Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries
Authors:   National Institute for Health and Care Research Global Health Research Unit on Global Surgery, Adisa Adewale , Bahrami-Hessari Michael , Bhangu Aneel , George Christina , Ghosh Dhruv , Glasbey James , Haque Parvez , Ingabire J C Allen , Kamarajah Sivesh Kathir , Kudrna Laura , Ledda Virginia , Li Elizabeth , Lillywhite Robert , Mittal Rohin , Nepogodiev Dmitri , Ntirenganya Faustin , Picciochi Maria , Simões Joana Filipa Ferreira , Booth L , Elliot R , Kennerton A S , Pettigrove K L , Pinney L , Richard H , Tottman R , Wheatstone P , Wolfenden John W D , Smith A , Sayed A Emad , Goswami Aakansha Giri , Malik Aamer , Mclean Aaron Lawson , Hassan Abbas , Nazimi Abd Jabar , Aladna Abdallah , Abdelgawad Abdalrahman , Saed Abdel , Abdelmageed Abdelfatah , Ghannam Abdelilah , Mahmoud Abdelrahman , Alvi Abdul , Ismail Abdulaziz , Adesunkanmi Abdulhafiz , Ebrahim Abdulla , Al-Mallah Abdullah , Alqallaf Abdullah , Durrani Abdullah , Gabr Abdullah , Kirfi Abdullahi Musa , Altaf Abdulmalik , Almutairi Abdulmjeed , Sabbagh Abdulrahman J , Ajiya Abdulrazak , Haddud Abdurrahman , Alnsour Abed Alfattah Mahmoud , Singh Abhinav , Mittal Abhishek , Semple Abigail , Adeniran Abiodun , Negussie Abraham , Oladimeji Abraham , Muhammad Abubakar Bala , Yassin Abubaker , Gungor Abuzer , Tarsitano Achille , Soibiharry Adaiah , Dyas Adam , Frankel Adam , Peckham-Cooper Adam , Truss Adam , Issaka Adamu , Ads Adel Mohamed , Aderogba Adeleke Akeem , Adeyeye Ademola , Ademuyiwa Adesoji , Sleem Adham , Papa Adrian , Cordova Adriana , Appiah-Kubi Adu , Meead Adullah , Nacion Aeris Jane D , Michael Afieharo , Forneris Agustin Albani , Duro Agustin , Gonzalez Agustin Rodriguez , Altouny Ahmad , Ghazal Ahmad , Khalifa Ahmad , Ozair Ahmad , Quzli Ahmad , Haddad Ahmad , Othman Ahmad Faidzal , Yahaya Ahmad Shuib , Elsherbiny Ahmed , Nazer Ahmed , Tarek Ahmed , Abu-Zaid Ahmed , Al-Nusairi Ahmed , Azab Ahmed , Elagili Ahmed , Elkazaz Ahmed , Kedwany Ahmed , Nuhu Ahmed Mohammed , Sakr Ahmed , Shehta Ahmed , Shirazi Ahmed , Mohamed Ahmed Mohamed Ibrahim , Sherif Ahmed Elshawadfy , Awad Ahmed K , Abbas Ahmed M , Abdelrahman Ahmed Saber , Ammar Ahmed Siddique , Azzam Ahmed Y , Ciftci Ahmet Burak , Dural Ahmet Cem , Sanli Ahmet Necati , Rahy-Martín Aida Cristina , Tantri Aida Rosita , Khan Aimal , Al-Touny Aiman , Tariq Aiman , Gmati Aimen , Costas-Chavarri Ainhoa , Auerkari Aino , Landaluce-Olavarria Aitor , Puri Ajay , Radhakrishnan Ajay , Ubom Akaninyene Eseme , Pradhan Akhilesh , Turna Akif , Adepiti Akinfolarin , Kuriyama Akira , Kassam Al-Faraaz , Hassouneh Ala , El-Hussuna Alaa , Habeebullah Alaa , Ads Alaa Mohamed , Mousli Alaa , Biloslavo Alan , Hoang Alan , Kirk Alan , Santini Alasdair , Melero Alba Vazquez , Calvache Albaro José Nieto , Baduell Albert , Chan Albert , Abrate Alberto , Balduzzi Alberto , Sánchez Alberto Cabañero , Navarrete-Peón Alberto , Porcu Alberto , Brolese Alberto , Barranquero Alberto G , Saibene Alberto Maria , Adam Albushra Altayeb , Vagge Aldo , Maquilón Alejandra Jara , Leon-Andrino Alejandro , Sekulić Aleksandar , Trifunovski Aleksandar , Mako Aleksandro , Bedada Alemayehu Ginbo , Broglia Alessandro , Coppola Alessandro , Giani Alessandro , Grandi Alessandro , Iacomino Alessandro , Moro Alessandro , D’amico Alessia , Malagnino Alessia , Tang Alethea , Doyle Alex , Alfieri Alex , Haynes Alex , Wilkins Alex , Baldwin Alexander , Heriot Alexander , Laird Alexander , Lazarides Alexander , O'connor Alexander , Trulson Alexander , Rokohl Alexander Christopher , Caziuc Alexandra , Triantafyllou Alexandra , Anesi Alexandre , Nikova Alexandrina , Andrianakis Alexandros , Charalabopoulos Alexandros , Tsolakidis Alexandros , Chirca Alexandru , Arnaud Alexis P , Narvaez-Rojas Alexis Rafael , Kavalakat Alfie , Spina Alfio , Recordare Alfonso , Annicchiarico Alfredo , Conti Alfredo , Mohammed Alhassan Datti , Kocataş Ali , Almhimid Ali , Arnaout Ali , Fahmy Ali , Mangi Ali , Modabber Ali , Ulas Ali Bilal , Mohamedahmed Ali Yasen Y , Frontali Alice , Moynihan Alice , Yunus Alif , Ahmad Aline , Kent Alistair J , Khamees Almu'atasim , Ugwu Aloy Okechukwu , Turan Alparslan , Mohammed Alsnosy Abdullah Khalefa , Navarro-Barrios Alvaro , Yebes Alvaro , De Sousa Álvaro Francisco Lopes , Moreno Amabelle , Sethi Aman , Dawson Amanda Caroline , Othman Amani Alsayd Abdulsalam , Kaur Amanjot , Wolde Amanuel , Antonelli Amedeo , Scifo Amedeo , Alhamad Ameen , Davis Amelia , Alderazi Amer , Harky Amer , Mohammed-Durosinlorun Amina , Seguya Amina , Okhakhu Amina , Chamakhi Amine , Sebai Amine , Souadka Amine , Asla Amir , Agrawal Amit , Persad Amit , Gupta Amit , Elgazar Amr , Kulkarni Amruta , Coates Amy , Bellés Ana Ciscar , Hadzibegovic Ana Danic , Jotic Ana , Kowark Ana , Martins Ana , Pineda Ana Mejía , Peral Ana , Gollarte Ana Sánchez , Senent-Boza Ana , Camarena Ana Isabel Avellaneda , Castaño-Leon Ana M , Bravo Ana Maria Minaya , Moro Ana María Gimeno , Musina Ana-Maria , Tapia-Herrero Ana-María , Kothari Anai , Gupta Anand , Raja Anand , Aljaiuossi Anas , Taha Anas , Majbar Anass Mohammed , Prodromidou Anastasia , Kanatas Anastasios , Gupte Anaya , Zakaria Andee Dzulkarnaen , Balla Andrea , Barberis Andrea , Bondurri Andrea , Bottari Andrea , Costantino Andrea , Figus Andrea , Lauretta Andrea , Mingoli Andrea , Romanzi Andrea , Sagnotta Andrea , Scacchi Andrea , Picchetto Andrea , Valadez Andrea Estefania Cueto , Luzzi Andrea-Pierre , Älgå Andreas , Fontalis Andreas , Hecker Andreas , Demetriades Andreas K , Serban Andreea-Madalina , Văcărașu Andrei Bogdan , Cokan Andrej , Isaza-Restrepo Andres , Beamish Andrew , Schache Andrew , Stevenson Andrew , Yiu Andrew , Cockbain Andrew J , Litvin Andrey , Abad-Motos Ane , Becerra Angel , Ramos Ángel Cilleruelo , Chiaradia Angela , Dell Angela , Romano Angela , Pascale Angelo , Marra Angelo Alessandro , Dimas Angelos , Kolias Angelos , Cerovac Anis , Koneru Anish , Tidjane Anisse , Agbeko Anita Eseenam , Bajaj Ankur , Gosain Ankush , Allan Anna , Carreras-Castañer Anna , D'amore Anna , Dare Anna , Maffioli Anna , Palepa Anna , Paspala Anna , Konney Anna , Gatta Anna Nunzia Della , Ezanno Anne-Cecile , Yiallourou Anneza , Kinnair Anthony , Rayner Anthony , Scafa Anthony Kevin , Bowan Antoinette Bediako , Veglia Antonella , Russo Antonino , Maniaci Antonino , Castaldi Antonio , Gil-Moreno Antonio , Maffuz-Aziz Antonio , Meola Antonio , Nenna Antonio , Ferrer Antonio Perez , Bonilla Antonio Ramos , Ramos-De La Medina Antonio , Infante Antonio Rodriguez , Santoro Antonio , Laganà Antonio Simone , Bateman Antony , Michael Antony Louis Rex , Abozid Anwaar , Seidu Anwar Sadat , Lowery Aoife , Tantraworasin Apichat , Rasheed Aqsa , Picciariello Arcangelo , Isik Arda , Saif Areeba , Anjum Arfa , Ioannidis Argyrios , Abeldaño Ariel , Hussain Arif , Nathan Arjun , Bedzhanyan Arkady , Perfecto Arkaitz , De Virgilio Armando , Galvan Armando , Sablotzki Armin , Böttcher Arne , Pellacani Arrigo , Gatti Arthur , Ibrahimli Arturan , Menon Arun , Sahni Arun , Mwenda Aruyaru Stanley , Choudhry Asad , Jayawardane Asanka , Gupta Ashish , Ramasamy Ashok , Mitul Ashrarur Rahman , Bawa Ashvind , Nugur Ashwani , Rammohan Ashwin , Sachdeva Ashwin , Mehraj Asif , Yildirim Asif , Alqaseer Asma , Radwan Asmaa , Sallam Asser , Syllaios Athanasios , Tampakis Athanasios , Alwael Athari , Samara Athina , Eroglu Atilla , Rahman Atiqur , Ulkucu Attila , Zaránd Attila , Dulskas Audrius , Tawiah Augustine , Zani Augusto , Vas Aurelia , Lukosiute-Urboniene Ausra , Adamu Auwal , Aujayeb Avinash , Malik Awais Amjad , İplikçi Ayberk , Mahmud Ayesha , Cil Aylin Pelin , Makanjuola Ayomide , Akwaisah Ayoub , Galandarova Aysuna , Saracoglu Ayten , Regan Azel , Barlas Aziz Mutlu , Alhassan Baba Alhaji Bin , Mostafa Badr , Hamida Baha Ben , Torun Bahar Canbay , Abdullah Bahiyah , Balagobi Balasingam , Banky Balazs , Singh Baljit , Alegbeleye Bamidele , Yigit Banu , Hajjaj Baraa Nabil , Burgos-Blasco Barbara , Seeliger Barbara , Alayande Barnabas , Alhazmi Barrag , Enodien Bassey , Torre Beatrice , Pérez Beatriz Gómez , Tamayo Beatriz Villota , De Andrés-Asenjo Beatriz , Quintana-Villamandos Begoña , Girgin Behiç , Barmayehvar Behrad , Beisenov Bekzat , Creavin Ben , Dunne Ben , Marson Ben , Waterson Ben , Martin Benjamin , Zucker Benjamin , Wong Benjamin Ngie Xiong , Ozmen Berk Baris , Hammond Bernard , Mbwele Bernard , Núñez Bernardo , Dhondt Bert , Gafsi Besma , Mcleish Bethan , Lieske Bettina , Tailor Bhavesh , La Pira Biagia , Picardi Biagio , Zampogna Biagio , Casagranda Biagio , Festa Bianca Maria , Panda Bijnya , Kirmani Bilal , Sulaiman Bilal , Gurung Binay , Zacharia Bincy , Bette Birgit , Ayana Birhanu , Nikolovska Bisera , Vilaró Blanca Capdevila , De Vega Sánchez Blanca , Hameed Bm Zeeshan , Diaconescu Bogdan , Kovacevic Bojan , Bumber Boris , Sakakushev Boris , Tadic Boris , Malek Bouhani , Alrayes Bourhan , Thomas Bradley , Gális Branislav , Gallagher Brendan , Knowles Brett , Cunningham Brian , Daley Brian , 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, De Oliveira Gabriel Paiva , Rodrigues Gabriel , Wagner Gabriela , Bellio Gabriele , Giarratano Gabriella , Capolupo Gabriella Teresa , Budd Gabrielle , Marom Gad , Poillucci Gaetano , Thiruchandran Gajendiran , Nicholson Gary , Groot Gary , Hoey Gary , Bass Gary Alan , Sachdev Gaurav , Agarwal Gaurav , Aggarwal Gaurav , Cormio Gennaro , Mazzarella Gennaro , Perrone Gennaro , Osterhoff Georg , Singer Georg , Dejeu George , Fowler George , Garas George , Gradinariu George , Theodoropoulos George , Tzimas George , Babis George , Wong George Kwok Chu , Cross George W V , Micha Georgia , Chrysovitsiotis Georgios , Koukoulis Georgios , Peros Georgios , Tsoulfas Georgios , Kapetanios Georgios , Karagiannidis Georgios , Verras Georgios-Ioannis , Ekwen Gerald , Perrotta Gerardo , Petruzzi Gerardo , Bertelli Giacomo , Calini Giacomo , Fiacchini Giacomo , Pirola Giacomo Maria , Dolci Giampiero , Mendiola Gian , Baiocchi Gian Luca , Palini Gian Marco , Prucher Gian Marco , D'andrea Giancarlo , Maggiore Giandomenico , Cassese Gianluca , Franceschini Gianluca , Pellino Gianluca , Saponaro Gianmarco , Pattacini Gianmaria Casoni , Pantuso Gianni , Iannella Giannicola , Bonsaana Gilbert Batieka , Lever Gillian , Brachini Gioia , Giraudo Giorgio , Lisi Giorgio , Russo Giorgio Ivan , Aprea Giovanni , Pascale Giovanni , Tomasicchio Giovanni , Sandri Giovanni Battista Levi , Armatura Giulia , Turri Giulia , Zaccaria Giulia , Barugola Giuliano , Lantone Giuliano , Gasparini Giulio , Iacob Giulio , Sozzi Giulio , Zancana Giuseppa , Mercante Giuseppe , Bianco Giuseppe , Brisinda Giuseppe , Consorti Giuseppe , Currò Giuseppe , Giannaccare Giuseppe , Palomba Giuseppe , Pascarella Giuseppe , Rotunno Giuseppe , Spriano Giuseppe , Vizzielli Giuseppe , Cucinella Giuseppe , Sica Giuseppe , Campisi Giuseppina , Baiocchi Glauco , Guerra Glen R , Pacheco Glenda Marina Falcon , Atis Gokhan , Augustin Goran , Šantak Goran , Chauhan Govind Singh , Branagan Graham , Harris Grant , Stewart Grant D , 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Hassan Fatemi , Mushtaq Hassan , Aljaaly Hattan , Hasan Hayat Ben , Ahmed Hayat Tarig Abdelhafiz , Martinez-Said Hector , Aguado Héctor J , Consani Heitor , Chaplin Helen , Mohan Helen , Van Vliet Helen , Lohse Helmut Alfredo Segovia , Shah Hemina , Claireaux Henry , Lule Herman , Juara Hernández , Abozied Hesham , Bayo Heura Llaquet , Alibrahim Hidar , Kroon Hidde M , Ulman Hilmican , Khan Hina , Yonekura Hiroshi , Abou-Taleb Hisham , Wong Ho Ying Flora , Carpenter Holly , Majd Hooman Soleymani , Zenha Horácio , Mayer Horacio F , Elghadban Hosam , Abdou Hossam , Elfeki Hossam , Yusefi Hossein , Gomez-Fernandez Hugo , Horsfall Hugo Layard , Meleiro Hugo , Sungurtekin Hulya , Junior Humberto Fenner Lyra , Moloo Husein , Bayhan Hüseyin , Şevi̇k Hüsnü , Embarek Hussein , Hamid Hytham K S , Pradeep I H D Saman , Donkin Ian , Ateca Ibabe Villalabeitia , Jafarov Ibrahim , Salisu Ibrahim , Abdalaal Ibrahim , Garzali Ibrahim Umar , Sall Ibrahima , Adebara Idowu , Aghadi Ifeanyi , Ugwu Ifeanyichukwu , Zapardiel Ignacio , Reis Igor , Nwafor Ikechuwu , Fakhradiyev Ildar , Surya Ilham Utama , Robo Ilma , Njokanma Iloba , Iannone Immacolata , Khan Imran , Correia Inês , Königsrainer Ingmar , Seiwerth Ingmar , Linero Inmaculada Benítez , Kadiri Innih , Florian Ioan-Alexandru , Tzima Ioanna , Akrida Ioanna , Baloyiannis Ioannis , Gerogiannis Ioannis , Katsaros Ioannis , Tsakiridis Ioannis , Valioulis Ioannis , Negoi Ionut , Yadev Ip , De Haro Jorge Irene , Vázquez Irene Ortega , Dajti Irida , Russo Iris Shari , Afzal Irrum , Wasserman Isaac , Chukwu Isaac , Gracia Isabel , Oliver Isabel Mora , Hughes Isabel , Mondi Isabella , Ncogoza Isaie , Bsisu Isam , Rashid Isbah , Balasubramanian Ishwarya , Omar Islam , Dominguez-Rosado Ismael , Smati Ismail , Vokshi Ismail , Al-Badawi Ismail A , Saleh Ismail Ali , Pilkington Isobel , Kirac Iva , Trostchansky Ivan , Gawron Iwona Magdalena , Trebol Jacobo , Martellucci Jacopo , Andreuccetti Jacopo , Abou-Khalil Jad , Shah Jaffer , 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Mantziari Styliani , Kykalos Stylianos , Goh Su Kah , Chowdhury Subhadip Pal , Ibrahim Sufyan , Elzwai Suha , Bansal Sujesh , Tripathy Sujit , Amrayev Sultan , Anwar Sumadi Lukman , Banerjee Sumit , Thakar Sumit , Saeed Summaya , Venkatappa Sunil Kumar , Das Sunit , Techapongsatorn Suphakarn , Dube Surya Kumar , Lee Susan , González-Suárez Susana , Henriques Susana , Konjevoda Suzana , Gisbertz Suzanne , Bravo Sybil Lizanne , Mannan Syed , Bukhari Syed Imran , Zafar Syed Nabeel , Batista Sylvia , Chin Synn Lynn , Arif Tahera , Lawal Taiwo Akeem , Aktokmakyan Talar Vartanoglu , Osborn Tamara , Szakmany Tamas , Sztipits Tamás , Triantafyllou Tania , Valadez Tania Abigail Cueto , Singh Tanveer , Khaliq Tanwir , Patel Tapan , Fadalla Tarig , Jichi Tarik , Sammour Tarik , Al-Shaiji Tariq , Naggs Taryn , Barišić Tatjana , Nikolouzakis Taxiarchis , Bisgin Tayfun , Perra Teresa , Uprak Tevfik Kıvılcım , Dagklis Themistoklis , Liakakos Theodore , Sidiropoulos Theodoros , Adjeso Theophilus Justus Kofi , Dölker Theresa , Oung Thida , Aherne Thomas , Diehl Thomas , Pinkney Thomas , Raymond Thomas , Rhomberg Thomas , Schmitz-Rixen Thomas , Madhuri Thumuluru Kavitha , Lohmann Tibor Karl , Yeoh Tien , Zaimis Tilemachos , Bright Tim , Vilz Tim O , Glowka Tim R , Board Timothy , Hardcastle Timothy , Cohnert Tina , Mahečić Tina Tomić , William Tinka George , Klatte Tobias , Abbott Tom , Watcyn-Jones Tom , Mendes Tome , Kulis Tomislav , Sečan Tomislav , Campagnaro Tommaso , Frisoni Tommaso , Simoncini Tommaso , Violante Tommaso , Safranovs Toms Janis , Risteski Toni , Pang Tony , Akinyemi Tosin , Yotsov Tsanko , Laeke Tsegazeab , Kochiyama Tsukasa , Sholadoye Tunde T , Alekberli Tural , Ezomike Uchechukwu , Giustizieri Ugo , Grossi Ugo , Köksoy Ülkü Ceren , Bork Ulrich , Kisser Ulrich , Ronellenfitsch Ulrich , Saeed Umar , Bracale Umberto , Jayarajah Umesh , Rauf Umme Habiba Abdul , Bumbasirevic Uros , Ferrer Ursula María Jariod , Ahmed Usama , Bello Usman Mohammed , Jogiat Uzair , Sadia Uzma , Galandarov Vagif , Narayanan Vairavan , Calu Valentin , Bianchi Valentina , Ciniero Valeria , Tonini Valeria , Silvestri Vania , Vijay Vardhini , Dewan Varun , Lohsiriwat Varut , Thuduvage Vasanthika , Mousafeiris Vasileios , Dragisic Vedran , Sasireka Veerasamy , Santric Veljko , Kusuma Venkata Ramana Murthy , Kolli Venkata Satish , Alonso Veronica , De Simone Veronica , Picotti Veronica , Martínez Verónica Martín , Panduro-Correa Vicky , Kakotkin Victor , Angulo Victor Pinto , Turrado-Rodriguez Victor , Krishnamoorthy Vijay , Ban Vin Shen , Shah Vinay , Maiola Vincenza , Giordano Vincenzo , La Vaccara Vincenzo , Lizzi Vincenzo , Papagni Vincenzo , Schiavone Vincenzo , Satchithanantham Vinojan , Garcia-Virto Virginia , Jimenez Virginia , Kumar Vishal , Shelat Vishal , Bhat Vivek , Sodhai Vivek , Graziadei Vivien , Kutuzov Vladislav , Stoyanov Vladislav , Oktseloglou Vlasios , Flis Vojko , Elhassan Wael Atif Fadl , Yang Wah , Soon Wai Cheong , Tashkandi Wail , Al-Khyatt Waleed , Mabood Waleed , Bijou Walid , Wijenayake Wasantha , D Wasim , Krawczyk Wiktor , Atkins William , Bolton William , White William , Ceelen Wim , Vagena Xanthoula , Gozal Yaacov , Baba Yabasin Iddrisu , Subramani Yamini , Jansen Yanina , Mittal Yash , Kara Yasi̇n , Zwain Yasir , Noureldin Yasser , Alawneh Yazan , Aydin Yener , Lam Yick Ho , Tang Yita , Lim Yizhe , Dean Yomna , Tanas Yousef , Su Yu-Xiong , Fujimoto Yuki , Altinel Yuksel , Frolova Yulia , Oshodi Yusuf , Fadel Zahir T , Zahid Zahra , Elahi Zain , Djama Zakarya , Zaheen Zakia , Jawad Zaynab , Demetrashvili Zaza , Gebremeskel Zersenay , Gudisa Zewdie , Alyami Ziyad , Garoufalia Zoe , Li Zoe , Zimak Zoran , Radin Zorana , Balogh Zsolt J 
Published: April 2023

Abstract

Background
Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

Methods
This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries.

Results
In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

Conclusion
This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries.