Environmental impacts of surgical procedures: life cycle assessment of hysterectomy in the United States
Open accessAbstract
The healthcare sector is a driver of economic growth in the U.S., with spending on healthcare in 2012 reaching $2.8 trillion, or 17% of the U.S. gross domestic product, but it is also a significant source of emissions that adversely impact environmental and public health. The current state of the healthcare industry offers significant opportunities for environmental efficiency improvements, potentially leading to reductions in costs, resource use, and waste without compromising patient care. However, limited research exists that can provide quantitative, sustainable solutions. The operating room is the most resource-intensive area of a hospital, and surgery is therefore an important focal point to understand healthcare-related emissions. Hybrid life cycle assessment (LCA) was used to quantify environmental emissions from four different surgical approaches (abdominal, vaginal, laparoscopic, and robotic) used in the second most common major procedure for women in the U.S., the hysterectomy. Data were collected from 62 cases of hysterectomy. Life cycle assessment results show that major sources of environmental emissions include the production of disposable materials and single-use surgical devices, energy used for heating, ventilation, and air conditioning, and anesthetic gases. By scientifically evaluating emissions, the healthcare industry can strategically optimize its transition to a more sustainable system.
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One study did not state either assumptions or exclusions.
“and one(7) did not state either.”
From The Carbon Footprint of Surgical Operations (2020) · cites this paper as [7]
The Experimental Methods specify the study’s system boundaries, from when the patient enters the operating room until she leaves. The Monte Carlo Analysis of Variability and Uncertainty section also explicitly states an exclusion: recycling impacts were omitted from that analysis and added to the post-analysis results. The claim that the paper stated neither assumptions nor exclusions is therefore contrary to our copy (page numbers unavailable). (LLM, conf=0.88)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredThree studies specifically identified single-use items as the largest contributors, responsible for up to 78% of the carbon footprint, with two of these studies referring to the same dataset.
“with three (7,33,34) specifically identifying single-use items to be largest contributors, responsible for up to 78% of the carbon footprint”
From The Carbon Footprint of Surgical Operations (2020) · cites this paper as [7]
The Discussion (Impacts in the Supply Chain: Packaging and Purchasing; page unavailable) says single-use materials and tools accounted for a majority of environmental impacts in nearly every category. It does not give a 78% share of the carbon footprint; the Results (Life Cycle Impacts of Hysterectomy; page unavailable) instead say anesthetic gases contributed about two-thirds of greenhouse gas emissions for abdominal and vaginal hysterectomies. This paper also does not establish that two of the three cited studies used the same dataset. (LLM, conf=0.86)
Experimental — accuracy not yet measuredHysterectomies in the USA generate 212,000 tonnes CO2e per year (~285-562 kg CO2e per operation).
“concluding that hysterectomies in the USA generate 212,000 tonnes CO2e per year (~285-562 kg CO2e per operation) (7)”
From The Carbon Footprint of Surgical Operations (2020) · cites this paper as [7]
The Discussion (page unavailable) estimates about 212,000 metric tons of CO2-eq per year for U.S. hysterectomies, projected from 500,000 annual cases. The Results discuss emissions per case and variation by surgical approach, but the passages in our copy do not substantiate the stated range of approximately 285–562 kg CO2e per operation. (LLM, conf=0.87)
Experimental — accuracy not yet measuredIn two studies where electricity use was broken down, the highest consumption of electricity was for maintaining the theatre environment (heating, ventilation and air-conditioning).
“In two studies where electricity use was broken down, the highest consumption of electricity was for maintaining the theatre environment (heating, ventilation and air-conditioning).(7,31)”
From The Carbon Footprint of Surgical Operations (2020) · cites this paper as [7]
The Results section (Life Cycle Impacts of Hysterectomy; page unavailable) says operating-room HVAC caused over 70% of energy impacts, more than the reported contribution from electricity for operating-room machines. That supports HVAC as the leading energy-related contributor in this study, but the passage measures environmental impacts rather than directly reporting that HVAC consumed the most electricity. The other study cited in the sentence is outside this verdict. (LLM, conf=0.82)
Experimental — accuracy not yet measuredThis review found that the carbon footprint of a single operation ranged from 6 kg CO2e for cataract surgery in India to 814 kg CO2e for a robotic hysterectomy in the US.
“This review found that the carbon footprint of a single operation ranged from 6 (for cataract surgery in India) (34) to 814 kg CO2e, (for a robotic hysterectomy in the US),( 7)”
From The Carbon Footprint of Surgical Operations (2020) · cites this paper as [7]
The Results (Life Cycle Impacts of Hysterectomy; page unavailable) report that robotic hysterectomy had the largest average environmental footprint among the hysterectomy types studied in the US. Our copy does not state the cited figure of 814 kg CO2e per operation. The cataract-surgery figure is attached to a different citation and is not assessed here. (LLM, conf=0.82)
Experimental — accuracy not yet measured
Operating rooms make a large contribution to the healthcare carbon footprint as they are typically the most resource-intensive area of a hospital.
“Operating rooms make a large contribution to the healthcare carbon footprint as they are typically the most resource-intensive area of a hospital.(7,8)”
From The Carbon Footprint of Surgical Operations (2020) · cites this paper as [7]
Five included studies used a hybrid approach using both EEIO and process-based methodologies; three termed this EIOLCA and one a component analysis study.
“Five studies used a hybrid approach, using both EEIO and process-based methodologies, of which three termed this an 'economic-' or 'environment input-output life cycle assessment (EIOLCA)' (7,33,34) and one a 'component analysis study'.(27)”
From The Carbon Footprint of Surgical Operations (2020) · cites this paper as [7]
Four studies found procurement to be the largest hotspot.
“By contrast, four studies (7,27,33,34) found procurement to be the largest hotspot”
From The Carbon Footprint of Surgical Operations (2020) · cites this paper as [7]
Three included studies used primary process activity data only, one used secondary financial activity data only, and all others used a mixture of data types.
“Three studies used primary process activity data only, (26,31,35) one used secondary financial activity data only (32) and all others used a mixture of data types (Supplementary Table 3).(7,27,33,34)”
From The Carbon Footprint of Surgical Operations (2020) · cites this paper as [7]
Allocation methods were explicitly stated by four included studies.
“Allocation methods were explicitly stated by four studies.(7,31,33,34)”
From The Carbon Footprint of Surgical Operations (2020) · cites this paper as [7]
Two studies reported limited numerical data, with some sub-process results presented as descriptive or graphical data.
“and two (7,34) reported limited numerical data, with some sub-process results presented as descriptive or graphical data.”
From The Carbon Footprint of Surgical Operations (2020) · cites this paper as [7]
Parameter uncertainty was calculated by two studies.
“Parameter uncertainty (uncertainty relating to the data collection or emissions factors) was calculated by two studies.(7,35)”
From The Carbon Footprint of Surgical Operations (2020) · cites this paper as [7]
Five studies reported the number of observations or data points ambiguously or for a limited number of processes.
“reported ambiguously or for a limited number of processes in five studies, (7,26,27,33,34)”
From The Carbon Footprint of Surgical Operations (2020) · cites this paper as [7]
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Carbon footprint and cost–effectiveness of cataract surgery
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Self-citationA comparative carbon footprint analysis of disposable and reusable vaginal specula
Donahue, L. M., Hilton, S. P., Bell, S., Williams, B. C., & Keoleian, G. A. (2020) · American Journal of Obstetrics and Gynecology · doi:10.1016/j.ajog.2020.02.007 · Cited by 76 · see citing works
Kampman, J. M., Hermanides, J., Hollmann, M. W., Gilhuis, C. N., Bloem, W. A., Schraag, S., Pradelli, L., Repping, S., & Weiland, N. H. S. (2024) · EClinicalMedicine · doi:10.1016/j.eclinm.2024.102636 · Cited by 74 · see citing works
Environmental Impact of Endoscopy: “Scope” of the Problem
Gayam, S. (2020) · The American Journal of Gastroenterology · doi:10.14309/ajg.0000000000001005 · Cited by 73 · see citing works
Ahmad, R., Liu, G., Santagata, R., Casazza, M., Xue, J., Khan, K., Nawab, J., Ulgiati, S., & Lega, M. (2019) · Sustainability · doi:10.3390/su11133501 · Cited by 72 · see citing works
Sanchez, S. A., Eckelman, M. J., & Sherman, J. D. (2020) · Resources Conservation and Recycling · doi:10.1016/j.resconrec.2019.104643 · Cited by 71 · see citing works
Self-citationEnvironmental effects of surgical procedures and strategies for sustainable surgery
Cunha, M. F., & Pellino, G. (2022) · Nature Reviews Gastroenterology & Hepatology · doi:10.1038/s41575-022-00716-5 · Cited by 68 · see citing works
Environmental impact reduction as a new dimension for quality measurement of healthcare services
Esmaeili, A., McGuire, C. W., OVERCASH, M. R., Ali, K., Soltani, S. A., & Twomey, J. M. (2018) · International Journal of Health Care Quality Assurance · doi:10.1108/ijhcqa-10-2016-0153 · Cited by 67 · see citing works
A survey on artificial intelligence for reducing the climate footprint in healthcare
Das, K. P., & Chandra, J. (2022) · Energy Nexus · doi:10.1016/j.nexus.2022.100167 · Cited by 67 · see citing works
Harris, H., Bhutta, M. F., & Rizan, C. (2021) · Annals of The Royal College of Surgeons of England · doi:10.1308/rcsann.2021.0271 · Cited by 66 · see citing works
Assessment of the environmental impacts of medical devices: a review
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Priority setting and net zero healthcare: how much health can a tonne of carbon buy?
Bhopal, A. S., & Norheim, O. F. (2021) · BMJ · doi:10.1136/bmj-2021-067199 · Cited by 63 · see citing works
Soete, W. D., Jiménez‐González, C., Dahlin, P., & Dewulf, J. P. (2017) · Green Chemistry · doi:10.1039/c7gc00833c · Cited by 63 · see citing works
Bolten, A., Kringos, D. S., Spijkerman, I. J. B., & Weiland, N. H. S. (2022) · Journal of Hospital Infection · doi:10.1016/j.jhin.2022.07.011 · Cited by 62 · see citing works
Steam sterilisation’s energy and water footprint
McGain, F., Moore, G. A., & Black, J. (2016) · Australian Health Review · doi:10.1071/ah15142 · Cited by 61 · see citing works
Use of personal protective equipment in nursing practice
Brown, L., Munro, J., & Rogers, S. (2019) · Nursing Standard · doi:10.7748/ns.2019.e11260 · Cited by 60 · see citing works
Life cycle assessment of biomedical waste management for reduced environmental impacts
Deepak, A., Sharma, V., & Kumar, D. (2022) · Journal of Cleaner Production · doi:10.1016/j.jclepro.2022.131376 · Cited by 59 · see citing works
Identifying Environmental Impact Factors for Sustainable Healthcare: A Scoping Review
Sijm-Eeken, M. E., Jaspers, M., & Peute, L. (2023) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph20186747 · Cited by 56 · see citing works
Lichter, K. E., Charbonneau, K., Lewy, J. R., Bloom, J. R., Shenker, R. F., Sabbagh, A., Chino, J., Rodrigues, A., Hearn, J. W. D., Grover, S., et al. (2024) · The Lancet Oncology · doi:10.1016/s1470-2045(24)00148-7 · Cited by 55 · see citing works
Self-citationCimprich, A., Karim, K. S., & Young, S. B. (2017) · The International Journal of Life Cycle Assessment · doi:10.1007/s11367-017-1418-4 · Cited by 55 · see citing works
Cimprich, A., Santillán‐Saldivar, J., Thiel, C. L., Sonnemann, G., & Young, S. B. (2019) · Journal of Industrial Ecology · doi:10.1111/jiec.12921 · Cited by 54 · see citing works
Self-citationEnvironmentally sustainable perioperative medicine: simple strategies for anesthetic practice
Petre, M.-A., & Malherbe, S. (2020) · Canadian Journal of Anesthesia/Journal canadien d anesthésie · doi:10.1007/s12630-020-01726-0 · Cited by 54 · see citing works
Waste generated during glaucoma surgery: A comparison of two global facilities
Namburar, S., Pillai, M., Puthuran, G. V., Thiel, C. L., & Robin, A. L. (2018) · American Journal of Ophthalmology Case Reports · doi:10.1016/j.ajoc.2018.10.002 · Cited by 53 · see citing works
Self-citationEco-audit of conventional heart surgery procedures
Grinberg, D., Buzzi, R., Pozzi, M., Schweizer, R., Capsal, J., Thinot, B., Le, M., Obadia, J., & Cottinet, P. (2021) · European Journal of Cardio-Thoracic Surgery · doi:10.1093/ejcts/ezab320 · Cited by 53 · see citing works
Waste audits in healthcare: A systematic review and description of best practices
Slutzman, J. E., Bockius, H., Gordon, I. O., Greene, H. C., Hsu, S., Huang, Y., Lam, M. H., Roberts, T. R., & Thiel, C. L. (2022) · Waste Management & Research The Journal for a Sustainable Circular Economy · doi:10.1177/0734242x221101531 · Cited by 52 · see citing works
Self-citationAttitude of US obstetricians and gynaecologists to global warming and medical waste
Thiel, C. L., Duncan, P., & Woods, N. C. (2017) · Journal of Health Services Research & Policy · doi:10.1177/1355819617697353 · Cited by 52 · see citing works
Self-citationSeifert, C., Koep, L., Wolf, P., & Guenther, E. (2019) · Health Care Management Review · doi:10.1097/hmr.0000000000000248 · Cited by 52 · see citing works
Environmental sustainability in veterinary anaesthesia
JONES, R. S., & West, E. (2019) · Veterinary Anaesthesia and Analgesia · doi:10.1016/j.vaa.2018.12.008 · Cited by 51 · see citing works
Carbon footprint of atrial fibrillation catheter ablation
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Unger, S. R., Hottle, T. A., Hobbs, S. R., Thiel, C. L., Campion, N., Bilec, M. M., & Landis, A. E. (2017) · Journal of Health Services Research & Policy · doi:10.1177/1355819617705683 · Cited by 49 · see citing works
Self-citationSepetis, A. K., Zaza, P. N., Rizos, F., & Bagos, P. G. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph19169821 · Cited by 48 · see citing works
McGain, F., Cy, S., Burrell, R., Percival, V. G., Roessler, P., Weatherall, A., Weber, I. A., & Kayak, E. A. (2019) · Anaesthesia and Intensive Care · doi:10.1177/0310057x19884075 · Cited by 47 · see citing works
Total Intravenous Anesthetic Versus Inhaled Anesthetic: Pick Your Poison
Sherman, J. D., & Barrick, B. P. (2019) · Anesthesia & Analgesia · doi:10.1213/ane.0000000000003898 · Cited by 46 · see citing works
Self-citationCarbon Emissions from Overuse of U.S. Health Care: Medical and Ethical Problems
Thiel, C. L., & Richie, C. (2022) · The Hastings Center Report · doi:10.1002/hast.1404 · Cited by 45 · see citing works
Self-citationBreth‐Petersen, M., Bell, K., Pickles, K. M., McGain, F., McAlister, S., & Barratt, A. L. (2022) · BMJ Open · doi:10.1136/bmjopen-2021-056997 · Cited by 45 · see citing works
Systematic review of carbon footprint of surgical procedures
de’Angelis, N., Conso, C., Bianchi, G., Rodríguez, A. G. B., Marchegiani, F., Carra, M. C., Lafont, C., Canouï‐Poitrine, F., Slim, K., & Pessaux, P. (2023) · Journal of Visceral Surgery · doi:10.1016/j.jviscsurg.2023.03.002 · Cited by 45 · see citing works
The Carbon Footprint of Hospital Services and Care Pathways: A State-of-the-Science Review
Kouwenberg, L. H. J. A., Cohen, E. S., Hehenkamp, W. J. K., Snijder, L. E., Kampman, J. M., Küçükkeles, B., Kourula, A. E., Meijers, M. H. C., Smit, E. S., Weiland, N. H. S., et al. (2024) · Environmental Health Perspectives · doi:10.1289/ehp14754 · Cited by 45 · see citing works
Qin, R. X., Velin, L., Yates, E. F., Omrani, O. E., McLeod, E. J., Tudravu, J., Samad, L., Woodward, A. J., & McClain, C. D. (2022) · The Lancet Regional Health - Western Pacific · doi:10.1016/j.lanwpc.2022.100407 · Cited by 43 · see citing works
Bhutta, M. F. (2021) · Annals of The Royal College of Surgeons of England · doi:10.1308/rcsann.2021.0297 · Cited by 43 · see citing works
Petre, M.-A., Bahrey, L., Levine, M., van Rensburg, A., Crawford, M., & Matava, C. T. (2020) · Canadian Journal of Anesthesia/Journal canadien d'anesthésie · doi:10.1007/s12630-020-01738-w · Cited by 42 · see citing works
Environmental Sustainability in Orthopaedic Surgery
Engler, I. D., Curley, A. J., Fu, F. H., & Bilec, M. M. (2022) · Journal of the American Academy of Orthopaedic Surgeons · doi:10.5435/jaaos-d-21-01254 · Cited by 42 · see citing works
Self-citationInnovations towards achieving environmentally sustainable operating theatres: A systematic review
Perry, H., Reeves, N. L., Ansell, J., Cornish, J. A., Torkington, J., Morris, D. S., Brennan, F., & Horwood, J. (2022) · The Surgeon · doi:10.1016/j.surge.2022.04.012 · Cited by 42 · see citing works
Evaluating quantifiable metrics for hospital green checklists
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Self-citationHealthcare in the era of climate change and the need for environmental sustainability
Tee, N. C. H., Yeo, J.-A., Choolani, M. A., Poh, K. K., & Ang, T. L. (2024) · Singapore Medical Journal · doi:10.4103/singaporemedj.smj-2024-035 · Cited by 40 · see citing works
Masud, F. N., Sasangohar, F., Ratnani, I., Fatima, S., Hernandez, M. A., Riley, T., Fischer, J. W., Dhala, A. F., Gooch, M., Keeling-Johnson, K., et al. (2024) · Critical Care · doi:10.1186/s13054-024-04937-9 · Cited by 40 · see citing works
Feng, D., Song, C., & Mo, W. (2021) · Journal of Environmental Management · doi:10.1016/j.jenvman.2021.112558 · Cited by 40 · see citing works
Transitioning to Environmentally Sustainable, Climate-Smart Radiation Oncology Care
Lichter, K. E., Anderson, J. D., Sim, A. J., Baniel, C., Thiel, C. L., Chuter, R., Collins, A., Carollo, E., Berg, C. D., Coleman, C. N., et al. (2022) · International Journal of Radiation Oncology*Biology*Physics · doi:10.1016/j.ijrobp.2022.04.039 · Cited by 40 · see citing works
Self-citationWhat a Waste! The Impact of Unused Surgical Supplies in Hand Surgery and How We Can Improve
Bravo, D., Thiel, C. L., Bello, R. A., Moses, A. R., Paksima, N., & Melamed, E. (2022) · Hand · doi:10.1177/15589447221084011 · Cited by 39 · see citing works
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Carbon footprint modelling of national health systems: Opportunities, challenges and recommendations
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Negative-carbon recycling of copper from waste as secondary resources using deep eutectic solvents
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New Method of Destroying Waste Anesthetic Gases Using Gas-Phase Photochemistry
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Going green: decreasing medical waste in a paediatric intensive care unit in the United States
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Almukhtar, A., Batcup, C., Bowman, M., Beatty, J. W., Leff, D. R., Demirel, P., Porat, T., & Judah, G. (2023) · International Journal of Surgery · doi:10.1097/js9.0000000000000829 · Cited by 36 · see citing works
Environmental Sustainability in Anesthesia
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The Environmental Impact of Open Versus Endoscopic Carpal Tunnel Release
Zhang, D., Dyer, G. S. M., BLAZAR, P. E., & Earp, B. E. (2022) · The Journal Of Hand Surgery · doi:10.1016/j.jhsa.2021.12.003 · Cited by 34 · see citing works
- Authors
- Thiel, C. L., Eckelman, M., Guido, R., Huddleston, M., Landis, A. E., Sherman, J., Shrake, S. O., Copley-Woods, N., & Bilec, M. M.
- Affiliations
- University of Pittsburgh (US)
- Northeastern University (US)
- Arizona State University (US)
- Yale University (US)
- University of Pittsburgh School of Medicine Magee-Womens Hospital of UPMC, , , 300 Halket Street , , ,
- Corresponding author
- Thiel, Cassandra L.
- Venue
- Environmental Science & Technology
- Publisher
- American Chemical Society (ACS)
- Published
- 2014-12-17
- Volume
- 49
- Issue
- 3
- Pages
- 1779-1786
- ISSN
- 0013-936X (ISSN-L)
- 1520-5851
- PMC
- PMC4319686
- OpenAlex
- W2312914809
- Cited by
- 416
- References
- 38
- Citations by year
- 2026: 51 · 2025: 63 · 2024: 73 · 2023: 58 · 2022: 54 · 2021: 36 · 2020: 30 · 2019: 17 · 2018: 12 · 2017: 10 · 2016: 7 · 2015: 4
- FWCI
- 5.38
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- Environmental Science & Technology (publishedVersion, other-oa)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Center for Research Resources (ULI RR024153)
- Office of Integrative Activities (050434)
- Topics
- Physical Sciences › Environmental Science › Environmental Engineering › Environmental Impact and Sustainability
- Social Sciences › Urban Studies › Healthcare Facilities Design and Sustainability
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Healthcare and Environmental Waste Management
- Keywords
- hysterectomy, environmental impact of healthcare, disposable medical supplies, inhalational anesthetics, laparoscopic surgery, robotic surgery, vaginal hysterectomy, abdominal hysterectomy, health system sustainability, life cycle assessment
- MeSH terms
- Environment, Female, Humans, Hysterectomy, United States
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