, 66.7±11.7 years) agreed to participate. The median return distance for patient travel was 42.5 (7.2 to 58.7) km. Median reduction in emissions using remote follow-up was 41.2 (24.5 to 80.3) kgCO₂e per patient (P<0.001). The carbon offsetting value of this method is planting 1 tree for every 6.9 patients. Total carbon footprint of face-to-face follow-up was 2895.3 kgCO₂e, compared to 1301.3 kgCO₂e when using a remote first approach (P<0.001). Carbon emissions in participants without wound complications was 700.2 kgCO₂e for clinic method and 28.8 kgCO₂e for remote follow-up.

Conclusion

This model shows that the hybrid life-cycle assessment approach is achievable and reproducible. Implementation of an asynchronous digital follow-up model is effective in substantially reducing the carbon footprint of a tertiary surgical centre. Further work is needed to corroborate these findings on a larger scale, quantify the impact of telemedicine on patient’s quality of life and incorporating kgCO₂e into the cost analysis of potential SSI monitoring strategies.

Disclosure

No conflict of interest

Introduction

Endoscopy devices are essential tools for minimally invasive diagnostic and therapeutic procedures. The use of single-use endoscopic devices has risen due to safety, infection control and logistical facility. However, their disposal after a single procedure generates significant waste that must be managed. Various strategies such as controlled reuse or redesigning to facilitate disposal have been proposed. All these alternatives present issues in terms of environmental impact, particularly regarding the carbon footprint over the device's life cycle.

Aims & Methods

To quantify the Product Carbon Footprint (PCF) of the available End of Life (EoL) treatment options for three single-use endoscopes (urethroscope, duodenoscope and cholangioscope) to assess their environmental impact. All data was collected in Germany during 2024. This study followed the guidelines of International Organization for Standardization (ISO) 14067 to quantify the PCF and applied the Global Warming Potential (GWP) over 100 years characterisation factors, including carbon climate feedback, developed by the Sixth Assessment Report (AR6) of the Intergovernmental Panel on Climate Change (IPCC). The mass and composition (plastics, metals and electronic components) of the endoscopes were considered. Packaging materials included polypropylene and polyurethane foam (collection box) or low-density polyethylene (plastic bag). The EoL treatment scenarios for the endoscopes were: incineration of endoscope and collection box (PCF 1.1), incineration of endoscope and plastic bag (PCF 1.2), recycling of endoscope and incineration of collection box (PCF 2.1), and recycling of endoscope and collection box (PCF 2.2). In the incineration scenario, endoscopes were incinerated in a thermal waste incinerator with energy recovery. In the recycling scenario, endoscopes were disinfected in an autoclave and transported in refrigerated trucks to an electronic waste recycling plant where metals were recovered, and plastics were divided between recovered and unrecovered (incinerated). Transport parameters such as truck idling and energy use were analyzed.

Results

This study showed that the recycling and material recovery strategy for both endoscopes and collection boxes (PCF 2.2) had the lowest GWP. When comparing both incineration scenarios, PCF 1.2 had a lower GWP compared to PCF 1.1 due to the impact of the plastic bags. Similarly, when comparing both recycling scenarios, PCF 2.2 had a lower GWP compared to PCF 2.1 due to the recycling of the collection box. The GWP was driven by fossil Greenhouse Gas (GHG) emissions, as the materials are primarily polymeric. However, the other ISO 14067 GWP categories had a negligible impact. Variations among endoscopes were due to differences in mass, composition and feasibility of material separation. The disinfection process and transport had minimal influence.

Conclusion

This study demonstrates that recycling and material recovery strategies offer clear environmental advantages compared to incineration and energy recovery, such as the reduction of GHG emissions, increased material value retention, minimizing toxic residues and lower operational cost over time. Therefore, it is recommended that the current EoL treatment of single-use endoscopes be shifted from incineration to recycling. Incorporating eco-design (lighter weight, easier disassembly) could further improve recyclability and reduce the impact of non-recoverable plastics.

Introduction

The Dutch healthcare sector is responsible for over 7% of the national carbon footprint and 4% of all produced waste, with a substantial contribution of the surgical community. (1-2) Numerous sustainability initiatives have emerged, each targeting specific aspects of surgical procedures such as utilization of disposables, waste management, and use of inhalation anaesthesia. However, for the surgical team to gain insights into the environmental impact of procedures and to identify the primary contributors guiding mitigation strategies, a comprehensive assessment of the surgical procedures is imperative. This study aimed to assess the carbon footprint of laparoscopic cholecystectomy (LC) and identify mitigation options by performing a life-cycle assessment (LCA).

Aims & Methods

A multicentre observation study of 15 elective LCs was conducted in 3 hospitals. This LCA studied the entire life cycle of processes and materials involved in the surgical procedure including all surgical instruments (i.e., reusable, and disposable instruments), medication (including anaesthesia), sterilisation process of reusable equipment, energy consumption, operating room (OR) scrubs and linen, and travel movements of operating room personnel and patients. The primary outcome measure was the carbon footprint in kg CO2 equivalents (eq.) of the operation. Secondary outcomes were identifying major contributing factors and mitigation options. Based on feasible mitigation measures, the carbon footprint of a best-case scenario was determined. The LCA was performed according to ISO14040 guidelines and ReCiPe 2016 methodology. (3-4)

Results

The carbon footprint of a LC was 56.5 kg CO2 eq. The main contributors were disposable materials, accounting for 40% of the total carbon footprint (22.7 kg CO2 eq. IQR 21.5-24.6), energy consumption (11%, 6.1 kg CO2 eq.; IQR 5.4-7.9), and transport of personnel (13%, 7.1 kg CO2 eq.; IQR 5.5-9.6). Reusable products made up 22% (12.5 kg CO2 eq.; IQR: 12.5-12.5) with 81% attributable to the sterilisation process. Medication made up 3.0 kg CO2 eq. (5%, IQR: 0.08-5.9), with inhalation anaesthetic, sevoflurane responsible for 96% of the carbon footprint. The Best-case scenario included transitioning to reusable instruments, reducing surgical drapes, adopting total intravenous anaesthesia, and switching to 100% green energy, reducing the total footprint by 23%.

Conclusion

This study showed the carbon footprint of a LC and provided insights in the most important contributing factors. A substantial reduction in the carbon footprint can be achieved by replacing disposable surgical instruments (trocars and clipper) with reusable alternatives, reducing surgical drapes, switching to total intravenous anaesthesia, and transitioning to 100% green energy. The results of this study extend beyond LC and can be used to accelerate and provide guidance for sustainability initiatives, an essential step towards sustainable surgical care.
Moreover, the most impactful approach to reduce the carbon footprint lies in avoiding unnecessary procedures. Recent studies have shown that a restrictive or conservative strategy for uncomplicated gallstone disease is comparable to cholecystectomy as a treatment option in terms of quality of life and biliary-related complications (5-6). Therefore, we are currently conducting a carbon footprint effectiveness analysis in the United Kingdom and the Netherlands to determine the carbon footprint reduction potential of a conservative or restrictive strategy for uncomplicated gallstone disease. We anticipate being able to present the results at the congress.

References

1. Steenmeijer MA, Rodrigues JFD, Zijp MC, et al. The environmental impact of the Dutch health-care sector beyond climate change: an input-output analysis. Lancet Planet Health. 2022;6(12):e949-e57.
2. MacNeill AJ, Lillywhite R, Brown CJ. The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems. Lancet Planet Health. 2017;1(9):e381-e8.
3. ISO 14040:2006(en) Environmental management — Life cycle assessment — Principles and framework 2006.
4. Huijbregts MAJ, Steinmann ZJN, Elshout PMF, et al. ReCiPe2016: a harmonised life cycle impact assessment method at midpoint and endpoint level. The International Journal of Life Cycle Assessment. 2017;22(2):138-47.
5. Ahmed I, Hudson J, Innes K, et al. Effectiveness of conservative management versus laparoscopic cholecystectomy in the prevention of recurrent symptoms and complications in adults with uncomplicated symptomatic gallstone disease (C-GALL trial): pragmatic, multicentre randomised controlled trial. Bmj. 2023;383:e075383.
6. van Dijk AH, Wennmacker SZ, de Reuver PR, et al. Restrictive strategy versus usual care for cholecystectomy in patients with gallstones and abdominal pain (SECURE): a multicentre, randomised, parallel-arm, non-inferiority trial. Lancet. 2019 Jun 8;393(10188):2322-2330. doi: 10.1016/S0140-6736(19)30941-9. Epub 2019 Apr 27. Erratum in: Lancet. 2019 May 11;393(10184):1936. PMID: 31036336.

Introduction

The rapid adoption of robotic surgical systems across Europe has led to a critical gap in training and certification for gastrointestinal (GI) surgical trainees [1]. Following a systematic review of existing multi-specialty robotic surgical curricula [2,3] and a pan-European survey to capture current robotic training practices [4], we generated consensus statements for a Delphi study to develop a robotic training curriculum for GI surgery trainees.

Aims & Methods

We aimed to develop a European consensus on a standardised robotic training curriculum for GI surgical trainees. A 99-item statement Delphi questionnaire was finalised by an international Steering Committee and patient and public advocates. The questionnaire was disseminated via Qualtrics XM platform [5] to a multidisciplinary panel of 83 robotic GI surgeons, trainees, representatives from the extended robotic theatre team (including anaesthetists, scrub nurses, robotic practitioners) and industry. A priori consensus standard was set at ≥70% for agreement to a statement across two rounds.

Results

Seventy-one (85.5%) participants, from 15 different countries, completed round one of the Delphi process. Responses were obtained from independent general surgeons (n = 16, 22.5%), upper GI/hepatopancreato-biliary surgeons (n = 15, 21.1%), lower GI surgeons (n = 15, 21.1%), GI trainees (n = 10, 14.1%), robotic theatre team and human factors experts (n = 7, 9.9%), and robotic industry providers (n = 8, 11.3%). Thirty-one (43.7%) participants performed more than 50 robotic cases independently. A total of 77 items (77.8%) reached consensus in the first round, with 32 new statements being generated based on free-text comments. Seventy members (98.6%) completed the 54-item round two questionnaire, with 32 items (59.3%) reaching consensus. Agreement was reached in the following areas on a robotic training curriculum for GI surgery trainees: (i) core learning skills of a bedside assistant and console surgeon; (ii) key components of a robotic training curriculum (including required e-learning modules, wet and dry lab simulation metrics); (iii) performance assessment (including technical skills assessment and clinical metrics); (v) requirements for certification and supervision and (vi) assessment of the long-term impact or success of a GI robotic training curriculum.

Conclusion

To our knowledge, this study provides the first European consensus and curriculum in robotic training, assessment and certification for GI surgery trainees. This consensus will potentially help shape the future of robotic surgical education, promote standardised training practices and ultimately improve patient safety.

References

1. Sheetz KH, Claflin J, Dimick JB. Trends in the adoption of robotic surgery for common surgical procedures. JAMA Network Open 2020;3:e1918911.
2. Fadel MG, Walshaw J, Pecchini F, Yiasemidou M, Boal M, Elhadi M, Fehervari M, Massey LH, Carrano FM, Antoniou SA, Nickel F, Perretta S, Fuchs HF, Hanna GB, Kontovounisios C, Francis NK; European Robotic Surgery Consensus (ERSC) study group. A pan-European survey of robotic training for gastrointestinal surgery: European Robotic Surgery Consensus (ERSC) initiative. Surg Endosc. 2025;39(2):907-921.
3. Fadel MG, Walshaw J, Pecchini F, Yiasemidou M, Boal M, Elhadi M, Fehervari M, Massey LH, Carrano FM, Antoniou SA, Nickel F, Perretta S, Fuchs HF, Hanna GB, Kontovounisios C, Francis NK; European Robotic Surgery Consensus (ERSC) study group. A pan-European survey of robotic training for gastrointestinal surgery: European Robotic Surgery Consensus (ERSC) initiative. Surg Endosc. 2025;39(2):907-921.
4. Walshaw J, Fadel MG, Boal M, Yiasemidou M, Elhadi M, Pecchini F, Carrano FM, Massey LH, Fehervari M, Khan O, Antoniou SA, Nickel F, Perretta S, Fuchs HF, Hanna GB, Francis NK, Kontovounisios C; European Robotic Surgery Consensus (ERSC) study group. Essential components and validation of multi-specialty robotic surgical training curricula: a systematic review. Int J Surg. 2025;111(4):2791-2809.
5. Qualtrics XM software. 2025.

Introduction

A surge in endoscopy requests, often discordant with International guideline recommendations, is overburdening services and wasting resources. Evidence suggests that up to 20-30% of upper gastrointestinal (GI) endoscopies and colonoscopies are inappropriate^1,2, and each procedure carries a significant carbon footprint (5.43 kg CO₂ for an upper GI endoscopy and 6.71 kg CO₂ for a colonoscopy)³. AI‑driven language models, such as ChatGPT, hold promise as decision‑support tools to help triage these requests. However, their efficacy in this context has yet to be validated.

Aims & Methods

The aim of this study was to compare ChatGPT o4-Mini’s appropriateness assessments with those of expert clinicians and model the potential environmental and economic benefits of reducing unnecessary procedures through AI-assisted decision making. Between February and April 2025, we prospectively collected endoscopy referrals from primary care physicians and other specialists to our tertiary referral centre. Each case was entered into ChatGPT-o4 Mini’s blank prompt, and appropriateness was evaluated according to the European and American guidelines. Two expert gastroenterologists independently reviewed the same referrals, and their assessment was used as Ground Truth.

Results

We evaluated 126 consecutive endoscopic examinations: 75 (60%) colonoscopies, 49 (39%) upper GI endoscopies, and 2 (1%) flexible sigmoidoscopies (FS). Overall, 21% of the endoscopic procedures were deemed inappropriate by expert review, and in particular 20% of colonoscopies, 20.4% of upper GI examinations, and 50% of FS. ChatGPT-o4 Mini demonstrated a comparable appropriateness estimate (AUC 0.91, 95% CI 0.83-0.98, sensitivity 99%, specificity 84%) to that provided by experts. Inter-rater agreement between experts and ChatGPT-o4 Mini appropriateness ratings was assessed using Cohen’s kappa and it results k = 0.87 indicating excellent agreement. In our simulated model, AI‑driven triage avoided 14 colonoscopies and 8 upper GI endoscopies, resulting in a reduction of 93.94 kg CO₂ per colonoscopy and 48.9 kg CO₂ per upper GI endoscopy, for a total carbon footprint saving of 142.84 kg CO₂.

Conclusion

ChatGPT‑o4 Mini demonstrated accuracy in assessing endoscopy appropriateness, with potential to reduce unnecessary procedures and their carbon footprint. With targeted training on clinical guidelines and referral data, such AI tools could act as autonomous triage filters, minimizing reliance on human reviewers. This approach may streamline resource allocation, enhance sustainability, and support guideline-adherent care. Further validation in real-world settings is warranted.

References

1. Zullo A, Manta R, De Francesco V, Fiorini G, Hassan C, Vaira D. Diagnostic yield of upper endoscopy according to appropriateness: A systematic review. Dig Liver Dis. 2019;51: 335–9.
2. Frazzoni L, La Marca M, Radaelli F, Spada C, Laterza L, Zagari RM, et al. Systematic review with meta-analysis: the appropriateness of colonoscopy increases the probability of relevant findings and cancer while reducing unnecessary exams. Vol. 53, Aliment Pharmacol Ther 2021; 53:22–32.
3. Elli L, La Mura S, Rimondi A, Scaramella L, Tontini GE, Monica F, et al. The carbon cost of inappropriate endoscopy. Gastrointest Endosc 2024;99:137-145.e3.

Introduction

Climate change is responsible for increasing global health consequences and healthcare-related expenses. Despite efforts to address these issues, the healthcare sector remains a significant contributor to the world's carbon footprint due to increasing greenhouse gas emissions, compromising its own sustainability. Particularly, endoscopy stands out as the second highest waste generator per clinical procedure, largely attributed to its resource-intensive processes and extensive use of single-use devices. This study aimed to assess the waste carbon footprint generated at a high-volume tertiary endoscopy center both before and after implementing a targeted sustainability intervention. Additionally, we assessed the intervention's impact on the daily workflow of the endoscopy staff.

Aims & Methods

A 3-stage prospective interventional study was conducted from December 2023 until March 2024. Pre-intervention: four-week observational audit, during which daily endoscopic waste (landfill, regulated medical waste (RMW), and recycled paper and plastic) was weighed in both endoscopy rooms and recovery areas. Intervention: following data collection, a dedicated training session was conducted for the endoscopy staff. The session included a presentation of the collected data and outlined key sustainability strategies aimed at enhancing waste segregation. Additionally, recycling streams were established with placement of dedicated bins in assessment areas. Post-intervention: four-week period during which daily endoscopic waste was weighed in both endoscopy rooms and recovery areas.
Weighing was conducted using an engineer-calibrated scale. For the purpose of this study, waste carbon footprint calculations were based on the equivalence of 1kg of landfill waste to 1kgCO_2e and 1kg of RMW to 3kgCO_2e.
Upon conclusion of the study, an anonymous survey was distributed to all staff members to assess the impact of the study on the daily work routine.

Results

Total waste carbon footprint was reduced by 28.2%. In endoscopy rooms, waste carbon footprint decreased 20.4% (pre- vs. post-intervention: 1472.8kgCO_2e vs. 1173.7kgCO_2e, p=0.552). RMW was reduced by 24.4% (pre- vs. post-intervention: 462.8kgvs. 336.3kg, p=0.020), whereas landfill waste (pre- vs. post-intervention: 72.2 vs. 151.1, p<0.001) and recycling waste increased (paper – pre- vs. post-intervention: 0 vs. 21, p<0.001; plastic – pre- vs. post-intervention: 0 vs. 33.6, p<0.001). Mean endoscopy load was similar (pre- vs. post-intervention: 517 vs. 541, p=0.48).
In recovery areas, waste carbon footprint decreased 58.3% (pre- vs. post-intervention: 386.7kgCO_2e vs. 161.1kgCO_2e, p=0.002). RMW was reduced by 42.1% (pre- vs. post-intervention: 109.4kgvs. 28kg, p<0.001), whereas landfill waste (pre- vs. post-intervention: 58.4 vs. 77.2, p=0.040) and recycling waste increased (paper – pre- vs. post-intervention: 0 vs. 6, p<0.001; plastic – pre- vs. post-intervention: 0 vs. 9.9, p<0.001).
All staff members agreed the project did not disrupt their daily work routine, emerging as a valuable asset for promoting further sustainable practices.

Conclusion

Our study demonstrated that reducing RMW and implementing daily recycling in endoscopy rooms and recovery areas are attainable objectives that do not hinder endoscopy productivity. As a result, a yearly reduction of 2104kgCO_2e could be achieved in our endoscopy unit. Additionally, this study highlighted the effectiveness of educational initiatives in raising awareness towards more sustainable endoscopy practices.