OGBN P04 Laparoscopic Cholecystectomy- can we make it both Greener and cheaper?
Authors: Gough Vivienne , Strunzova Agata , Curry Heather 
Published: December 2022

Abstract

Background
Laparoscopic cholecystectomy is one of the most common operations in the UK, with around 60,000 performed in the UK each year. Large numbers of single use instruments are used in laparoscopic surgery, despite the availability of reusable and hybrid alternatives. A hybrid instrument is one where most of the instrument is reusable but it also has a single use replaceable component
Operating theatres are a major carbon hotspot within healthcare. The NHS alone is estimated to be responsible for about 4% of England's carbon emissions, thought to be similar in Scotland and operating theatres account for up to 33% of solid waste produced in hospitals. The NHS has a target of reaching net zero emissions by 2040. There is a wide variability in surgical instruments use for laparoscopic cholecystectomy between operators and hospitals - our aim was to examine what was currently being used within 7 different hospital within a single health board, and to suggest the ‘greenest ’ possible instrument tray. It has already been shown that for a single procedure, the cost of using a hybrid laparoscopic clip appliers, scissors, and ports was 47% of that of single-use equivalents, and the carbon footprint 76% lower (Rizan 2021)

Methods
Visits to the 7 hospital sites currently performing laparoscopic cholecystectomy within a single health board was carried out by 3rd Year medical Student, as part of a Sustainability in Surgery SSC, during a 4 week period in May 2022. This was a snap shot audit and only one surgeon per site was visited. The items used during laparoscopic cholecystectomy were recorded with focus on the use of reusable, hybrid and single use tools. Costs and supplier information were gathered from theatre staff and company representatives. The relevant elements of the surgical tray setups were collated into a table and costs were compared. CO2 footprint was also collated when available.

Results
There was a wide variation in surgical set ups between hospitals within the same health board.
3 hospitals no longer had any reusable laparoscopic instruments and used all single use, the rest used a combination of single use, hybrid and disposable. All hospitals except one used single use laparoscopic ports- the other used hybrid ports. Most hospitals used single use clip appliers- one surgeon used ties instead. 2 hospitals used skin staples for skin closure. No single hospital utilised the most sustainable option in every item analysed.
Costs were analysed below. Single use items were cheaper than reusables for nearly all key items but more expensive in the long term. Hybrid items had lower or similar costs to single use and much lower carbon emissions. Waste and decontamination costs were not taken into account in this analysis.

Conclusions
Taking the most sustainable practises from the hospitals we visited, an ‘ideal setup’ from an environmental viewpoint was devised using items already available within the health-board.
We suggest that this be adopted to reduce both carbon emissions as well as costs. Where the upfront costs of purchasing new reusable instruments are prohibitive, hybrid instruments are recommended. Addressing simple things such as swapping low cost single use plastic item for their reusable counterparts is important and often overlooked.
Using reusable instruments to the end of their lifespan, efficient decontamination and regular maintenance also play a role in reducing impact and costs. Further work is required by the healthcare sector and manufacturers to carry out environmental analyses for commonly used items and provide data upon which purchasing decisions could be made to improve sustainability and allow the NHS to meet its net zero target.