The Carbon Footprint of Surgical Operations

In the paper

“with three (7,33,34) specifically identifying single-use items to be largest contributors, responsible for up to 78% of the carbon footprint”

What the sources say

• Partly supported

  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)

  cites [7] 7. Thiel CL, Eckelman M, Guido R, Huddleston M, Landis AE, Sherman J, et al. Environmental impacts of surgical procedures: life cycle assessment of hysterectomy in the United States. Environ Sci Technol. 2015;49(3):1779-86. sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [33] 33. Thiel CL, Woods NC, Bilec MM. Strategies to reduce greenhouse gas emissions from laparoscopic surgery. Am J Public Health. 2018;108(S2):S158-S64. source
• Disputed

  The Results (Lifecycle Assessment Results; page unavailable) identify reusable instruments and their sterilization—not single-use items—as responsible for more than half of emissions in most impact categories. Single-use materials contribute the largest share only to ozone depletion. The paper does not report that they account for up to 78% of the carbon footprint. (LLM, conf=0.88)

  Checked by a reasoning model — may be wrong.

  cites [34] 34. Thiel CL, Schehlein E, Ravilla T, Ravindran RD, Robin AL, Saeedi OJ, et al. Cataract surgery and environmental sustainability: Waste and lifecycle assessment of phacoemulsification at a private healthcare facility. J Cataract Refract Surg. 2017;43(11):1391-8. sourceExperimental — accuracy not yet measured

In the paper

“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)”

What the sources say

• Supported

  The Introduction states that the operating room is the most resource-intensive area of a hospital and that understanding surgery’s environmental impact is critical to understanding healthcare-related emissions. This supports the citing sentence’s qualitative claim; no page number is provided in our copy. (LLM, conf=0.91)

  cites [7] 7. Thiel CL, Eckelman M, Guido R, Huddleston M, Landis AE, Sherman J, et al. Environmental impacts of surgical procedures: life cycle assessment of hysterectomy in the United States. Environ Sci Technol. 2015;49(3):1779-86. source
• ?Not checked — no full text of the sourcecites [8] 8. Lee BK, Ellenbecker MJ, Moure-Eraso R. Analyses of the recycling potential of medical plastic wastes. Waste Manag. 2002;22(5):461-70. source

In the paper

“and are three to six times more energy intensive than the rest of the hospital which can be largely attributed to maintenance of the theatre environment (heating, ventilation and air-conditioning).(12)”

What the sources say

• Supported

  The Summary (p. 2) states that theatres were three to six times more energy-intensive than the hospital as a whole, primarily because of heating, ventilation, and air-conditioning requirements. The Results (p. 5) give the underlying hospital-to-theatre comparison, and the Discussion (p. 7) reports that HVAC accounted for 90–99% of theatre energy use. (LLM, conf=0.95)

  cites [12] 12. MacNeill A, Lillywhite R, Brown C. The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems. The Lancet Planetary Health. 2017;1(9):e381-e8. source

In the paper

“Hybrid methods exist which attempt either to incorporate the detail of the process-based approach alongside inclusivity of EEIO models, or which use top-down approaches for attributable components for which process data cannot be obtained.(19,21)”

What the sources say

• ?Not checked — no full text of the sourcecites [19] 19. Berners-Lee M, Howard DC, Moss J, Kaivanto K, Scott WA. Greenhouse gas footprinting for small businesses-the use of input-output data. Sci Total Environ. 2011;409(5):883-91. source
• Partly supported

  Section 5 describes coupling multiregional input-output databases to process-based LCA, supporting the claim that hybrid methods combine the two approaches. The Conclusions discuss process-based truncation errors, but the passages do not say that hybrid methods use top-down estimates specifically for components whose process data cannot be obtained. No page numbers are available in our copy. (LLM, conf=0.82)

  cites [21] 21. Pomponi F, Lenzen M. Hybrid life cycle assessment (LCA) will likely yield more accurate results than process-based LCA. Journal of Cleaner Production. 2018;176:210-5. sourceExperimental — accuracy not yet measured

In the paper

“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)”

What the sources say

• Supported

  Split into 2 atoms — 2 confirmed, 0 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

  cites [7] 7. Thiel CL, Eckelman M, Guido R, Huddleston M, Landis AE, Sherman J, et al. Environmental impacts of surgical procedures: life cycle assessment of hysterectomy in the United States. Environ Sci Technol. 2015;49(3):1779-86. source
• ?Not checked — no full text of the sourcecites [33] 33. Thiel CL, Woods NC, Bilec MM. Strategies to reduce greenhouse gas emissions from laparoscopic surgery. Am J Public Health. 2018;108(S2):S158-S64. source
• Partly supported

  Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

  cites [34] 34. Thiel CL, Schehlein E, Ravilla T, Ravindran RD, Robin AL, Saeedi OJ, et al. Cataract surgery and environmental sustainability: Waste and lifecycle assessment of phacoemulsification at a private healthcare facility. J Cataract Refract Surg. 2017;43(11):1391-8. sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [27] 27. Morris DS, Wright T, Somner JE, Connor A. The carbon footprint of cataract surgery. Eye. 2013;27(4):495-501. source

In the paper

“Three studies exclusively used 'bottom-up' process-based approaches, of which one simply described their method as a 'carbon footprint',(35) one described it as a 'multi-component analysis/carbon footprint', (26) and the other conducted full LCA.(31)”

What the sources say

• ?Not checked — no full text of the sourcecites [35] 35. Woods DL, McAndrew T, Nevadunsky N, Hou JY, Goldberg G, Yi-Shin Kuo D, et al. Carbon footprint of robotically-assisted laparoscopy, laparoscopy and laparotomy: a comparison. Int J Med Robot. 2015;11(4):406-12. source
• ?Not checked — no full text of the sourcecites [26] 26. Berner JE, Gras MDP, Troisi L, Chapman T, Vidal P. Measuring the carbon footprint of plastic surgery: A preliminary experience in a Chilean teaching hospital. J Plast Reconstr Aesthet Surg. 2017;70(12):1777-9. source
• Supported

  Citation (31) supports the part of the sentence identifying this study as a process-based LCA; it is not being cited for the descriptions of the other two studies. The Methods section describes a process LCA framework with hospital-level inventory data and life cycle impact assessment. No page number is available in our copy. (LLM, conf=0.91)

  cites [31] 31. Campion N, Thiel CL, DeBlois J, Woods NC, Landis AE, Bilec MM. Life cycle assessment perspectives on delivering an infant in the US. Sci Total Environ. 2012;425:191- 8. source

In the paper

“There is debate between the relative accuracy and value of top-down and bottom-up approaches.(21)”

What the sources say

• Supported

  The Conclusions (page unavailable) explicitly describe a debate over whether hybrid LCA produces more accurate results than process-based LCA. The paper also compares their errors and discusses the merits of the input-output and process systems involved, supporting the citing sentence’s broad characterization of a debate over approaches. (LLM, conf=0.85)

  cites [21] 21. Pomponi F, Lenzen M. Hybrid life cycle assessment (LCA) will likely yield more accurate results than process-based LCA. Journal of Cleaner Production. 2018;176:210-5. source

In the paper

“Published emission factors can be applied, which provide average emissions for given attributable processes (for example electricity consumption, transportation, and production of a given material).This enables detailed analysis with high specificity, allowing comparison between items from the same sector.(20)”

What the sources say

• Partly supported

  Section 2.2 describes process-based carbon accounting as an itemised estimate of emissions at each step of a product’s life cycle, supporting the detailed-analysis part of the claim. Section 4.1 also discusses calculated emission factors. The passages do not establish that applying published average factors provides high specificity or enables comparisons between items within the same sector; those parts are unsupported by our copy. (LLM, conf=0.79)

  cites [20] 20. Kennelly C, Berners-Lee M, Hewitt C. Hybrid life-cycle assessment for robust, best- practice carbon accounting. Journal of Cleaner Production. 2019;208:35-43. sourceExperimental — accuracy not yet measured

In the paper

“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)”

What the sources say

• ?Not checked — no full text of the sourcecites [26] 26. Berner JE, Gras MDP, Troisi L, Chapman T, Vidal P. Measuring the carbon footprint of plastic surgery: A preliminary experience in a Chilean teaching hospital. J Plast Reconstr Aesthet Surg. 2017;70(12):1777-9. source
• Supported

  The citation to this paper is attached to the group described as using a mixture of data types, not to the counts of studies using only one type. In Methods §2.1.2 (page unavailable), the paper describes collecting activity data at the hospital and using published life-cycle inventory databases for unit processes, supporting its classification as a mixed-data study. (LLM, conf=0.93)

  cites [31] 31. Campion N, Thiel CL, DeBlois J, Woods NC, Landis AE, Bilec MM. Life cycle assessment perspectives on delivering an infant in the US. Sci Total Environ. 2012;425:191- 8. source
• ?Not checked — no full text of the sourcecites [35] 35. Woods DL, McAndrew T, Nevadunsky N, Hou JY, Goldberg G, Yi-Shin Kuo D, et al. Carbon footprint of robotically-assisted laparoscopy, laparoscopy and laparotomy: a comparison. Int J Med Robot. 2015;11(4):406-12. source
• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [32] 32. Gatenby PA. Modelling the carbon footprint of reflux control. Int J Surg. 2011;9(1):72-4.
• Supported

  The Experimental Methods section identifies this study as a hybrid LCA using both process and economic input-output data. The Waste Audit section describes primary data collection, while Hybrid LCA Approach describes financial inputs evaluated with an EIO-LCA model. This supports classifying the cited study among those using a mixture of data types; it does not establish the counts for the other studies. (LLM, conf=0.91)

  cites [7] 7. Thiel CL, Eckelman M, Guido R, Huddleston M, Landis AE, Sherman J, et al. Environmental impacts of surgical procedures: life cycle assessment of hysterectomy in the United States. Environ Sci Technol. 2015;49(3):1779-86. source
• ?Not checked — no full text of the sourcecites [27] 27. Morris DS, Wright T, Somner JE, Connor A. The carbon footprint of cataract surgery. Eye. 2013;27(4):495-501. source
• ?Not checked — no full text of the sourcecites [33] 33. Thiel CL, Woods NC, Bilec MM. Strategies to reduce greenhouse gas emissions from laparoscopic surgery. Am J Public Health. 2018;108(S2):S158-S64. source
• Supported

  The Data Collection section describes primary process data gathered through observation, measurement, and hospital records. The Lifecycle Assessment section also describes using financial spending data in an economic input-output model for pharmaceuticals. This supports classifying this study as using a mixture of data types; the counts of other studies are not claims this source alone can establish. (LLM, conf=0.90)

  cites [34] 34. Thiel CL, Schehlein E, Ravilla T, Ravindran RD, Robin AL, Saeedi OJ, et al. Cataract surgery and environmental sustainability: Waste and lifecycle assessment of phacoemulsification at a private healthcare facility. J Cataract Refract Surg. 2017;43(11):1391-8. source

In the paper

“Campion et al. (31) found that the carbon footprint of a caesarean section is twice that of a vaginal delivery.”

What the sources say

• Partly supported

  Section 3.1 (page not provided) says cesarean births have a higher environmental footprint than vaginal births. The Results and Discussion discuss global warming potential for both delivery modes, but the passages do not give a two-to-one carbon-footprint comparison. The claimed magnitude is therefore unsupported by our copy. (LLM, conf=0.82)

  cites [31] 31. Campion N, Thiel CL, DeBlois J, Woods NC, Landis AE, Bilec MM. Life cycle assessment perspectives on delivering an infant in the US. Sci Total Environ. 2012;425:191- 8. sourceExperimental — accuracy not yet measured

In the paper

“Allocation methods were explicitly stated by four studies.(7,31,33,34)”

What the sources say

• Supported

  The Life Cycle Inventory section (page unavailable) explicitly states how impacts from reusable linens were allocated and gives an estimated lifespan for reusable stainless steel instruments. This supports citing this paper as one of the studies that stated an allocation method; the total of four refers to the citing document’s set of studies, not a count this paper needs to establish. (LLM, conf=0.91)

  cites [7] 7. Thiel CL, Eckelman M, Guido R, Huddleston M, Landis AE, Sherman J, et al. Environmental impacts of surgical procedures: life cycle assessment of hysterectomy in the United States. Environ Sci Technol. 2015;49(3):1779-86. source
• Supported

  The Methods section (2.1, page not provided) explicitly describes an allocation choice for autoclave electricity and assumes 10 kits per cycle. It also states that the weight of mixed-material products was divided evenly among their materials. This supports identifying this paper as a study that stated its allocation methods; the other three studies are outside this citation. (LLM, conf=0.90)

  cites [31] 31. Campion N, Thiel CL, DeBlois J, Woods NC, Landis AE, Bilec MM. Life cycle assessment perspectives on delivering an infant in the US. Sci Total Environ. 2012;425:191- 8. source
• ?Not checked — no full text of the sourcecites [33] 33. Thiel CL, Woods NC, Bilec MM. Strategies to reduce greenhouse gas emissions from laparoscopic surgery. Am J Public Health. 2018;108(S2):S158-S64. source
• Supported

  The Materials and Methods > Data Collection section explicitly describes how water, ventilation, sterilization electricity, and diesel-generator emissions were allocated to a phacoemulsification case. This supports citing the paper as one study that stated its allocation methods; the count of four is the citing document’s synthesis across its cited studies. (LLM, conf=0.91)

  cites [34] 34. Thiel CL, Schehlein E, Ravilla T, Ravindran RD, Robin AL, Saeedi OJ, et al. Cataract surgery and environmental sustainability: Waste and lifecycle assessment of phacoemulsification at a private healthcare facility. J Cataract Refract Surg. 2017;43(11):1391-8. source

In the paper

“Three studies (26,31,35) found electricity to be the largest source of GHG emissions, accounting for 63-78% of the carbon footprint of whole operations”

What the sources say

• ?Not checked — no full text of the sourcecites [26] 26. Berner JE, Gras MDP, Troisi L, Chapman T, Vidal P. Measuring the carbon footprint of plastic surgery: A preliminary experience in a Chilean teaching hospital. J Plast Reconstr Aesthet Surg. 2017;70(12):1777-9. source
• Partly supported

  The Results and Discussion section reports that machines, lighting, and HVAC contributed the largest share of global warming potential for both delivery modes. It attributes those impacts to electricity and natural gas together, not electricity alone. The passages do not give a 63–78% share or assess whole operations rather than individual births (page unavailable in our copy). (LLM, conf=0.86)

  cites [31] 31. Campion N, Thiel CL, DeBlois J, Woods NC, Landis AE, Bilec MM. Life cycle assessment perspectives on delivering an infant in the US. Sci Total Environ. 2012;425:191- 8. sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [35] 35. Woods DL, McAndrew T, Nevadunsky N, Hou JY, Goldberg G, Yi-Shin Kuo D, et al. Carbon footprint of robotically-assisted laparoscopy, laparoscopy and laparotomy: a comparison. Int J Med Robot. 2015;11(4):406-12. source

In the paper

“results of average operations were in keeping with included studies, with emissions of 146 kg CO2e per average case at the Canadian hospital, compared with 173 kg CO2e in the UK, and 232 kg CO2e in the US.”

What the sources say

• Supported

  The Results (p. 6) give the same per-operation emissions: 146 kg CO2e at VGH, 173 kg at JRH, and 232 kg at UMMC. The Summary (p. 2) identifies those hospitals as the Canadian, UK, and US sites, respectively. (LLM, conf=0.95)

  cites [12] 12. MacNeill A, Lillywhite R, Brown C. The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems. The Lancet Planetary Health. 2017;1(9):e381-e8. source

In the paper

“MacNeill et al. calculated and compared the carbon footprint of whole operating suites across one year in three large hospitals in the UK, Canada and US, (12) finding this ranged between 3,219-5,188 tonnes CO2e.”

What the sources say

• Supported

  The Summary (p. 2) describes a one-year study of surgical suites at three hospitals in Canada, the USA, and the UK. The Results (p. 6) give annual footprints of 3,218,907 to 5,187,936 kg CO₂e, which round to 3,219–5,188 tonnes CO₂e. (LLM, conf=0.95)

  cites [12] 12. MacNeill A, Lillywhite R, Brown C. The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems. The Lancet Planetary Health. 2017;1(9):e381-e8. source

In the paper

“Parameter uncertainty (uncertainty relating to the data collection or emissions factors) was calculated by two studies.(7,35)”

What the sources say

• Supported

  The Experimental Methods section, under “Monte Carlo Analysis of Variability and Uncertainty” (page not provided), says the study used Monte Carlo analysis to account for uncertainty in life cycle inventory data and sampled distributions of materials and their impacts. This supports identifying this paper as one of the studies that calculated parameter uncertainty; the other cited study is outside this verdict. (LLM, conf=0.90)

  cites [7] 7. Thiel CL, Eckelman M, Guido R, Huddleston M, Landis AE, Sherman J, et al. Environmental impacts of surgical procedures: life cycle assessment of hysterectomy in the United States. Environ Sci Technol. 2015;49(3):1779-86. source
• ?Not checked — no full text of the sourcecites [35] 35. Woods DL, McAndrew T, Nevadunsky N, Hou JY, Goldberg G, Yi-Shin Kuo D, et al. Carbon footprint of robotically-assisted laparoscopy, laparoscopy and laparotomy: a comparison. Int J Med Robot. 2015;11(4):406-12. source

In the paper

“One study reported only descriptive or graphical data.(31)”

What the sources say

• Supported

  The Results and Discussion sections present the environmental-impact findings in figures and descriptive comparisons, including references to Figures 2, 3, and 5. Section 3.2 also gives some percentages in prose, so “only descriptive or graphical data” is accurate as a characterization of how the findings are reported, not a claim that the paper contains no numbers. (LLM, conf=0.84)

  cites [31] 31. Campion N, Thiel CL, DeBlois J, Woods NC, Landis AE, Bilec MM. Life cycle assessment perspectives on delivering an infant in the US. Sci Total Environ. 2012;425:191- 8. source

In the paper

“A 'top-down' EEIO was used exclusively by one study (35) but was referred to as a 'carbon footprint'.”

What the sources say

• ?Not checked — no full text of the sourcecites [35] 35. Woods DL, McAndrew T, Nevadunsky N, Hou JY, Goldberg G, Yi-Shin Kuo D, et al. Carbon footprint of robotically-assisted laparoscopy, laparoscopy and laparotomy: a comparison. Int J Med Robot. 2015;11(4):406-12. source

In the paper

“Screening of titles excluded 4,381 of these and of the remaining 223, 83 were duplicates, leaving 140 articles for full text evaluation.”

In the paper

“The search strategy identified 4,604 records (Figure 1).”

In the paper

“Of these, four were conducted exclusively in the US, (7,31,33,35) two in the UK, (27,32), one in Chile (26), and one in India (Table 1).(34)”

In the paper

“Other studies did not specify the number of GHGs included, (7,31,(33)(34)(35) although this can be deduced (bracketed in Table 1) based on the guidelines or databases used.”

In the paper

“The functional unit of all included studies were individual operations.”

In the paper

“Four studies (7,31,33,34) reported following ISO guidelines,(16) one(35) following the GHG Protocol(14) and two (27,35) using PAS 2050 guidelines.(15)”

What the sources say

• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [16] 16. International Organization for Standardization. ISO 14040:2006 Environmental management-life cycle assessment-principles and framework. Geneva, Switzerland: ISO; 2006.
• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [14] 14. World Resources Institute. Greenhouse gas protocol, product life cycle accounting and reporting standard. USA: World Resources Institute; 2011.
• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [15] 15. Department for Business Innovation and Skills. PAS 2050:2011 Specification for the assessment of the life cycle greenhouse gas emissions of goods and services. UK: Department for Business Innovation and Skills; 2011.

In the paper

“Four studies examined operations in the field of Obstetrics and Gynaecology, (7,31,33,35) two Ophthalmological operations, (27,34) one Gastrointestinal, (32), and one Plastic surgery.(26)”

In the paper

“With regards to the scope of GHGs included, two studies calculated CO2 emissions only.(26,32)”

What the sources say

• ?Not checked — no full text of the sourcecites [26] 26. Berner JE, Gras MDP, Troisi L, Chapman T, Vidal P. Measuring the carbon footprint of plastic surgery: A preliminary experience in a Chilean teaching hospital. J Plast Reconstr Aesthet Surg. 2017;70(12):1777-9. source
• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [32] 32. Gatenby PA. Modelling the carbon footprint of reflux control. Int J Surg. 2011;9(1):72-4.

In the paper

“Two studies did not state the use of guidelines.(26,32)”

What the sources say

• ?Not checked — no full text of the sourcecites [26] 26. Berner JE, Gras MDP, Troisi L, Chapman T, Vidal P. Measuring the carbon footprint of plastic surgery: A preliminary experience in a Chilean teaching hospital. J Plast Reconstr Aesthet Surg. 2017;70(12):1777-9. source
• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [32] 32. Gatenby PA. Modelling the carbon footprint of reflux control. Int J Surg. 2011;9(1):72-4.

In the paper

“However none of these studies considered any processes beyond the theatre boundary, and did not take into account the impact different surgical approaches have on length of stay, infection rate and need for further intervention (all with associated carbon dioxide emissions).”

In the paper

“Gatenby (32) found that the carbon footprint of surgical approaches to gastrooesophageal reflux disease treatment is higher than medical treatment up to nine years after the operation, but becomes more carbon efficient thereafter, following patients up until end of life.”

What the sources say

• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [32] 32. Gatenby PA. Modelling the carbon footprint of reflux control. Int J Surg. 2011;9(1):72-4.

In the paper

“(35) found that the most carbon intensive approach to gynaecological surgery was robotic, followed by the laparoscopic approach, followed by laparotomy (followed by trans-vaginal approach within the former study).”

What the sources say

• ?Not checked — no full text of the sourcecites [35] 35. Woods DL, McAndrew T, Nevadunsky N, Hou JY, Goldberg G, Yi-Shin Kuo D, et al. Carbon footprint of robotically-assisted laparoscopy, laparoscopy and laparotomy: a comparison. Int J Med Robot. 2015;11(4):406-12. source

In the paper

“A range of data sources were used for emission factors and GWPs.”

In the paper

“The majority of studies omitted pre-and post-operative processes, patient and staff travel, capital goods manufacture, water use, processing of reusable equipment (all scope three), and pharmaceuticals (including scope one anaesthetics gases).”

In the paper

“whilst another(36) finding this varied results by 0.3-19%.”

What the sources say

• ?Not checked — no full text of the sourcecites [36] 36. Ibbotson S, Dettmer T, Kara S, Herrmann C. Eco-efficiency of disposable and reusable surgical instruments-a scissors case. The International Journal of Life Cycle Assessment. 2013;18:1137-48. source

In the paper

“Carbon footprinting can be used as a tool to model the relative impact of different measures aimed at reducing the GHG emissions of operative services, based upon existing variation in surgical care and hypothetical interventions.”

In the paper

“LCA is an inclusive measure but the endpoints are numerous and vary with the approaches and data sources used, reducing the extent to which direct comparisons can be made between studies.”

In the paper

“The first is a 'top-down' environmentally extended input-output (EEIO) model, which uses the monetary cost of a unit of interest to estimate the carbon footprint, on the premise that more expensive items involve greater resource use, with higher associated GHG emissions.”

What the sources say

• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [13] 13. Berners-Lee M. How bad are bananas; the carbon footprint of everything. London: Profile Books; 2010.
• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [17] 17. World Resources Institute. Technical guidance for calculating scope 3 emissions. USA: World Resources Institute; 2013.

In the paper

“Estimating the carbon footprint of surgical operations enables their GHG emissions to be quantified, and perhaps more importantly, allows the identification and targeting of carbon hotspots (largest GHG contributors) within surgery.”

In the paper

“Studies were appraised independently by two researchers (CR, IS) using the system detailed in Supplementary Table 2, and discrepancies were discussed and resolved.”

In the paper

“Where processes are omitted, this underestimates the carbon footprint of a given process.”

In the paper

“The alternative 'bottom-up' process-based method involves collecting data on all the component processes underpinning the unit of interest.(13,17)”

What the sources say

• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [13] 13. Berners-Lee M. How bad are bananas; the carbon footprint of everything. London: Profile Books; 2010.
• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [17] 17. World Resources Institute. Technical guidance for calculating scope 3 emissions. USA: World Resources Institute; 2013.

In the paper

“It is relatively inexpensive and simple to perform,(17) but lacks specificity and detail, and should not be used for comparing the carbon footprint of products from within the same industrial sector.(19)”

What the sources say

• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [17] 17. World Resources Institute. Technical guidance for calculating scope 3 emissions. USA: World Resources Institute; 2013.
• ?Not checked — no full text of the sourcecites [19] 19. Berners-Lee M, Howard DC, Moss J, Kaivanto K, Scott WA. Greenhouse gas footprinting for small businesses-the use of input-output data. Sci Total Environ. 2011;409(5):883-91. source

In the paper

“Despite limitations, a given carbon footprinting methodology can be used to identify hotspots and evaluate alternatives if it is consistently applied within a study.”

In the paper

“However, it is often difficult to obtain data on processes beyond the boundary of the hospital under investigation, and the inventory boundary could always be expanded, (e.g. to include higher tier supporting industries such as research and development, or even the food eaten by theatre staff).”

In the paper

“Data were extracted independently by two authors (CR, IS).”

In the paper

“The EEIO approach incorporates all emission sources from upstream processes in the supply chain (either direct or indirect, and including flow between sectors), taking into account 'hidden' sectors such as marketing, and research and development (e.g.behind the drugs administered during an operation).(18)”

What the sources say

• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [18] 18. Minx J, Wiedmann T, Barrett J and Suh S. Methods review to support the PAS for the calculation of the embodied greenhouse gas emissions of goods and services. London: Stockholm Environment Institute and University of Minnesota; 2008.

In the paper

“However, these reviews are predominantly based on low level evidence such as opinion reports, and included studies using a wide variety of methods to measure environmental sustainability (e.g.weight of waste, volume of water, and cost).”

In the paper

“This review was conducted and reported in accordance with PRISMA guidelines (28) and registered with the International Prospective Register of Systematic Reviews (PROSPERO, ID 109928).”

What the sources say

• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [28] 28. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535.

In the paper

“However, this method is resource intensive and requires study boundaries to be carefully defined, resulting in 'truncation error' due to the omission of certain processes, or where the so called 'hidden' sectors are overlooked.(17)”

What the sources say

• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [17] 17. World Resources Institute. Technical guidance for calculating scope 3 emissions. USA: World Resources Institute; 2013.

In the paper

“The search was conducted independently by two authors (CR, RN).”

In the paper

“The main value of estimating a carbon footprint via an EEIO method is for the rapid identification of hotspots, indicating where it may be useful to perform a more detailed carbon footprint.”

In the paper

“Other investigators have recommended adding in reprocessing of single-use devices (processing to allow for additional use(s)), environmentally preferable procurement, and energy consumption management.(25)”

What the sources say

• ?Not checked — no full text of the sourcecites [25] 25. Kwakye G, Brat GA, Makary MA. Green surgical practices for health care. Arch Surg. 2011;146(2):131-6. source

In the paper

“Heterogeneity in functional units, methodology and reporting of results limits comparison across studies, and means meta-analysis is inappropriate.”

In the paper

“The carbon footprint of different operations will vary, and are likely to be dependent upon the invasiveness of the procedure, patient factors, and the surgical team, which will each impact on operative time and consumables used.(35)”

What the sources say

• ?Not checked — no full text of the sourcecites [35] 35. Woods DL, McAndrew T, Nevadunsky N, Hou JY, Goldberg G, Yi-Shin Kuo D, et al. Carbon footprint of robotically-assisted laparoscopy, laparoscopy and laparotomy: a comparison. Int J Med Robot. 2015;11(4):406-12. source

In the paper

“This variation may be due to differences in methods and boundaries, but is also affected by the type of operation and the institution where it is performed.”

In the paper

“Where studies used secondary financial activity data within an EEIO model, this incorporates all three scopes of GHG emissions where relevant.”

In the paper

“No study stated a clear hypothesis, increasing risk of post-hoc analysis and selective reporting.”

In the paper

“Whereas use of reusable rather than disposable items is a good general principle, this preference is context specific and may not be universal.”

In the paper

“Improving the energy efficiency of USA hospitals by 30% has been estimated could save $1 billion and a reduction in carbon emissions of 11 million tonnes.(39)”

What the sources say

• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [39] 39. Healthcare without Harm. Health care's climate footprint climate-smart health care series green paper number one. Healthcare without Harm and ARUP; 2019.

In the paper

“A life cycle assessment study examining seven single use medical devices (including endoscopic trocars, ligasure, arthroscopic shavers and ultrasonic scalpels) found that reprocessed devices conferred lower global warming impacts alongside financial benefits.(51)”

What the sources say

• ?Not checked — no full text of the sourcecites [51] 51. Farrelly JS, Clemons C, Witkins S, Hall W, Christison-Lagay ER, Ozgediz DE, et al. Surgical tray optimization as a simple means to decrease perioperative costs. J Surg Res. 2017;220:320-6. source

In the paper

“hence changing processes to only open equipment when needed could bring financial as well as carbon savings.”

What the sources say

• ?Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  cites [53] 53. NHS Institute for Innovation and Improvement. Improving quality and efficiency in the operating theatre. Coventry: NHS; 2009.

In the paper

“Berner et al.(26) found that an abdominoplasty had a greater carbon footprint than rhinoplasty, which in turn was greater than bilateral breast augmentation.”

What the sources say

• ?Not checked — no full text of the sourcecites [26] 26. Berner JE, Gras MDP, Troisi L, Chapman T, Vidal P. Measuring the carbon footprint of plastic surgery: A preliminary experience in a Chilean teaching hospital. J Plast Reconstr Aesthet Surg. 2017;70(12):1777-9. source

In the paper

“Thiel et al. (33) modelled that the carbon footprint of a hysterectomy operation could be reduced by up to 83%, through optimising the instrument tray via minimal materials and maximum reuse(49%), switching anaesthesia to intravenous anaesthesia with propofol or similar agents (28%), and using renewable energy (6%).”

What the sources say

• ?Not checked — no full text of the sourcecites [33] 33. Thiel CL, Woods NC, Bilec MM. Strategies to reduce greenhouse gas emissions from laparoscopic surgery. Am J Public Health. 2018;108(S2):S158-S64. source