Royal College of Surgeons of England celebrates research initiatives

We read with interest the recent publication from Spinelli and La Raja exploring simulation and virtual reality in robotically assisted surgery (RAS) training1. Adoption of RAS is likely to continue as technologies advance, more platforms become available and further patient benefits are established. Developing RAS training programmes is a priority to standardise learning and assessment.

Spinelli and La Raja focus on technical aspects of simulation and immersive-based training. In doing so, an opportunity was missed to address the non-technical skills that are predictive of surgical outcomes2. In RAS, the surgeon spends the majority of time away from the operating table, necessitating excellent communication skills to coordinate with the surgical team. High performing teams overcome similar challenges by emphasising closed-loop communication3. Other non-technical skills, including situation awareness and leadership, are fundamentally altered by the Human Factors and design of RAS, necessitating specific strategies for safe performance4.

We appreciate the thoughtful commentary by Dick et al. on our publication regarding the importance of integrating non-technical skills in robotically assisted surgery (RAS) training.

While our publication focused primarily on the technical aspects of simulation and immersive reality (IR)-based training, we fully support the inclusion of non-technical skills in RAS training curricula. The emphasis on the importance of non-technical skills, such as communication, environmental awareness, anticipation and teamwork is indeed critical and complements the technical aspects we focused on in our paper1. Unfortunately, assessment and reporting on non-technical skills is still scarce1. The combination of technical proficiency and consiousness of non-technical skills will undoubtedly produce more well-rounded surgeons and safer outcomes for patients.

This cutting-edge paper by Ang et al.1 addresses the carbon footprint of surgery for non-melanoma skin cancer (NMSC) surgery at the Welsh Centre for Burns and Plastic Surgery in Swansea, UK. They demonstrated a high carbon footprint from surgery for NSMC, the most common cancer in the UK. Addressing the impact of healthcare facilities on climate change is a key global priority2. An estimated 4-6% of global carbon emissions comes from healthcare3. Within this, surgery is the largest contributor; operating theatres generate 50-70% more waste and use up to 6 times as much energy as other hospital departments4. Reducing healthcare carbon emissions is a priority of the NHS with new initiatives such as the “Greener Operations: Sustainable Perioperative Practice Priority Setting Partnership”5. This article expands on how surgical departments can help decarbonise healthcare.

Measuring the carbon footprint is a fundamental first step. The authors have performed a lifecycle study to assess the carbon footprint of NMSC surgery, estimating average emissions of 29.76 - 34.26kgCO2eq per operation. As NMSC is the most common cancer in the UK, the net carbon emissions from this disease is significant, and this paper forecasts a 25% increase by 2035. Furthermore, this study highlights the difficulties of decarbonising surgery. Operating theatres are energy intensive, using ventilators, medical devices such as diathermy, lights and control of air flow and temperature4. Due to the sterility requirements, there is a high use of single-use surgical consumables. Production, transport and waste disposal of these mostly plastic items contributes to carbon emissions. In comparing direct skin closure to the more complex full-thickness skin graft, the authors have shown how more technical and longer procedures generate higher carbon emissions.

Other studies have also demonstrated high carbon emissions from surgical supplies6,7. Changing to reusable surgical equipment may reduce carbon footprint by 50-97%8. However, further research is needed to fully explore carbon footprint of reusable versus single use surgical items, such as surgical drapes. Carbon models are needed that capture complete healthcare pathways, including the carbon cost of operative complications. The role that hospital energy supply contributes to carbon emissions varies, depending on the source of electricity7-9. Hospitals can reduce their carbon emissions by transitioning to renewable energy, such as solar power. Further carbon foot-printing research is needed, conducted through similarly reproducible life cycle methodology. Carbon foot-printing should be expanded to cover the full pathway including patient transportation, staff commuting, and perioperative care which all add to healthcare-related emissions.