Objective:
To systematically evaluate interventions designed to improve the sustainability of surgical practice with respect to their environmental and financial impact.

Background:
Surgery contributes significantly to emissions attributed to healthcare due to its high resource and energy use. Several interventions across the operative pathway have, therefore, been trialed to minimize this impact. Few comparisons of the environmental and financial effects of these interventions exist.

Materials and Methods:
A search of studies published up to 2nd February 2022 describing interventions to increase surgical sustainability was undertaken. Articles regarding the environmental impact of only anesthetic agents were excluded. Data regarding environmental and financial outcomes were extracted with a quality assessment completed dependent upon study design.

Results:
1162 articles were retrieved, of which 21 studies met inclusion criteria. 25 interventions were described, which were categorized into 5 domains: ‘reduce and rationalize’, ‘reusable equipment and textiles’, ‘recycling and waste segregation’, ‘anesthetic alternatives’ and ‘other’. 11/21 studies examined reusable devices; those demonstrating a benefit, reported 40-66% lower emissions than with single-use alternatives. In studies not showing a lower carbon footprint, reduction in manufacturing emissions were offset by the high environmental impact of local fossil-fuel based energy required for sterilization. The per use monetary cost of reusable equipment was 47-83% of the single-use equivalent.

Conclusions:
A narrow repertoire of interventions to improve the environmental sustainability of surgery has been trialed. The majority focus upon reusable equipment. Emissions and cost data is limited, with longitudinal impacts rarely investigated. Real-world appraisals will facilitate implementation, as will an understanding of how sustainability impacts surgical decision-making.