Background
Surgical practices generate the largest share of hospital waste and significantly contribute to NHS carbon emissions, highlighting the need for sustainable interventions. Lean management, which optimises efficiency and reduces waste, offers a pathway to address these concerns. However, its application in surgical settings remains fragmented and under-researched. This review explores how Lean methodologies can improve environmental outcomes in surgery and identifies systemic barriers to their implementation.

Methods
A scoping review of five databases (MEDLINE, EMBASE, SCOPUS, EBSCO, and Cochrane) and grey literature, following PRISMA-P protocols, yielded 24 academic and 13 grey literature sources from 5,011 search results. Quality assessment was performed using validated tools, and thematic analysis was applied to synthesise data and identify key challenges and opportunities.

Results
The review found limited evidence quantifying environmental benefits of Lean practices, including waste reduction, lower carbon emissions, and decreased energy consumption. 11 articles demonstrated quantifiable environmental outcomes, primarily in hand surgery and anaesthesia. Potential environmental benefits included waste reduction, nitrous oxide cylinder turnover minimisation, decreased carbon footprint, and reduction in anaesthetic use. Overall, four primary barriers were identified: lack of responsibility ownership, overly hierarchical organisational structures, collaboration challenges, and limited education and awareness.

Conclusion
As healthcare systems progress toward Net Zero targets, Lean management offers potential for simultaneous environmental and operational improvements. However, their successful application is hindered by significant barriers. Targeted educational initiatives, interdepartmental collaboration with aligned sustainable goals, and strategic support are crucial for successfully embedding environmental sustainability within surgery.