Green surgery: a systematic review of the environmental impact of laparotomy, laparoscopy, and robotics

Surgery is the most energy-intensive healthcare sector, but data on the environmental impact of abdominal surgical techniques are limited. This systematic review aims to identify the most sustainable approach among open, laparoscopic, and robotic surgeries. We searched MEDLINE, Cochrane, and Web of Science databases (inception to March 2024) for studies on the carbon footprint of abdominal surgery, focusing on carbon dioxide equivalents (CO_2e) or CO₂ emissions. The Joanna Briggs Institute checklist was used to assess bias. (PROSPERO: 298486). Of 2155 records, eight cohort studies were included, showing low to moderate risk of bias but high heterogeneity. Two studies on hysterectomy found robotic surgery had the highest carbon footprint (12.0-40.3 kgCO_2e) compared to laparoscopic (10.7-29.2 kgCO_2e) and open surgery (7.1-22.7 kgCO_2e). Another study found laparoscopic prostatectomy produced more emissions than robotic surgery (59.7 vs. 47.3 kgCO_2e) due to higher disposable devices, surgery time and length of stay. Single-use devices in laparoscopic cholecystectomy emitted more CO_2e than hybrid devices (7.194 vs. 1.756 kgCO_2e). CO₂ used in minimally invasive surgery had negligible environmental effects (0.9 kgCO_2e). Qualitative subgroup analyses revealed significant differences between surgery types and measurement methodologies, contributing to data heterogeneity. Minimally invasive surgeries often have higher carbon footprints due to disposable tools and waste. However, one study showed robotic surgery may reduce the overall environmental impact by shortening hospital stays. Due to methodological heterogeneity across studies, definitive conclusions remain limited. Standardized life-cycle assessment methodologies and inclusion of clinical outcomes in future studies are urgently needed to clarify the environmental sustainability of surgical practices.