Green Surgery: Current Evidence, Challenges, and Future Directions

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

I was pleased to review your manuscript: Green Surgery: Pragmatic Research in Environmentally. It approaches a very interesting topic which also connects with Sustainability, therefore interdisciplinary.

My comments are as follows:

1. The methodology section would benefit from a more transparent description of the literature identification and selection process. Although the authors describe a combined automated and manual search across multiple databases and provide a list of keywords, the manuscript does not report the number of records identified, screened, excluded, or finally included in the review. As a result, the reader cannot fully assess the breadth of the evidence base or the extent to which the final narrative reflects the available literature.
2. Given that the review is presented as a narrative review rather than a systematic review, a formal PRISMA approach is not necessarily required. Nevertheless, even for narrative reviews, a concise description of the search yield would substantially improve transparency and reproducibility. The authors may consider reporting the approximate number of retrieved records, the number of articles assessed in full text, and the number ultimately retained for narrative synthesis. This addition would help readers better understand the evidentiary foundation supporting the conclusions presented throughout the manuscript.  
3. The inclusion and exclusion criteria are generally appropriate; however, the rationale for restricting the review to English-language publications should be briefly acknowledged as a potential source of language bias. Considering the global nature of sustainability initiatives in surgery, important experiences from non-English healthcare systems may have been excluded. A short statement in the limitations section would be sufficient.  
4. Please clarify whether duplicate records identified across PubMed, Scopus, Ovid, and Cochrane were removed before screening.  
5. The manuscript states that two reviewers independently screened titles, abstracts, and full texts, with disagreements resolved by discussion. This approach is appropriate. However, the methodology would be strengthened by briefly indicating whether reviewer agreement was formally assessed (e.g., percentage agreement or kappa statistic) or whether the process remained entirely consensus-based.  
6. The review combines evidence originating from markedly different source types, including peer-reviewed original studies, narrative reviews, institutional reports, professional society documents, conference-related materials, and organizational webpages. While this broad approach is understandable in an emerging field such as environmentally sustainable surgery, the manuscript would benefit from a clearer explanation of how the authors evaluated the credibility and relevance of these heterogeneous sources.
7. Several key examples discussed in the Results and Clinical Feasibility sections appear to be derived from institutional reports, professional communications, or implementation case studies rather than conventional primary research. Consequently, readers may find it difficult to distinguish between evidence supported by formal empirical investigation and evidence describing local initiatives or organizational experiences. A brief methodological statement explaining how such sources were selected and incorporated into the narrative synthesis would improve the scientific rigor of the review and assist readers in interpreting the strength of the available evidence.  
8. No formal assessment of methodological quality or risk of bias is reported. While this is acceptable for a narrative review, the absence of a structured quality appraisal should be explicitly acknowledged as a limitation of the review methodology.  
9. Please indicate the exact date on which the literature search was completed, rather than stating only that the search extended to May 2025.  
10. The manuscript would benefit from a brief explanation of how the final thematic structure of the review was developed. Specifically, it is unclear whether the sections addressing historical context, clinical feasibility, and future recommendations emerged inductively from the literature or were predefined by the authors before evidence synthesis. Clarification would improve methodological transparency.  

I think implementation of all these will improve the quality of the manuscript and contribute to the global Knowledge.

My overall assessment is: Minor Revision.

 

Author Response

Answer to Reviewer’s 3 Comments and Recommendations:

Comment 1: The methodology section would benefit from a more transparent description of the literature identification and selection process. Although the authors describe a combined automated and manual search across multiple databases and provide a list of keywords, the manuscript does not report the number of records identified, screened, excluded, or finally included in the review. As a result, the reader cannot fully assess the breadth of the evidence base or the extent to which the final narrative reflects the available literature.

Answer 1: We thank the reviewer for this constructive comment. In response, we have expanded the Materials and Methods section to provide a clearer description of the literature search strategy, including the databases searched, search terms, independent screening process, inclusion and exclusion criteria, and the method used to resolve disagreements between reviewers. Because this manuscript was designed as a narrative review supported by a structured literature search rather than a formal systematic review, we did not constuct a PRISMA study-selection process or flow diagram. We have clarified this distinction within the revised manuscript and emphasized the methodological steps taken to ensure transparency and reproducibility.

Comment 2: Given that the review is presented as a narrative review rather than a systematic review, a formal PRISMA approach is not necessarily required. Nevertheless, even for narrative reviews, a concise description of the search yield would substantially improve transparency and reproducibility. The authors may consider reporting the approximate number of retrieved records, the number of articles assessed in full text, and the number ultimately retained for narrative synthesis. This addition would help readers better understand the evidentiary foundation supporting the conclusions presented throughout the manuscript. 

Answer 2: We thank the reviewer for this thoughtful suggestion. We agree that reporting the search yield may improve transparency in many review articles. However, the present manuscript was intentionally designed as a narrative review informed by a structured literature search rather than as a formal systematic review. Consequently, the literature search was performed to identify the most relevant and representative evidence on Green Surgery rather than to generate a comprehensive study inventory suitable for quantitative reporting. Because the search yield was not prospectively recorded, we considered it inappropriate to retrospectively estimate or approximate the number of retrieved and screened records. Instead, we have revised the Materials and Methods section to provide a more detailed description of the literature search strategy, databases searched, search terms, independent screening process, and predefined inclusion and exclusion criteria, thereby improving the transparency and reproducibility of our methodology while maintaining the narrative nature of the review.

Comment 3: The inclusion and exclusion criteria are generally appropriate; however, the rationale for restricting the review to English-language publications should be briefly acknowledged as a potential source of language bias. Considering the global nature of sustainability initiatives in surgery, important experiences from non-English healthcare systems may have been excluded. A short statement in the limitations section would be sufficient. 

Answer 3: We thank the reviewer for this helpful suggestion. We agree that restricting the review to English-language publications may represent a source of language bias, particularly given the international scope of sustainability initiatives in surgery. Accordingly, we have added a statement to the Conclusions acknowledging this limitation and noting that relevant experiences from non-English-speaking healthcare systems may not have been captured.

Comment 4: Please clarify whether duplicate records identified across PubMed, Scopus, Ovid, and Cochrane were removed before screening. 

Answer 4: We thank the reviewer for highlighting this point. We have clarified the methodology to explicitly state that duplicate records identified across the electronic databases (PubMed, Scopus, Ovid, and Cochrane Library) were removed prior to title and abstract screening.

Comment 5: The manuscript states that two reviewers independently screened titles, abstracts, and full texts, with disagreements resolved by discussion. This approach is appropriate. However, the methodology would be strengthened by briefly indicating whether reviewer agreement was formally assessed (e.g., percentage agreement or kappa statistic) or whether the process remained entirely consensus-based. 

Answer 5: We thank the reviewer for this helpful suggestion. We have clarified the methodology by stating that reviewer agreement was not formally quantified (e.g., by percentage agreement or Cohen's kappa statistic). Instead, disagreements were resolved through discussion and consensus between the two reviewers, which was considered appropriate for this structured narrative review.

Comment 6: The review combines evidence originating from markedly different source types, including peer-reviewed original studies, narrative reviews, institutional reports, professional society documents, conference-related materials, and organizational webpages. While this broad approach is understandable in an emerging field such as environmentally sustainable surgery, the manuscript would benefit from a clearer explanation of how the authors evaluated the credibility and relevance of these heterogeneous sources.

Answer 6: We thank the reviewer for this valuable observation. We agree that the heterogeneous nature of the available literature on environmentally sustainable surgery warrants clarification. Accordingly, we have expanded the Materials and Methods section to explain that priority was given to peer-reviewed literature whenever available, while non-peer-reviewed sources were included only when they originated from recognized healthcare organizations, professional societies, academic institutions, or governmental bodies and were considered directly relevant to the objectives of the review. We also clarify that institutional reports and professional guidance were used primarily to provide context and examples of current implementation initiatives, whereas the main conclusions were based predominantly on peer-reviewed evidence.

Comment 7: Several key examples discussed in the Results and Clinical Feasibility sections appear to be derived from institutional reports, professional communications, or implementation case studies rather than conventional primary research. Consequently, readers may find it difficult to distinguish between evidence supported by formal empirical investigation and evidence describing local initiatives or organizational experiences. A brief methodological statement explaining how such sources were selected and incorporated into the narrative synthesis would improve the scientific rigor of the review and assist readers in interpreting the strength of the available evidence. 

Answer 7: We thank the reviewer for this insightful comment. We agree that the heterogeneous nature of the available literature warrants clarification regarding the role of different evidence sources within the narrative synthesis. Accordingly, we have expanded the Materials and Methods section to explain that peer-reviewed original studies, Life Cycle Assessment analyses, and review articles formed the primary evidence base for evaluating the effectiveness of sustainable surgical interventions. Institutional reports, professional society documents, organizational publications, and implementation case studies were included only when they originated from recognized organizations and were used primarily to illustrate current implementation strategies and real-world examples of Green Surgery rather than as standalone evidence of effectiveness. We have also added an introductory statement to the Clinical Feasibility section to clarify that these examples are intended to provide contextual illustrations of current practice and should be interpreted alongside the available peer-reviewed evidence.

Comment 8: No formal assessment of methodological quality or risk of bias is reported. While this is acceptable for a narrative review, the absence of a structured quality appraisal should be explicitly acknowledged as a limitation of the review methodology.

Answer 8: We thank the reviewer for this constructive suggestion. We agree that, although a formal methodological quality assessment or risk-of-bias evaluation is not routinely required for narrative reviews, its absence should be acknowledged. Accordingly, we have revised the manuscript to state that no formal quality appraisal or risk-of-bias assessment was performed, consistent with the narrative design of the review, and we have included this as a methodological limitation in the Conclusions.

Comment 9: Please indicate the exact date on which the literature search was completed, rather than stating only that the search extended to May 2025.  

Answer 9: We thank the reviewer for this helpful suggestion. The manuscript has been revised to specify the exact date on which the literature search was completed. The Materials and Methods section now states that the structured literature search covered publications available up to and including 21 May 2025, thereby improving the transparency and reproducibility of the review methodology. The same clarification has also been incorporated into the Abstract for consistency.

Comment 10: The manuscript would benefit from a brief explanation of how the final thematic structure of the review was developed. Specifically, it is unclear whether the sections addressing historical context, clinical feasibility, and future recommendations emerged inductively from the literature or were predefined by the authors before evidence synthesis. Clarification would improve methodological transparency. 

Answer 10: We thank the reviewer for this thoughtful suggestion. To improve methodological transparency, we have expanded the Materials and Methods section to clarify the development of the review framework. Specifically, we now state that the overall thematic structure of the review was predefined by the authors according to the objectives of the manuscript, while the evidence identified through the structured literature search was narratively synthesized and incorporated into the section that most appropriately reflected its principal focus. This clarification better explains the organization of the review and the approach used for narrative evidence synthesis.

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript addresses a highly relevant and increasingly important topic in modern healthcare. The environmental impact of surgical practice is receiving growing attention worldwide, and the authors provide a broad overview of current green surgery initiatives and sustainability efforts. The paper is informative and covers several important aspects of sustainable surgical practice. However, there are a number of areas that require further development before the manuscript is suitable for publication.

1. I believe the title could be revised to better reflect the actual content of the manuscript. The current title emphasizes "pragmatic research," whereas the paper primarily presents an overview of current concepts, initiatives, and future directions in green surgery. A title such as "Green Surgery: Current Evidence, Challenges, and Future Directions"may better capture the scope of the review.
2. The manuscript is presented as a narrative review; however, the methodology section includes several elements that are typically associated with a systematic review, such as a systematic database search, independent screening by reviewers, and predefined inclusion and exclusion criteria. This creates some uncertainty regarding the intended study design. The authors should clarify whether this is a narrative review or a systematic review and ensure that the methodology is consistent with the chosen approach.

 

3. At present, the manuscript largely summarizes existing concepts and sustainability initiatives but provides limited critical appraisal of the available evidence. The review would be strengthened by addressing questions such as:

• Which sustainability interventions currently have the strongest supporting evidence?
• Which strategies produce the greatest reductions in carbon emissions?
• What are the main barriers to implementation?
• What trade-offs may exist between sustainability, cost, patient safety, and clinical effectiveness?

A more critical comparison of interventions, discussion of evidence quality, identification of knowledge gaps, and consideration of conflicting findings would considerably enhance the scientific value of the review.

4. A review focused on sustainability should include more quantitative evidence whenever possible. Examples may include carbon dioxide equivalent (CO₂e) reductions, waste reduction rates, energy savings, economic outcomes, and life-cycle assessment data.

Although the manuscript frequently states that various interventions reduce environmental impact, the magnitude of these benefits is often not reported. I would encourage the authors to include one or more summary tables presenting key quantitative findings from the literature.

5. The discussion of minimally invasive surgery is relatively brief. Given the growing use of robotic surgery and the ongoing debate regarding its environmental impact, this topic deserves further attention. Issues such as disposable instrument use, energy consumption, supply-chain requirements, and cost implications should be discussed in greater detail. A comparison between robotic and laparoscopic surgery from a sustainability perspective would be particularly valuable.

 

6. The successful adoption of sustainable practices is often closely linked to financial considerations. While the manuscript discusses environmental benefits, there is limited discussion of implementation costs, return on investment, budgetary constraints, and potential financial incentives. Adding a subsection focused on the economic aspects of sustainable surgery would strengthen the paper and improve its practical relevance.

 

 

7. Figures 1 and 2 are relevant to the topic, but the accompanying explanations are relatively brief. Additional interpretation and practical examples would help readers better understand how these frameworks can be applied in everyday surgical practice.
8. The manuscript would benefit from careful proofreading and language editing. For example, in the abstract, the abbreviation "OR" appears before it is defined. In addition, several concepts are repeated throughout the manuscript, including discussions of climate change, net-zero targets, operating room carbon footprints, and sustainability definitions.

There are also a number of grammatical and stylistic issues that should be addressed. For example, the phrase "This groundbreaking procedures" should be revised to "These groundbreaking procedures." A thorough English-language revision is recommended to improve readability and flow.

Overall Assessment

This manuscript addresses an important and rapidly evolving area of surgical practice. However, in its current form, it reads more as a descriptive overview than a critical review of the literature. Strengthening the methodology, incorporating more quantitative evidence, expanding the critical discussion, reducing repetition, and improving the overall presentation would significantly enhance the quality of the manuscript. With these revisions, the paper has the potential to make a useful contribution to the growing literature on sustainable surgery.

Author Response

Answer to Reviewer’s 2 Comments and Recommendations:

This manuscript addresses a highly relevant and increasingly important topic in modern healthcare. The environmental impact of surgical practice is receiving growing attention worldwide, and the authors provide a broad overview of current green surgery initiatives and sustainability efforts. The paper is informative and covers several important aspects of sustainable surgical practice. However, there are a number of areas that require further development before the manuscript is suitable for publication.

Comment 1: I believe the title could be revised to better reflect the actual content of the manuscript. The current title emphasizes "pragmatic research," whereas the paper primarily presents an overview of current concepts, initiatives, and future directions in green surgery. A title such as "Green Surgery: Current Evidence, Challenges, and Future Directions" may better capture the scope of the review.

Answer 1: According to your constructive proposal the title of the article has been altered and modified to “Green Surgery: Current Evidence, Challenges, and Future Directions” which better captures the scope of the review.

Comment 2: The manuscript is presented as a narrative review; however, the methodology section includes several elements that are typically associated with a systematic review, such as a systematic database search, independent screening by reviewers, and predefined inclusion and exclusion criteria. This creates some uncertainty regarding the intended study design. The authors should clarify whether this is a narrative review or a systematic review and ensure that the methodology is consistent with the chosen approach.

Answer 2: We have addressed this issue which is raised by the first reviewer as well in that this work is a narrative review with a systematic type of literature search. Despite the fact that our methodology does incorporate several elements commonly associated with a systematic reviews including a structured database search and predefined eligibility criteria due to limitations in available raw data in the literature a meta-analysis was not possible to perform. Consequently, the authors feel the article is not a systematic review without said meta-analysis and the methodology and evidence/literature presented are more consistent with a narrative one. We have explained this in our methodology section.

Comment 3: At present, the manuscript largely summarizes existing concepts and sustainability initiatives but provides limited critical appraisal of the available evidence. The review would be strengthened by addressing questions such as:

1. Which sustainability interventions currently have the strongest supporting evidence?
2. Which strategies produce the greatest reductions in carbon emissions?
3. What are the main barriers to implementation?
4. What trade-offs may exist between sustainability, cost, patient safety, and clinical effectiveness?
5. A more critical comparison of interventions, discussion of evidence quality, identification of knowledge gaps, and consideration of conflicting findings would considerably enhance the scientific value of the review.

Answer 3: We thank the reviewer for this comment. We have accordingly created a new section (section 6) titled “Critical Appraisal of Current Evidence and Remaining Challenges” where we provide a more critical comparison of interventions and discuss the quality of evidence, the strategies and the main barriers to implementation.

Comment 4: A review focused on sustainability should include more quantitative evidence whenever possible. Examples may include carbon dioxide equivalent (CO₂e) reductions, waste reduction rates, energy savings, economic outcomes, and life-cycle assessment data. Although the manuscript frequently states that various interventions reduce environmental impact, the magnitude of these benefits is often not reported. I would encourage the authors to include one or more summary tables presenting key quantitative findings from the literature.

Answer 4: We sincerely thank the reviewer for this valuable suggestion. We fully agree that presenting quantitative evidence substantially strengthens the scientific value of the review and facilitates comparison between different sustainability interventions.

To address this comment, we have added two new summary tables to the revised manuscript as suggested. In addition, we expanded the discussion to emphasize that direct comparison of quantitative outcomes should be interpreted cautiously because published studies differ considerably in their life-cycle assessment methodology, functional units, healthcare settings, electricity mixes, and system boundaries. We believe these additions provide the quantitative synthesis requested by the reviewer while simultaneously offering a more critical appraisal of the current evidence base.

Comment 5: The discussion of minimally invasive surgery is relatively brief. Given the growing use of robotic surgery and the ongoing debate regarding its environmental impact, this topic deserves further attention. Issues such as disposable instrument use, energy consumption, supply-chain requirements, and cost implications should be discussed in greater detail. A comparison between robotic and laparoscopic surgery from a sustainability perspective would be particularly valuable.

Answer 5: We thank the reviewer for this important and constructive comment. We agree that the increasing use of robotic-assisted surgery warrants a more detailed and balanced discussion from a sustainability perspective.

In response, we have substantially expanded the manuscript by adding a dedicated subsection entitled “Robotic versus laparoscopic surgery: balancing innovation with sustainability.” The revised text now discusses the principal environmental determinants of robotic surgery, including higher operating-room energy requirements, greater reliance on disposable and limited-use instruments, more complex supply-chain and maintenance requirements, sterilization demands, and substantially higher capital and procedural costs. We also acknowledge that robotic surgery may offer important clinical advantages in selected procedures, such as improved dexterity, visualization, precision, and potentially reduced conversion or complication rates, and that these benefits should be weighed against the additional environmental burden.

We have also added Table 3, “Comparative assessment of laparoscopic and robotic surgery across key sustainability domains,” which directly compares the two approaches with respect to energy consumption, disposable instrument use, availability of reusable devices, procurement-related emissions, carbon footprint, waste generation, supply-chain complexity, equipment maintenance, upfront cost, clinical advantages, and overall sustainability.

The discussion has been supported with additional references on environmental sustainability in robotic and laparoscopic surgery, together with relevant life-cycle assessment and surgical sustainability literature. We have also revised the surrounding text to emphasize that robotic surgery should not be regarded as uniformly environmentally unfavourable; rather, its sustainability should be assessed on a procedure-specific basis, integrating environmental outcomes with clinical effectiveness, patient safety, and healthcare value.

We believe these additions provide a more comprehensive and evidence-based appraisal of minimally invasive surgery and directly address the reviewer’s recommendation.

Comment 6: The successful adoption of sustainable practices is often closely linked to financial considerations. While the manuscript discusses environmental benefits, there is limited discussion of implementation costs, return on investment, budgetary constraints, and potential financial incentives. Adding a subsection focused on the economic aspects of sustainable surgery would strengthen the paper and improve its practical relevance.

Answer 6: We thank the Reviewer for this valuable suggestion. In response, we have substantially expanded the manuscript by adding a new standalone section entitled "Economic Considerations and Cost-Effectiveness of Green Surgery". This section discusses the economic feasibility of implementing sustainable surgical practices, including upfront implementation costs, budgetary constraints, life-cycle financial considerations, long-term cost savings associated with reusable devices, low-flow anaesthesia, and improved waste management, as well as the current limitations of economic evidence in this field. The discussion is supported by the literature as cited in the manuscript. In addition, Table 2 also includes an "Economic implications" column, providing a comparative overview of the financial aspects of the principal sustainability interventions. These additions strengthen the practical relevance of the review by emphasizing that successful implementation of Green Surgery requires consideration of both environmental and economic sustainability.

Comment 7: Figures 1 and 2 are relevant to the topic, but the accompanying explanations are relatively brief. Additional interpretation and practical examples would help readers better understand how these frameworks can be applied in everyday surgical practice.

Answer 7: We thank the reviewer for this helpful suggestion. In response, we have expanded the accompanying text in the manuscript to provide additional interpretation of both frameworks. Specifically, we included brief practical examples illustrating how the 10R Model of Circular Economy can guide everyday operating-room sustainability initiatives and how Life Cycle Assessment (LCA) can be applied to compare surgical products and techniques, thereby supporting evidence-based procurement and quality improvement. We believe these additions improve the practical relevance and clarity of both figures.

Comment 8: The manuscript would benefit from careful proofreading and language editing. For example, in the abstract, the abbreviation "OR" appears before it is defined. In addition, several concepts are repeated throughout the manuscript, including discussions of climate change, net-zero targets, operating room carbon footprints, and sustainability definitions.

Answer 8: We thank the reviewer for this valuable observation. The manuscript has undergone careful proofreading and language editing to improve clarity, readability, and consistency. We verified that all abbreviations, are defined at their first appearance in the text. In addition, we reviewed the manuscript to reduce unnecessary repetition of concepts related to climate change, net-zero targets, operating-room carbon footprints, and sustainability definitions, while preserving sufficient background information appropriate for a narrative review. These revisions have improved the overall flow and readability of the manuscript.

 

Reviewer 3 Report

Comments and Suggestions for Authors

Materials & Methods: The methodological positioning of the review would benefit from clarification. While the manuscript is presented as a narrative review, the methods incorporate several elements commonly associated with systematic review methodology (e.g., structured database searching, predefined eligibility criteria, and independent screening). Clarifying whether this represents a narrative review informed by a structured literature search or another review design would improve methodological transparency.

Line 186: The title "Clinical Feasibility of Sustainable Surgery" may slightly overstate the level of evidence presented, as the section primarily describes implementation examples from selected institutions rather than demonstrating feasibility across healthcare systems more broadly. Consider a title that more closely reflects the descriptive nature of the content.

Author Response

Answer to Reviewer’s 1 Comments and Recommendations:

Comment 1: Materials & Methods: The methodological positioning of the review would benefit from clarification. While the manuscript is presented as a narrative review, the methods incorporate several elements commonly associated with systematic review methodology (e.g., structured database searching, predefined eligibility criteria, and independent screening). Clarifying whether this represents a narrative review informed by a structured literature search or another review design would improve methodological transparency.

Answer 1: Regarding your first comment above we would like to ascertain that the manuscript is a narrative review performed by a structured literature search, despite the fact that our methodology incorporates several elements commonly associated with systematic reviews including structured database searching and predefined eligibility criteria. This is because due to limitations in available raw data in the literature a meta-analysis was not possible and thus not performed. Consequently, the authors feel the article is not a systematic review and its methodology and evidence presented are more consistent with a narrative one.

Comment 2. Line 186: The title "Clinical Feasibility of Sustainable Surgery" may slightly overstate the level of evidence presented, as the section primarily describes implementation examples from selected institutions rather than demonstrating feasibility across healthcare systems more broadly. Consider a title that more closely reflects the descriptive nature of the content.

Answer 2: In accordance with your recommendation, in line 186, the title "Clinical Feasibility of Sustainable Surgery" has been replaced by this one "Practical Feasibility of Sustainable Surgery"