Enablers and barriers for using reusable trocars: a qualitative study of surgeons' and residents' perspectives

Operating rooms (ORs) are among the most carbon-intensive areas of healthcare, with minimally invasive surgery (MIS) heavily reliant on disposable instruments. Trocars-essential for MIS and available in disposable and reusable forms-are major contributors to surgical emissions. Yet adoption of reusables remains limited. Effective measures to increase the use of reusables requires understanding the behavioral determinants of instrument choice. This study aimed to identify enablers and barriers to reusable trocar usage.

We conducted a qualitative interview study guided by the Theoretical Domains Framework (TDF). Between September 2024 and May 2025, 20 surgeons and residents from seven Dutch hospitals participated in semi-structured interviews. Data were analyzed using a combination of deductive TDF coding, inductive coding and grouping into themes.

We identified 36 enablers and barriers grouped into nine themes: usability, workflow integration, training and skills, institutional systems, decision-making and ownership, culture and norms, safety, and perspectives on environmental and economic benefits. Most mapped to the TDF domains Beliefs about Consequences, Environmental Context and Resources, Skills, and Social/Professional Role and Identity. Usability concerns were manageable through surgical technique adaptations or design refinements. Workflow barriers diminished when reusables were integrated into trays and supported by clear sterilization protocols. Limited exposure during training reduced confidence, while demonstrations and senior role-modelling may facilitate uptake. Routine opening of disposables reinforced default single-use practices. Participants emphasized the need for environmental and economic data and noted the influence of procurement and management systems on the adoption.

Many perceived enablers and barriers appear to stem more from environmental and contextual factors than from the devices themselves. Mapping our findings to the TDF highlights the domains that can guide implementation strategies. Coordinated, multi-level efforts may enable reusable trocars to become a practical and scalable intervention to reduce surgical emissions.