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World J Gastrointest Surg. Jul 27, 2023; 15(7): 1277-1285
Published online Jul 27, 2023. doi: 10.4240/wjgs.v15.i7.1277
Carbon footprints in minimally invasive surgery: Good patient outcomes, but costly for the environment
Kai Siang Chan, Hong Yee Lo, Vishal G Shelat
Kai Siang Chan, Hong Yee Lo, Vishal G Shelat, Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
Vishal G Shelat, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
Vishal G Shelat, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
Author contributions: Chan KS performed the literature review and wrote the manuscript; Lo HY supervised and revised the manuscript; Shelat VG conceptualized the idea, supervised and revised the manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Kai Siang Chan, MBBS, Doctor, Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore. kchan023@e.ntu.edu.sg
Received: December 27, 2022
Peer-review started: December 27, 2022
First decision: February 20, 2023
Revised: March 2, 2023
Accepted: April 18, 2023
Article in press: April 18, 2023
Published online: July 27, 2023
Processing time: 205 Days and 20.1 Hours
Abstract

Advancements in technology and surgical training programs have increased the adaptability of minimally invasive surgery (MIS). Gastrointestinal MIS is superior to its open counterparts regarding post-operative morbidity and mortality. MIS has become the first-line surgical intervention for some types of gastrointestinal surgery, such as laparoscopic cholecystectomy and appendicectomy. Carbon dioxide (CO2) is the main gas used for insufflation in MIS. CO2 contributes 9%-26% of the greenhouse effect, resulting in global warming. The rise in global CO2 concentration since 2000 is about 20 ppm per decade, up to 10 times faster than any sustained rise in CO2 during the past 800000 years. Since 1970, there has been a steady yet worrying increase in average global temperature by 1.7 °C per century. A recent systematic review of the carbon footprint in MIS showed a range of 6-814 kg of CO2 emission per surgery, with higher CO2 emission following robotic compared to laparoscopic surgery. However, with superior benefits of MIS over open surgery, this poses an ethical dilemma to surgeons. A recent survey in the United Kingdom of 130 surgeons showed that the majority (94%) were concerned with climate change but felt that the lack of leadership was a barrier to improving environmental sustainability. Given the deleterious environmental effects of MIS, this study aims to summarize the trends of MIS and its carbon footprint, awareness and attitudes towards this issue, and efforts and challenges to ensuring environmental sustainability.

Keywords: Carbon footprint; Environment; Environmental pollution; Minimally invasive surgical procedures; Sustainability

Core Tip: Many minimally-invasive surgeries (MIS) have better post-operative outcomes than their open counterparts. However, MIS requires using carbon dioxide to achieve pneumoperitoneum, sterilization, and production and disposal of equipment. Concerns over the iatrogenic transmission of infectious diseases have led to the preference for disposable equipment; however, disposable equipment has higher carbon footprints than reusable ones. This review summarizes the impact of MIS on carbon footprints, awareness and attitudes of relevant stakeholders towards environmental sustainability, and challenges in reducing carbon footprint in MIS.