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The Leaner,GreenerScalpel : AdvancingSustainability in Surgery ESNEFTSUSTAINABILITYCONFERENCE, March 2025 MissSunitaSaha ConsultantOncoplasticBreastSurgeon Colchester Hospital,ESNEFTWhy ?Waste TheatreWaste • Gloves –Sterile andNon-sterile • Gowns andhats • Masks • IncoSheets • Drapes • Sliding sheet • Bairhugger device • Radioactive waste • Packaging • Instruments • Gallipots/kidney dishes • Sharps Recyclable or ReusableAlternatives • Gloves –Sterile andNon-sterile • Gowns andhats • Masks • Inco sheets • Drapes • Sliding sheet • Bairhugger device • Radioactivewaste • Packaging • Instruments • Gallipots/kidney dishes • Sharps COVID impact on PPE From DOH andSocialcare policypaper-PPEstrategy:Stabiliseand buildresilience2022 Sustainable aims for NHS • The NHS accounts for 4.6% of the UK’s total carbon footprint • Health and Care act 2022 - aim to deliver a Net zero NHS by 2045 • NHS produces 5.4% of the UK’s greenhouse gasesHealthcare accounts for ~4.4% carbon emissionsworldwide Environmental Impact of Healthcare Within hospitals, theatres contribute upto 25% of environmental impact Source:NHS England2022; Deliveringa “Net zero” National Health serviceEnvironmentalChallengesinSurgery AnaestheticGasesandMedicines EnergyConsumption WasteGenerationWhat DoesCarbon Footprint Mean? • CO2e=carboncostofanintervention • Reusable v. disposable medical equipmentneedtoconsiderits full lifecycle including: • costs ofmanufactureandpackaging • transportation • maintenanceandsterilisation • wastedisposalEnvironmentalCost ofSurgical Procedures 23% of product types were responsible for >80% of the 0.22kgCO2e permile carbon footprint; Tonsillectomy 7.5 kgCO2e 34 miles (Ipswich Return) Open Inguinal Hernia Repair 11.7kgCO2e 53 miles (Norwich) • Single use gown • Bone cementmix 12kgCO2e 55miles • Single use table drape LaparoscopicCholecystectomy 20.3 kgCO2e 91 miles (Oxford) • Single use clip applicator Kneearthroplasty 85.5kgCO2e 389 miles (Edinburgh) Gov.ukwebsite. Greenhouse gas reporting:Conversions factors 2024urgicaloperations.JRSM 2023 CorrelationofCost andSustainability Inmanycases, the greener option is inth“leaner” cheaper option Short term versuslongterms costs in sustainable practicesE.g. • Reusableversus Single-usegowns and drapes • Reusableversus Single use equipment • Energy efficient equipment • Waste management(Clinical versusGeneral versusRecyclable waste) • Virtual/Telephonerather than FTF clinical appointments • Sevofluraneversus DesfluraneIntercollegiate GreenTheatre Checklist PrinciplesofGreenerSurgicalPathways Considerthe whole patient pathway Primary prevention Health promotion Diseaseprevention/optimisation Surgery may be lessimpactful than conservative/medicalmeasures Where surgerynecessary; Streamlinewhole pathway Virtualand one stop clinics Minimisinginvestigations Reusable/low carbon options GIRFT IntercollegiateGreen checklist GreenSurgeryReport:Reducingthe environmental impactof surgicalcare (2023)Baseline Practice BreastTheatres Scoping study - evaluation of current practice • Data collection regarding components of checklist; • March 2023 – Anaesthesia component • Type of GA • Use of IV medications with oral alternatives • Recycling • July 2023 – Surgical component • Warming device • Gowns and drapes • Waste management • Single use equipment • Environmental and Cost analysis Anaesthesia Intraoperative • Oral pre-medication and fluid • Reusable gowns loading pre-operative (analgesia/antiemetic/PPI) • Reusable drapes • TIVA versus Inhalational GA • Hot dog warming rather than Bair hugger • Liberal pre-incision LA to • Reduce single use items reduce opiate requirement peri-operatively • Only open single use items when needed Oral Pre-Medications • Oral pre-medication 30 mins before theatre Vs intravenous intra-operatively • Good data on bio-availability and efficacy of oral preparation Unit cost IV PO Paracetamol £0.49 £0.02 Dexamethasone £0.38 £0.17 Ondansetron £0.18 £0.01 • “Cradle to grave” carbon footprint of paracetamol th • Oral Paracetamol = 0.003 KgCO2e per 1g Paracetamol (1/68 ) • IV in plastic = 0.130 KgCO2e per 1g Paracetamol Switch from IV to oral paracetamol = carbon foot print saving 47KgCOe p.a. = cost saving £174 GreenAnaesthesia • TIVA =2.42KgCO2eper intervention • InhalationalAnaesthesia =upto48.85kg CO2eperintervention Additional benefitsTIVA • ReducedPostoperative nausea&vomiting • Possible oncologicalbenefitwhen usedin cancersurgery intravenous anesthesia: a systematicreview and meta-analysishalationalanesthesia and total Single-use vs Reusable Gowns • Gown Manufacture and Supply Chain • Packaging manufacturing and supply chain Re-Usable Disposable • Laundry Gowns per 100 Gowns per 100 Costs £183.30 £206.80 • Sterilisation • Use of phase transport Carbon Footprint 52.36 Kg ofC2 153.74 Kg ofC2 • Cost and carbon footprint calculations based on use of reusable gowns once HOWEVER they may be used up to 30 times in life cycle Single-useV ReusableGowns Safe & Effective CO2e Waste Water Cheaper From Health Innovation NWCoast Report for NHS England Single-use vs Reusable Drapes Green checklist recommends evaluating need for PPE equipment Non-sterile gloves – “gloves are off” GOSH campaign -> 1/3 reduction Perianal cases – Non-sterile drape; no difference SSIs (save £106 per case) • No evidence that reusable drapes are inferior to single use drapes in terms of SSIs Review and Rationalise Instruments • Surgeon preference lists • Rationalise instrument sets (reduced “overage”) • Reduce single use items -> reusable alternatives • Laparoscopic ports and equipment • Single use clip applicators • Single use retractors • Kidney dish/Gallipots • Open items as required • Low carbon alternatives Sterilisable, reusable gallipots/kidney dishes/light handles are available – explored switch however issues with CSSD processes Patient warming • The ‘Hot Dog’ system • Benefits: • reduced electricity usage • Reduced running cost • Efficient heating • No disposable or single use component • Drawbacks • Initial outlay costs of hot-dog systemWasteBin slide picture! Waste & Recycling • Separationwaste • Plastic • Paper • Generalnon-clinical • Clinical • Sharps and clinical disposal x4 greater cost compared to general waste • Radioactive waste • RepairSwitch off! Heating • Save 44,774 kg Ventilation CO2e pa by switching off Air-Con equipment when Equipment not in use Lights AGSS • Associated financial Computers saving estimated to be £26000 pa This Photo by Unknown Author is licensed under CC BY-SA Where do we go from here…. • Furtherimprovements in theatre • Lookat other aspects ofthe patient pathway • Education patient andstaff • Review sourcesofenergyNHS buildings The Patient Pathway – BreastServices InitialGP consultationand Initialassessment •and imagingPA referral – onestop Diagnostic process Follow-Up Primary Secondary Treatment & care care • Tertiary service Screening • Surgery Tertiary • Genetics Programme • Drug treatment Care • Complex cases • Radiotherapy • Research Chemotherapy Radiotherapy • Chemo bus – community Fastforward protocols chemotherapytreatments is non-inferiorto the standardeek treatment of 40Gyin fifteen fractionsover three weeks Intra-operative radiotherapy TARGIT-A – increased local recurrence(expensive) The RoadAhead: The Future ofSustainableSurgery • Emerging technologies • SmartOperating rooms • 3D printed surgicaltoolsanddevices • sustainablematerials • The potentialofAIanddataanalyticsin optimising sustainability • Improvedprecisionandreduced complications • AI assistedplanning e.g.roboticprocedures, telesurgery • Fewer repeat surgeries,reducedcost andreduced waste • Prevention betterthancure • BUTdrawbacksofAI - high carbonfoot print andenergy demandof data centres required forhigh computationalpower Sustainability: AVital Investment for the Future QuestionsorSuggestions?