Gyno Procedures Can Be Less Wasteful: Why Aren’t They?
With an increased focus on how climate change affects global health, gynecologists are examining ways they can play a positive role in reducing the field’s carbon footprint while balancing patient outcomes and clinician preference in tools.
Healthcare systems generate more than 4% of the global emissions of carbon dioxide — twice that of the aviation industry. From the tools used during a wellness exam to the type of anesthesia during surgery, gynecology is not exactly a green specialty.
“Our industry gets almost no scrutiny in the name of patient safety, infection control, convenience, and cost-effectiveness, but the evidence really shows that the things leading to our large carbon footprint really aren’t making patients safer,” said Kelly Wright, MD, director of the Division of Minimally Invasive Gynecologic Surgery at Cedars-Sinai Medical Center in Los Angeles, California.
In a new narrative review, Wright and her colleagues outlined the ways climate change, air pollution, and microplastics harm women’s health — and the ways gynecology contributes to the problem with preferences for disposable tools and procedure methods that add to waste.
Reducing Waste
Wright’s group found operating rooms are one of the biggest sources of waste in gynecology, generating vast amounts of disposable plastics, in the form of bottles, basins, wrappers, gowns, and drapes.
Stainless steel speculums, which can be sanitized and reused, have a much smaller environmental footprint than versions made of disposable acrylic, even after accounting for chemicals used to reprocess the instruments. But many physicians prefer using disposable versions, according to Noedahn Copley-Woods, MD, an assistant professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences and assistant dean of healthcare sustainability at the University of Pittsburgh Medical Center, Pennsylvania.
“When there are reusable instruments, they are usually inferior to disposable,” Copley-Woods said. “We need to put pressure on our surgical supply companies to provide comparable reusable instruments as an option.”
Disposable models often include LED lights and are transparent, which some providers feel enhances visibility during procedures and examinations.
“But that light is used once for 30 seconds and then thrown away for an eternity,” Alexandra I. Melnyk, MD, MeD, a urogynecologist at the Cleveland Clinic in Ohio, told Medscape Medical News.
Are Outcomes Worth the Waste?
Hysterectomy, the second-most common surgery for women in the United States, is performed nearly 500,000 times each year.
Each type of hysterectomy creates varying levels of waste. Among the four methods — abdominal, vaginal, laparoscopic, and robotic — the latter two contribute the most waste. A 2014 report found robotic-assisted hysterectomies, for instance, produced 30% more waste than the other procedures.
But robotic-assisted operations have become increasingly common in most surgical specialties, including gynecology and hysterectomies. Many healthcare systems also tout the benefits of this technology.
Some clinicians say robotic surgery could lead to better patient outcomes, according to Emma Rossi, MD, a gynecologic oncologist at Duke University Medical Center in Durham, North Carolina. According to Rossi, robotic surgery eliminates the need for large incisions and allows patients to spend less time recovering in the hospital.
However, whether robotic surgery facilitates better outcomes is a hotly debated topic among obstetricians and gynecologists, according to Copley-Woods.
A 2022 review found the method of hysterectomy that is the best for patient outcomes likely differs based on the purpose of the procedure.
A review of 25 studies in 2021 looked at patient outcomes after robotic and conventional laparoscopic hysterectomy. The researchers concluded the two procedures did not have significant differences in operating time, complications, or survival.
Robotic surgery also entails the use of robotic arms, which are disposable and are replaced after a few procedures, creating more waste than traditional laparoscopic surgery.
Small Steps Toward Progress
Some moves toward sustainability will require top-level change from hospital administrators. Healthcare systems can stop using anesthesia like desflurane, the most potent greenhouse gas of the currently available anesthetic gasses. Intravenous anesthesia has a smaller overall carbon footprint. The University of Pittsburgh Medical Center, where Copley-Woods works, is phasing out desflurane by the end of 2023.
Other interventions can come from clinicians, like moving toward performing procedures in the office rather than an operating room.
Outpatient procedures have a smaller environmental footprint than those done in the operating room. For instance, dilation and curettages can often safely be performed in the office without compromising patient care and patients often view this setting as more convenient, Copley-Woods said.
Another way to reduce waste without sacrificing patient outcomes is reducing the amount of open materials used during surgery, she added. Operating rooms are a major source of waste in a hospital.
Studies have shown that depending on the field, as many as 13% of tools opened as part of a pull sheet are never used. Copley-Woods said surgeons, including those performing gynecologic procedures, should review their pull sheet annually and remove materials they know they don’t use.
Simply communicating the issue to hospital staff is often the first step toward change.
“Sometimes we need to just be shown the numbers associated with each of those instruments so we can make the decision: Can I create less waste by not using something that isn’t needed?” Rossi said.
Kaitlin Sullivan is a freelance journalist.
