Summary of background data and objectives: Operating theatres are typically the most resource-intensive area of a hospital, 3–6 times more energy-intensive than the rest of the hospital and a major contributor of waste. The primary objective of this systematic review was to evaluate existing literature calculating the carbon footprint of surgical operations, determining opportunities for improving the environmental impact of surgery. Methods: A systematic review was conducted in accordance with PRISMA guidelines. The Cochrane Database, Embase, Ovid MEDLINE, and PubMed were searched and inclusion criteria applied. The study endpoints were extracted and compared, with the risk of bias determined. Results: A total of 4604 records were identified, and 8 were eligible for inclusion. This review found that the carbon footprint of a single operation ranged 6–814 kg carbon dioxide equivalents. The studies found that major carbon hotspots within the examined operating theatres were electricity use, and procurement of consumables. It was possible to reduce the carbon footprint of surgery through improving energy-efficiency of theatres, using reusable or reprocessed surgical devices and streamlining processes. There were significant methodological limitations within included studies. Conclusions: Future research should focus on optimizing the carbon footprint of operating theatres through streamlining operations, expanding assessments to other surgical contexts, and determining ways to reduce the footprint through targeting carbon hotspots.

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Objective To quantify the environmental impact of personal protective equipment (PPE) distributed for use by the health and social care system to control the spread of SARS-CoV-2 in England, and model strategies for mitigating the environmental impact. Design Life cycle assessment was used to determine environmental impacts of PPE distributed to health and social care in England during the first six months of the COVID-19 pandemic. The base scenario assumed all products were single-use and disposed of via clinical waste. Scenario modelling was used to determine the effect of environmental mitigation strategies: (1) eliminating international travel during supply; (2) eliminating glove use; (3) reusing gowns and face shields; and (4) maximal recycling. Setting Royal Sussex County Hospital, Brighton, UK. Main outcome measures The carbon footprint of PPE distributed during the study period totalled 106,478 tonnes CO2e, with greatest contributions from gloves, aprons, face shields and Type IIR surgical masks. The estimated damage to human health was 239 DALYs (disability-adjusted life years), impact on ecosystems was 0.47 species.year (loss of local species per year), and impact on resource depletion was costed at US $12.7m (GBP £9.3m). Scenario modelling indicated UK manufacture would have reduced the carbon footprint by 12%, eliminating gloves by 45%, reusing gowns and gloves by 10% and maximal recycling by 35%. Results A combination of strategies may have reduced the carbon footprint by 75% compared with the base scenario, and saved an estimated 183 DALYS, 0.34 species.year and US $7.4m (GBP £5.4m) due to resource depletion. Conclusion The environmental impact of PPE is large and could be reduced through domestic manufacture, rationalising glove use, using reusables where possible and optimising waste management.