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 ¤ Introduction
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Year : 2021  |  Volume : 17  |  Issue : 3  |  Page : 294-298

Environmental safety in minimal access surgery and its bio-economics

Date of Submission27-May-2020
Date of Acceptance04-Jun-2020
Date of Web Publication05-Sep-2020

Correspondence Address:
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.JMAS_130_20

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How to cite this article:
. Environmental safety in minimal access surgery and its bio-economics. J Min Access Surg 2021;17:294-8

How to cite this URL:
. Environmental safety in minimal access surgery and its bio-economics. J Min Access Surg [serial online] 2021 [cited 2022 Oct 7];17:294-8. Available from:

Correction: Environmental safety in minimal access surgery and its bio-economics

Correction to: JMAS_130_20 AOP; DOI: 10.4103/jmas.JMAS_130_20

This article's category is being changed from 'Original article' to 'Review article'. As the article was published 'Ahead of Print' as 'Original Article', a correction notice is being published to reflect the change in the category.

Environmental safety in minimal access surgery and its bio-economics

Subhash Khanna1, Arup Kumar Hazarika2, Unmilan Kalita3

1 Department of Minimal Access, Bariatric and G.I. Surgery, Swagat Super Speciality Surgical Institute and Swagat Academy of Medical Sciences, Guwahati, Assam, India

2 Department of Zoology, Cotton University, Guwahati, Assam, India

3 Department of Economics, Cotton University, Guwahati, Assam, India


Introduction: Minimal access surgery has altered the field of surgery with its revolutionary advancements with respect to laparoscopy wherein the latter has been elevated to a safer procedure than ever before. However, along with its benefits, minimally invasive surgical procedures have detrimental environmental implications as well. Further, the overall bio-economics of carbon emissions during the surgery is another important factor.

Aim: The present article makes an effort to discuss and analyse the carbon footprint of minimal access surgery and to understand the co-benefits and co-costs in terms of environmental safety and bio-economics.

Results: The findings indicate that carbon footprint in these surgical procedures are rarely studied which otherwise bear significant negative relations with respect to the environment.

Conclusion: The study concludes that work on improving the design of these technologies is to be done so that apart from reducing the costs improvement of safety, comfort and better impact on future generation can also be achieved.

Keywords: Bio-economics, carbon dioxide, ecology, environment, minimal access surgery

Address for correspondence: Prof. Subhash Khanna, Swagat Super Speciality Surgical Institute and Swagat Academy of Medical Sciences, Guwahati, Assam, India.

E.mail: [email protected]

Submitted: 27-May-2020, Accepted in Revised Form: 04-Jun-2020, Published: 05-Sep-2020

 ¤ Introduction Top

In the last three decades, laparoscopic surgery has expanded dramatically and from a small beginning as a diagnostic laparoscopic procedure, it has almost become a procedure and technique of choice for most of the abdominal, thoracic and gynaecological procedures. With the introduction of robot-assisted surgery, there has been further exponential rise of various advanced procedures, including complex neck, oncological and urological procedures. In urological surgery, more than half of the nephrectomies and radical prostatectomy are currently being performed robotically. Despite the significant impact of health-care procedures and facilities, the environmental costs of surgery are often overlooked and ignored. Most of the environmental campaigning related to hospital typically focuses on waste reduction, but we hardly have any research or major studies on the environmental collateral effects of minimally invasive surgery (MIS). Of all parts of a complex hospital structure, the operating room is the most resource intensive area, and thus surgery becomes an important focal point to understand healthcare-related emissions [Figure 1].
Figure 1: A view of the modern complex operation theater with various equipments

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Carbon dioxide (CO2) is the principle gas used in endoscopy and laparoscopic surgery for insufflation, to create space so that we can visualise and operate in such CO2 insufflated space. Despite the heightened worldwide interest in sustainable healthcare, the carbon footprint in the healthcare sector has not been estimated. The principle gases accounted for Green House Gas (GHG) emissions include CO2 methane, nitrous oxide and chlorofluorocarbons. They are also expressed in terms of global warming.

The environmental collateral effects of MIS had never been worked, more so in Asian countries and in India where due to the volume of patient and the large number of such procedures carried out, the demand and need for such work is the need of the hour. Chung and Meltzer published one of the first research articles on a study of the environmental impact of healthcare in the United States, the second highest producer of CO2 emission in the world and contribute over all 19.91% of global contribution of such emissions and 7% of the entire US CO2 emission.[1] Whereas hospitals have started working scientifically to evaluate the source of negative environmental impacts in the current medical practice, especially in relation to energy, but it seems there is very little research being done on the environmental impacts of the upcoming procedures that use various new technologies. A significant implication of excess carbon emissions relates to distortions in the circular ecology of the environment.[2] GHG emissions not only bring about climate change but also have negative effects with regard to terrestrial acidification,[3] freshwater eutrophication, marine eutrophication[4] and terrestrial and freshwater ecotoxicity. Therefore, our aim should be to quantitate the carbon footprint of minimal access surgery and to understand the co-benefits and co-costs in terms of environmental safety and work on improving the design of these technologies so that apart from reducing the costs we can also improve safely, comfort and impact on future generation.

 ¤ Carbon Dioxide Footprint of Minimal Access Surgery Top

There had been very few studies on this subject and these were targeted to study the various components of the overall carbon footprint common to surgery in general and looked into operating theatre, electricity use, patient travel and paper product used. Apart from these some studies[5] have also tried to look into the contamination resulting from aerosolised fluid and surgical smoke [Figure 2]a and [Figure 2]b. The one major factor that is unique to surgery and more so in MIS is the use of CO2 for insufflations [Figure 3]. Apart from CO2 the other major GHG used in surgery are the anaesthetic gases, most of these are responsible for some ozone depletion.
Figure 2: (a) The surgical electrocautery machine used for cutting and coagulation, (b) the electrocautery machine with coagulation and cutting options

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Figure 3: A modern carbon dioxide automatic insufflator

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 ¤ Audit of Carbon Dioxide Emissions Top

To study the CO2 emissions related to MIS, the first step is to separate the contributing factors into the various scope of emissions. Scope 1 is defined by GHG as the direct GHG emissions from the source, whereas scope 2 denotes indirect GHG emission resulting from the generation of electricity, heating and cooling and the steam generated offsite, scope 3 involves indirect GHG emissions from the sources not owned or controlled by a particular entity or institution but related to its activities. Scope 1 CO2 emission is considered as the gas that leaks during the endoscopic or the surgical procedure either from the port sites during the procedure while exchanging the instruments and also while insufflating or desufflating the abdominal or thoracic cavity during or after the procedure. These emissions also include the CO2 gas that has been absorbed by the patient from the cavity and the gases that leak into the subcutaneous planes and finally these are eliminated through the respiration into the atmosphere.[6] Usually, this amount of absorbed gas is very negligible compared to the other direct CO2 emissions from the source including those from the leaking supply cylinders and the leaking tubings.

A typical CO2 supply cylinder in our institutions operating room weight 6.8 kgs and 31 kgs of compressed CO2, surprisingly there is no mention of medical grade CO2 in Indian pharmacopeia, and many times, it appears that the supplier supplies the CO2 from commercial source filling in smaller medical grade cylinders [Figure 4]. Further research is needed to understand the purity and status of such gases. As per the Ideal Gas Law 1, mole of gas occupies 22.4 l at 1 atmospheric pressure and 1 mole of CO2 weighs 44 gm. As per the records of one supplier, the total supply of CO2 cylinder in only Guwahati and neighbouring cities is 10,000 kg per month.
Figure 4: A carbon dioxide manufacturing plant

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Although on an average 3.5 l of CO2 is required in an adult to create the abdominal pressure of 12 mm of Hg for doing any procedure, but due to loss of CO2 during the procedure (scope 1), the hourly loss of CO2 during the procedure may vary from 1.5 litres to 10 litres in advanced procedures. The recent CO2 insufflation devices are all electronically controlled and show the flow rate and the total CO2 consumed during the procedure. The total amount of CO2 used during a procedure can thus easily be calculated by calculating the total volume consumed per hour and the total duration of various MIS procedures.[6] Lately, we have also routinely started using CO2 for various endoscopic procedures in gastrointestinal endoscopy in both diagnostic and therapeutic procedures. As compared to the atmospheric gas, CO2 is rapidly absorbed in the blood stream and thus much comfortable to the patient, but the only environmental hazard is that the CO2 emission is very high, and it is almost like directly releasing the CO2 into the environment.

The theory of Input Output Life Cycle Assessment originally conceived by the Nobel Prize winner, Wassily Leontief (1973) may be used to estimate CO2 emission involved capture/compression. One more area of concern is the purity of CO2, as medical grade CO2 is mined from natural CO2 springs and one need to confirm the source of CO2 that is being supplied to his institution.[7] One more concern that needs to be looked into is the emissions and losses during transportation of the CO2 cylinders to the facility that may include the distance and the mode of transportation. However, another issue in the minimal access surgery is the use of disposable instruments, especially laparoscopic trocars as some of these are not reautoclaved and being used as a single use instrument in advanced procedures and three or four such disposable instruments are regularly being used in robot-assisted procedures.

As almost all components of these disposable instruments are plastic a simple way to calculate is the emission of about 6 kgs of CO2 if we incinerate 1 kg of plastic products. One such research study, one of its first kinds conducted by a team of researchers led by Dr. Nicholas E. Power of the Department of surgery at the University of Western Ontario, USA, came up with alarming figure of the total calculated emission of 355,924 tons of CO2 in a year. This probably was the first attempt to quantity emission related to MIS in the United States.

The biggest threat to human species survival may come from Donald Rumsfeld's 'Unknown Unknowns.'[8] Biologists know that the most common cause of species collapses or extinction is co-existence. Small changes in ever-growing environmental temperature, atmospheric CO2, salinity, etc., may have a huge impact on the ecological balance of bacteria, plants, fungi, insects, birds and animals. This is the ecological pyramid on which the mankind relies. The climate change is a serious problem difficult to define without “Stopping Rules,” and difficult to solve because of various changing requirement in health care and that of society, most of these are not recognised easily.

Whereas we all know that climate change will be the defining issue for health systems in the 21st century, but ironically, the health-care industry accounts for about > 8% of the total CO2 emitter in the United States. The environmental footprint of perioperative service seems to be the largest in all of health care. However, another environmental threat of global warming is the anaesthetic gases, and almost all the currently used inhalational anaesthetics, desflurane, nitrous oxide, sevoflurance and isoflurance are the GHGs having global warming potentials [Figure 5].
Figure 5: A modern anesthesia work station with isoflurane and sevoflurane vaporizer

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A previous study from the University of Liverpool conducted in 2008 on the carbon footprint of surgery concluded that CO2 contributes a negligible total amount of CO2 emission to global warming. It seems this study did not take into consideration various aspects of MIS and was probably shortlisted and only considered CO2 emissions.[9] While looking into the impact of CO2 that is used in laparoscopic and endoscopic surgery, we should not only study the amount utilised only in a particular patient but also need a deep thinking and research on all the processes involved in manufacturing transportation, delivering and disposal. Thus, as discussed, we need to consider all the three scopes in any such study.

 ¤ Bio-Economics Perspective Top

Carbon footprint in the health-care sector is gaining critical attention from economists and policymakers worldwide, besides physicians. A recent study notes that healthcare in OECD nations on an average account for 5% of their national CO2 footprints.[10] Contemporary evidence indicates that the health-care sector which contributes almost 18% of US GDP (gross domestic product) invariably leads to approximately 9% of global GG emissions as well as 8% of total carbon emissions.[10] Similarly, the Australian health-care system spent around USD 162 billion on healthcare leading to CO2 emissions of 35,772 kilotons with a national carbon footprint of 7%.[11] In case of China, USD 2539 billion was spent on healthcare with high-CO2 emissions.[12] As such, it becomes relatively clear that there are high environmental costs associated with increasing use of CO2 in the health-care sector. While industrial emissions are generally closely monitored with appropriate restrictions such as levies and cess, in place, these remain highly unclear in case of the healthcare sector. Such unregulated use of CO2 highly incentivizes practitioners for the “easy way out.” Hence, it becomes imperative that health-care ministries and policy-makers chalk out appropriate guidelines to monitor the use of carbon in hospitals through audits while placing appropriate restrictions in the form of cess or tax legislations. This will lead to a progressive effect of incentivising practitioners to shift to greener techniques[13] and technology which will compel the manufacturers to augment their research and development activities.

 ¤ Conclusion Top

Although many attempts have been there in the past to replace the CO2 used in laparoscopic study, starting from gasless laparoscopy to the use of other gaseous medium such as helium or argon but none of these have proved superior or safer compared to CO2 for use in MIS.[14] Consideration of various other measures of insufflation or creating space in cavities to manoeuvre instruments need to be considered in future potential research strategies.[15] We need to work with other similar gases in an attempt to reduce the overall carbon footprint. We must also understand that contrary to strategy and regulations of pollution prevention in the industry where an industry generates or waste material that can be easily recycled, reversed and reprocessed, in healthcare many of such operations are not applicable or feasible. Thus, we must consider this issue while developing and implementing effective pollution prevention solutions. The overwhelming majority of CO2 emissions seem to be indirect and we need to work with our supplier to reduce the overall footprint. The surgical team also needs to be careful and make all attempts to reduce the inadvertent CO2 release during any MIS procedure. Various studies including the inputs from our own supplier have observed that the CO2 use has markedly increased over the years. If this trend continues the dream of sustainable healthcare may become a remote possibility.

CO2 such as many anaesthetic gases has not been included in our climate change mitigation strategy as they are deemed “medically necessary.” There are no proper quantitative studies to study emission and environmental hazards of such gases and also no policy limiting the discharge of many gases into the atmosphere. Such emission may have a significant impact on the environment in future and strategies need to be defined now so that the carbon footprint can be minimised.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 ¤ References Top

Chung JW, Meltzer DO. Estimate of the carbon footprint of the US health care sector. JAMA 2009;302:1970-2.  Back to cited text no. 1
Baldocchi D, Penuelas J. The physics and ecology of mining carbon dioxide from the atmosphere by ecosystems. Glob Chang Biol 2018;25:18-25.  Back to cited text no. 2
Watson JEM, Venter O. Ecology: A global plan for nature conservation. Nature 2017;550:48-9.  Back to cited text no. 3
Abrams JF, Hohn S, Rixen T, Baum A, Merico A. The impact of Indonesian peatland degradation on downstream marine ecosystems and the global carbon cycle. Glob Chang Biol 2016;22:325-37.  Back to cited text no. 4
Englehardt RK, Nowak BM, Seger MV, Duperier FD. Contamination resulting from aerosolized fluid during laparoscopic surgery. JSLS 2014;18:e2014.00361.  Back to cited text no. 5
Ryan SM, Nielsen CJ. Global warming potential of inhaled anesthetics: Application to clinical use. Anesth Analg 2010;111:92-8.  Back to cited text no. 6
Hendrickson CT, Lave LB, Matthews HS, Horvath A. Environmental Life Cycle Assessment of Goods and Services: An Input-Output Approach. Baltimore, MD, USA: Resources for the Future; 2006.  Back to cited text no. 7
Rumsfeld D. Known and Unknown: A Memoir. USA: Penguin; 2011.  Back to cited text no. 8
Power NE, Silberstein JL, Ghoneim TP, Guillonneau B, Touijer KA. Environmental impact of minimally invasive surgery in the United States: An estimate of the carbon dioxide footprint. J Endourol 2012;26:1639-44.  Back to cited text no. 9
Pichler PP, Jaccard IS, Weisz U, Weisz H. International comparison of health care carbon footprints. Environ Res Lett 2019;14:1-8.  Back to cited text no. 10
Malik A, Lenzen M, McAlister S, McGain F. The carbon footprint of Australian health care. Lancet Planet Health 2018;2:e27-35.  Back to cited text no. 11
Wu R. The carbon footprint of the Chinese health-care system: An environmentally extended input-output and structural path analysis study. Lancet Planet Health 2019;3:e413-9.  Back to cited text no. 12
Kwakye G, Brat GA, Makary MA. Green surgical practices for health care. Arch Surg 2011;146:131-6.  Back to cited text no. 13
Gilliam AD, Davidson B, Guest J. The carbon footprint of laparoscopic surgery: Should we offset? Surg Endosc 2008;22:573.  Back to cited text no. 14
Goldberg ME, Vekeman D, Torjman MC, Seltzer JL, Kynes T. Medical waste in the environment: Do anesthesia personnel have a role to play? J Clin Anesth 1996;8:475-9.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

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