Environmental sustainability in robotic and laparoscopic surgery: systematic review

Background Minimally invasive surgical (MIS) techniques are considered the gold standard of surgical interventions, but they have a high environmental cost. With global temperatures rising and unmet surgical needs persisting, this review investigates the carbon and material footprint of MIS and summarizes strategies to make MIS greener. Methods The MEDLINE, Embase, and Web of Science databases were interrogated between 1974 and July 2021. The search strategy encompassed surgical setting, waste, carbon footprint, environmental sustainability, and MIS. Two investigators independently performed abstract/full-text reviews. An analysis of disability-adjusted life years (DALYs) averted per ton of carbon dioxide equivalents (CO(2)e) or waste produced was generated. Results From the 2456 abstracts identified, 16 studies were selected reporting on 5203 MIS procedures. Greenhouse gas (GHG) emissions ranged from 6 kg to 814 kg CO(2)e per case. Carbon footprint hotspots included production of disposables and anaesthetics. The material footprint of MIS ranged from 0.25 kg to 14.3 kg per case. Waste-reduction strategies included repackaging disposables, limiting open and unused instruments, and educational interventions. Robotic procedures result in 43.5 per cent higher GHG emissions, 24 per cent higher waste production, fewer DALYs averted per ton of CO2, and less waste than laparoscopic alternatives. Conclusion The increased environmental impact of robotic surgery may not sufficiently offset the clinical benefit. Utilizing alternative surgical approaches, reusable equipment, repackaging, surgeon preference cards, and increasing staff awareness on open and unused equipment and desflurane avoidance can reduce GHG emissions and waste. Robotic procedures result in higher greenhouse gas emissions, higher waste production, fewer disability-adjusted life years averted per tonne of CO2, and less waste than laparoscopic alternatives. The increased environmental impact of robotic surgery may not be sufficiently offset by clinical benefit. Carbon footprint hotspots included the production of disposables and anaesthetics. A combination of propofol anaesthesia, minimal instrument operations, and maximum reuse decrease the carbon footprint, while waste reduction strategies include replacing staplers with polymeric clips, repackaging disposables, limiting open and unused instruments, and educational interventions.