Circularity in the operating theatre
The veterinary operating theater offers numerous opportunities to improve sustainability and to develop a circular approach for using consumables.
Key points
The operating theater has a high environmental impact, generating a large proportion of a practice’s carbon footprint related to consumables and medical equipment.
Embracing the circular economy model can reduce the environmental impact, alongside affording operational resilience and reduced financial cost.
Reuse of equipment or materials in the operating theater depends upon rigorous decontamination protocols, effective sterilization and thorough regular monitoring.
Ongoing monitoring of surgical site infections is essential, and any change made for sustainability must ensure ongoing optimal quality of care.
Introduction
Healthcare has a significant environmental impact, due to its high consumable use, energy consumption and use of anesthetic gases. The operating theater is a carbon footprint hotspot, and there is increasing recognition amongst surgical teams of this, and the potential role of the team in creating change. Alongside this awareness is a desire for better understanding about adaptations that can be made whilst maintaining optimal patient care. Basically, the principles of circularity should be applied wherever possible within the operating theater to reduce the environmental impact, save resources and create a blueprint for sustainable surgical care into the future.
Circularity is an economic model that aims to reduce waste and extend the life of products. It is based on the idea of reusing, repairing and recycling materials. Circularity is the foundation of the circular economy: a system whereby materials are kept in circulation. Within such an economy, waste is recognized as a valuable resource. Sustainable healthcare requires that medical waste infrastructures are designed to capture waste streams that are recyclable. Currently, a large proportion of potentially recyclable waste is lost due to lack of appropriate segregation or lack of local or regional infrastructure to achieve this. Inadequate waste segregation has a significant environmental and financial cost.
As we strive for optimal quality of care, and emulate standards in the human operating theater, it is important that the veterinary sector recognizes that single-use is no longer synonymous with the highest quality of care.
Surgical asepsis, infection control and reuse
The success of modern surgery is dependent upon asepsis, achieved predominantly by handwashing, sterilization, the use of sterile surgical gloves and an aseptic surgical field, alongside the appropriate use of perioperative antibiotics. With the advent of modern plastics in the 1980s, medical technology has been revolutionized, providing new standards of care that were not previously possible: for example, polymer materials allowing safe sterile intravenous catheterization. Without doubt, the nature of an intravenous catheter requires that it is single-use; however, contemporaneously, a transformative shift to single-use items has occurred throughout medicine and surgery, replacing previously reusable items such as surgical drapes and gowns.
Single-use disposable surgical textiles have been marketed as the gold standard in recent decades, but a review of the evidence does not demonstrate improved performance or a lower incidence of surgical site infection (1,2). In fact, when modern surgical gowns and drapes are compared with their single-use alternatives, their performance and user comfort has been demonstrated to be superior (3). Reusable surgical textiles obviously must be appropriately laundered and resterilized for repeated use, and this uses water, energy and time. It has often been suggested that once the carbon footprint of reprocessing is taken into account for reusable surgical textiles, the environmental impact would be equivalent to single-use. This is not true, as demonstrated by a comprehensive life cycle analysis, comparing the environmental impact of single-use versus reusable surgical gowns with regards to energy consumption, water use, global warming potential and generation of waste (Figure 1) (4).
Whilst single-use surgical textiles have been widely adopted in higher socioeconomic countries in human healthcare, reusable textiles have continued to be used in less affluent countries. This has been mirrored in the veterinary sector. Additionally, referral veterinary hospitals have more broadly adopted single-use textiles, but a combination of re-usable and single-use are typically used in primary care practices. Colleagues have generally aspired to switch to single-use surgical textiles in the veterinary sector, due to a perception that this reflects gold standard care. However, increasingly within human healthcare, a switch has been made to high quality modern reusables surgical textiles, affording a huge reduction in both the carbon footprint and the financial costs (5) – for example, some hospitals have switched to reusable textiles for orthopedic surgery, including joint replacements.
It is, however, essential that a thorough reprocessing facility is available to guarantee optimal laundering and resterilization of these textiles; they must also be monitored for their number of uses, and routinely checked for signs of wear and tear. Once a reusable gown has reached the limit of its lifespan, the material can then be recycled. As we strive for optimal quality of care, and emulate standards in the human operating theater, it is important that the veterinary sector recognizes that single-use is no longer synonymous with the highest quality of care.
Reusable alternatives in the operating theater
There are several other areas where circularity has been embraced in the operating theater. Cloth scrub caps (Figure 2) have been demonstrated to have superior performance to single-use caps when comparing particle count and microbial contamination of the operating theater (6). Reusable sharps bins (Figure 3) are collected once full, with their contents then incinerated, and are cleaned and reused; this circular model saves money and also reduces the carbon footprint of sharps disposal by over 30% (7). Reusable sterilization tins for surgical instruments (Figure 4), in place of layers of blue surgical wrap, are another very effective solution to reduce waste, with many remaining in use for decades after purchase.
Reuse depends upon rigorous processes of decontamination and resterilization, predominantly currently via autoclave, but alternative methods are necessary for heat and moisture-sensitive instruments. Hydrogen peroxide gas plasma sterilization is now available, and is far preferable to ethylene oxide (EO) sterilization (EO is both mutagenic and carcinogenic), due to lack of toxic residues and personnel and environment safety.
Waste segregation and recycling
Optimal waste segregation will ensure that waste is appropriately managed according to local regulations, and also that items that may be reused or recycled are collected (Figure 5). Without appropriate knowledge and adherence to correct segregation, waste may be over or under treated. It is more common that waste has been over-treated in recent years; overtreatment (i.e., high temperature incineration for waste materials that could have been treated in an alternative way, or possibly even recycled) has a higher financial and environmental cost, and should be avoided. There are some novel options for re-use or recycling in the operating theater.
Aluminum segregation
Individual suture packets are commonly made of aluminum. This metal can be infinitely recycled without losing quality; recycling saves 95% of the energy needed to produce new aluminum from raw materials, lowering the carbon footprint. Recycling also minimizes landfill waste and prevents habitat destruction from mining. Some clinics may opt to collect aluminum suture packets separately; where these packets are processing within the dry mixed recycling waste stream, it is advised to bunch up the packets and roll them into a ball (Figure 6) because individual packets may slip though at the waste processing facility, whilst a larger bunch will not.
Recently, AI scanning technology has been introduced into some waste processing facilities, allowing identification of materials, assessment of their value, detection of lost resources, and optimization of recycling efficiency for sustainable waste management. It is valuable to engage with your waste service provider to discuss the best option for waste management from an environmental sustainability perspective and according to local regulations.
Pet hair as a resource
Clean pet hair, collected at groomers and veterinary practices (Figure 7), has a novel application as an innovative material used in the creation of mats designed to manage oil spills. Due to its natural absorbent qualities, pet hair can soak up large quantities of oil from water. The hair is processed into mats that can be deployed to absorb oil and other hydrocarbons from spilled environments, reducing the impact on wildlife and ecosystems. This eco-friendly solution not only repurposes pet hair that would otherwise go to waste, but also provides an efficient, low-cost alternative to traditional oil-spill containment methods.
Anesthetic gas recapture
Volatile anesthetic agents – including halogenated hydrocarbons: isoflurane, sevoflurane and desflurane – in addition to nitrous oxide, are potent greenhouse gases, and our veterinary patients frequently require extended anesthesia. The inhalant anesthetic agents have been traditionally exhausted from the anesthetic circuit into the atmosphere, or to an adsorbent canister, later to be discharged into the atmosphere when they are incinerated. The use of lower flow anesthesia protocols has been recommended to reduce overall inhalant agent usage and therefore reduced environmental impact. Anesthetic gas recapture technology now exists, utilizing a specialized canister (Figure 8) that sits in place of traditional scavenging systems; this allows agents such as isoflurane to be recaptured, preventing release into the atmosphere. Once the canister is full, it is purified and reprocessed by the manufacturer into a product that can then be reused; this option currently in use for human healthcare and is now available to the veterinary market too.
Conclusion
Circularity in the operating theater must be embraced to allow outstanding veterinary care to be delivered into the future. The concept must be introduced whenever new systems, practices or hospitals are designed, as well as being promoted within education and continued professional development, and during product and protocol design. This reduces the environmental impact of medical care, but also affords financial savings and improved operational resilience. Alongside any change introduced for environmental sustainability, there must be ongoing monitoring for surgical site infections. Current literature indicates no difference in the incidence of surgical site infection with reusable surgical textiles versus single use, but further monitoring and documentation is essential to maintain optimal quality and expand the evidence base for supporting changes for a sustainable future.
References
- Global Guidelines for the Prevention of Surgical Site Infection. Geneva: World Health Organization 2018. Web Appendix 17, Summary of a systematic review on drapes and gowns. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536409/ Accessed 31st March 2025.
- Vasanthakumar M. Reducing veterinary waste: surgical site infection risk and the ecological impact of woven and disposable drapes. Vet. Evid. 2019;4(3). https://doi.org/10.18849/ve.v4i3.251
- McQuerry M, Easter E, Cao A. Disposable versus reusable medical gowns: A performance comparison. Am. J. Infect. Control. 2021;49(5):563-570. Doi: 10.1016/j.ajic.2020.10.013. Epub 2020 Oct 20. PMID: 33091509; PMCID: PMC7572274.
- Vozolla E, Overcash M, Griffing E. An environmental analysis of reusable and disposable surgical gowns. AORN J. 2020;111(3):315-325. Doi: 10.1002/aorn.12885.
- Bhutta M, Rizan C. The Green Surgery report: a guide to reducing the environmental impact of surgical care, but will it be implemented? Annals R. C. Surg. Eng. 2024;106. 10.1308/rcsann.2024.0005
- Markel TA, Gormley T, Greeley D, et al. Hats Off: A study of different operating room headgear assessed by environmental quality indicators. J. Am. Coll. Surg. 2017;225(5):573-581. Doi: 10.1016/j.jamcollsurg.2017.08.014. PMID: 29106842
Zoë Halfacree
MA, VetMB, MSc, Cert. VDI, Cert. SAS, FHEA, Dip. ECVS, FRCVS Davies Veterinary Specialists, Hitchin, UK
Dr. Halfacree graduated from Cambridge University in 2001 and spent two years in small animal practice before moving to the Queen Mother Hospital for Animals at the Royal Veterinary College, where she completed a general small animal internship. She subsequently served as senior lecturer and head of soft tissue surgery at the College before moving to a private referral center near London in 2020. Her passion for environmental sustainability and education led her to undertake further studies at the Cambridge Institute of Sustainable Leadership, and she holds a Masters in Sustainability and Behaviour Change from the Centre for Alternative Technology in Wales. She is currently also a director of Vet Sustain, a not-for-profit organization that champions sustainability in the veterinary profession.
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