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Become a member and receive career-enhancing benefits

Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.

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Sustainable Surgery—A Call to Action

Madeline Matthys, BS; Tejas S. Sathe, MD; Jaeyun Jane Wang, MD; Ava Yap, MD, MHS; Seema Gandhi, MD; Adnan Alseidi, MD, EdM

Madeline Matthys, BS; Tejas S. Sathe, MD; Jaeyun Jane Wang, MD; Ava Yap, MD, MHS; Seema Gandhi, MD; Adnan Alseidi, MD, EdM

January 3, 2024

Key Learning Points

  • The healthcare industry contributes significantly to climate change, which harms current and future patients.
  • Changes implemented by individual surgeons and trainees can spark a movement towards sustainable surgical practices at the departmental and institutional levels.
  • Education is at the crux of current and future sustainability movements and policy making.

The healthcare industry contributes significantly to climate change and accounts for 8.5% of US greenhouse gas emissions.1 The destructive effects of climate change are well established and have a tangible impact on our patients. For example, increased pollution and extreme heat lead to substantially higher rates of asthma and cardiovascular disease.2 Changes in vector ecology lead to increased infectious disease incidence and unpredictability.2 Increasing severe weather events lead to food insecurity, morbidity, and fatality.2 In 2018, pollution from the US healthcare system cost 388,000 disability-adjusted life years.1 As surgeons and surgical trainees, it is our moral and ethical duty to not only understand how our decisions contribute to climate change, but also how to mitigate these impacts.

The 2016 Paris Climate Accord is a legally binding treaty signed by 175 countries that aims to limit global warming to 1.5°C from pre-industrial levels.3 In the US, the Inflation Reduction Act, which aims to reduce greenhouse gas emissions by 40% by 2030, was signed into law in 2022.4 Furthermore, the Biden administration launched a pledge initiative for hospitals to reduce greenhouse gas emissions by 50% by the year 2030.5 Because operating rooms are the most energy-intensive component of the healthcare system—accounting for more than 30% of total emissions6—surgeons and other perioperative leaders must play a prominent role in waste reduction and decarbonization efforts.

Several recent studies have outlined the carbon footprint of operating rooms, but many are technical and relatively inaccessible to a busy surgeon. This paper presents an overview of measurable steps that individual surgeons, departments, and institutions can take to reduce their carbon footprint.

As an Individual Surgeon, How Can I Reduce My Carbon Footprint?

Individual surgeons can champion green practices before, during, and after each operation.7 Prior to operating, surgeons can use waterless scrub practices, which can save approximately 1 million liters of water per 15,000 operations.8 In addition, compared to water-based scrubbing,  alcohol-based scrubbing has similar or better antiseptic efficacy, is not associated with any significant difference in surgical-site infections, and confers a 67% reduction in cost.9-11

Unused instruments and procedural supplies are a significant contributor to preventable operating room waste, making this area particularly attractive for waste reduction.12 Surgeons should reformulate preference cards to identify the essential items that must be opened prior to operating versus items that can be opened as needed. During the operation, they should limit use of nonessential items. This will significantly reduce the waste and emissions associated with unnecessarily opened single-use items as well as future packaging and sterilization.12

Conducting visits with patients via telehealth when clinically appropriate avoids emission costs associated with transportation, hospital electricity use, and in-house physical documentation. The COVID-19 pandemic provided ample opportunity to study these effects. One notable study published in Nature in 2020 reported that 640,000 digital appointments saved 6,655 net tons of carbon dioxide emissions.13 Secondary benefits included high patient satisfaction and a reduction in hospital-transmitted infection.13

How Can My Department Reduce Its Carbon Footprint?

Designating a departmental “Green Committee” to spearhead sustainability education and identify areas for growth will be key to optimizing buy-in and promoting change. Surgeons willing to streamline preference cards can serve as departmental champions for procedure kit and case cart standardization across common procedures.14 For example, at one institution, reformulating a chemotherapy port placement kit from 44 to 27 items saved $50, 1 pound of waste per kit, and 64 pounds of CO2 emissions in one year.15

Anesthetic choice is an underrecognized but major contributor to greenhouse gas emissions, accounting for 5% of hospital emissions and 50% of operating room emissions in high-income countries.16 Surgeons should work alongside anesthesiologists to consider local or neuraxial anesthetic options when possible, and limit the use of desflurane and N2O. Desflurane, which has lower potency and significantly higher atmospheric longevity than isoflurane and sevoflurane, has 40–50 times the global warming potential compared to sevoflurane and isoflurane over a 100-year period.16,17 N2O has similarly low potency with a long atmospheric life.

Finally, mandatory departmental and institutional education may be the single most important component of this process. All individuals in the operating room need to understand the importance of greener perioperative practices. The department or Green Committee should organize and promote collaborative seminars and interdisciplinary workshops to prioritize education. Further opportunities for individual and departmental learning can be found at Practice Greenhealth’s Greening the OR website and the Royal College of Surgeon’s Green Theatre Checklist.6,7

How Can My Institution Reduce Its Carbon Footprint?

To realize the largest environmental impact, entire hospitals and health systems must work in concert to reduce their carbon footprints through overarching guidelines and policy implementation.

Following an operation, waste needs to be properly sorted and routed for processing. Institutional guidelines should ensure proper disposal of recyclable materials and minimize red bag waste to biohazardous materials only. This can significantly reduce the carbon emissions of improperly processing noninfectious waste as hazardous, which requires incineration and has a carbon footprint that is over 6 times higher than regular waste and 50 times greater than recycling.18

Heating, ventilation, and air conditioning (HVAC) comprises 90%–99% of overall operating room energy consumption.19 Prioritizing occupancy-based HVAC usage, such as reducing air flow rates overnight while still leaving a small number of operating rooms online for emergency cases, can reduce energy consumption by 50%.

Disposable linens account for the greatest percentage of OR waste (39%) followed by plastics (26%).20 At one medical center, reusable linens saved 138,748 pounds of waste in 1 year and saved the hospital $38,800 annually in waste disposal fees.21,22 Thus, institutions should strive to develop workflows that integrate reusable textiles, instruments, and equipment in the operating room, and recycle or repurpose the remainder when able. 


Though climate change is often portrayed as an overwhelming global issue that is difficult to address, surgeons can have a meaningful impact. Individual action spurs departmental change, which sways institutional and national policy. In time, we hope to collectively develop national standards for actionable goals, as well as measurement systems that identify individual hospitals’ strengths and potential for improvement towards greener operating rooms. Education for surgical trainees—mandated through the American Board of Surgery’s curriculum—will be key to standardizing this knowledge. We encourage surgeons to integrate the aforementioned techniques, educate their peers and trainees, and contribute to a national movement towards operating room sustainability.


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Madeline Matthys, MD candidate
University of California, San Francisco department of surgery
Tejas S. Sathe, MD
Resident physician and surgical innovation fellow
University of California, San Francisco department of surgery
Columbia University, department of surgery
Jaeyun Jane Wang, MD
Resident physician
University of California, San Francisco department of surgery
Ava Yap, MD, MHS
Resident physician
University of California, San Francisco department of surgery
Seema Gandhi, MD
Associate clinical professor of anesthesiology
University of California, San Francisco department of anesthesia
Adnan Alseidi, MD, EdM
Professor of clinical surgery and vice chair for education
University of California, San Francisco department of surgery
President, Association of Surgical Education