Green surgery: a systematic review of the environmental impact of laparotomy, laparoscopy, and robotics
Miguel F Cunha, João Cunha Neves, Joana Roseira, Gianluca Pellino, Pedro Castelo‐Branco
Abstract
Abstract Surgery is the most energy-intensive healthcare sector, but data on the environmental impact of abdominal surgical techniques are limited. This systematic review aims to identify the most sustainable approach among open, laparoscopic, and robotic surgeries. We searched MEDLINE, Cochrane, and Web of Science databases (inception to March 2024) for studies on the carbon footprint of abdominal surgery, focusing on carbon dioxide equivalents (CO 2e ) or CO 2 emissions. The Joanna Briggs Institute checklist was used to assess bias. (PROSPERO: 298486). Of 2155 records, eight cohort studies were included, showing low to moderate risk of bias but high heterogeneity. Two studies on hysterectomy found robotic surgery had the highest carbon footprint (12.0–40.3 kgCO 2e ) compared to laparoscopic (10.7–29.2 kgCO 2e ) and open surgery (7.1–22.7 kgCO 2e ). Another study found laparoscopic prostatectomy produced more emissions than robotic surgery (59.7 vs. 47.3 kgCO 2e ) due to higher disposable devices, surgery time and length of stay. Single-use devices in laparoscopic cholecystectomy emitted more CO 2e than hybrid devices (7.194 vs. 1.756 kgCO 2e ). CO 2 used in minimally invasive surgery had negligible environmental effects (0.9 kgCO 2e ). Qualitative subgroup analyses revealed significant differences between surgery types and measurement methodologies, contributing to data heterogeneity. Minimally invasive surgeries often have higher carbon footprints due to disposable tools and waste. However, one study showed robotic surgery may reduce the overall environmental impact by shortening hospital stays. Due to methodological heterogeneity across studies, definitive conclusions remain limited. Standardized life-cycle assessment methodologies and inclusion of clinical outcomes in future studies are urgently needed to clarify the environmental sustainability of surgical practices.