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.
