Greening the Operating Room: A Narrative Review of Global Frameworks for Sustainable Surgical Practice

Climate change is a major global health threat, and healthcare contributes 4-5% of global greenhouse gas emissions. Operating rooms (ORs) are particularly resource-intensive, producing high levels of waste and emissions. Sustainable surgical practices are essential to reduce the environmental impact of healthcare. This review aims to summarise and compare key international initiatives that promote sustainability in the OR.

A narrative review was conducted between January and March 2025. Resources were identified through searches of PubMed, Google Scholar, and professional society websites. Inclusion criteria included publication or endorsement by recognised academic or professional bodies, availability in English, and provision of practical guidance on surgical sustainability. No formal quality assessment was performed due to the heterogeneity of sources.

Four major frameworks were identified: the Intercollegiate Green Theatre Checklist, which offers actionable perioperative recommendations including reusable equipment, waste reduction, and energy savings; the European Association for Endoscopic Surgery (EAES)/the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Taskforce, which focuses on leadership, education, and international collaboration; the Harvard Climate in Obstetrics, Anaesthesia and Surgery Team (COAST) Group, which promotes equity-focused, low-cost, and scalable solutions suitable for varied healthcare settings; the World Federation of Societies of Anaesthesiologists (WFSA) Global Consensus, which outlines sustainable anaesthetic practices and education. These frameworks align with the "5R" model-Reduce, Reuse, Recycle, Rethink, and Research-and highlight the OR as a key area for intervention.

Despite implementation barriers, these frameworks provide practical, scalable strategies for surgical teams to reduce emissions. Embedding sustainability in surgical practice is critical for achieving healthcare decarbonisation and improving planetary health.