Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Endoscopic, endonasal decompression of spinal stenosis with myelopathy secondary to cranio-vertebral tuberculosis: Two cases

Background: Tuberculosis can cause extensive osseo-ligamentous destruction at the cranio-vertebral junction, leading to atlanto-axial instability and compression of vital cervico-medullary centres. This may manifest as quadriparesis, bulbar dysfunction and respiratory insufficiency. Aim: We report two patients presenting with spinal stenosis and cord compression secondary to cranio-vertebral tuberculosis, who were successfully decompressed via an endoscopic, endonasal approach. Study design: Two case reports. Methods and results: Both patients were successfully decompressed via an endoscopic, endonasal approach which provided access to the cranio-vertebral junction and upper cervical spine. Conclusion: An endoscopic, endonasal approach is feasible for the surgical management of cranio-vertebral junction stenosis; such an approach minimises surgical trauma to critical structures, reducing post-operative morbidity and the duration of hospital stay

The learning curve for endonasal surgery of the cranial base: a systematic approach to training

Proper training in endoscopic endonasal surgery of the cranial base is essential to avoid unnecessary morbidity and mortality. An incremental program for the training of skull base surgeons is described that accounts for complex skull base anatomy, technical difficulty, potential risk of neural and vascular injury, extent of intradural dissection, and type of pathology. There are multiple pathways for training in endoscopic skull base surgery. The most important feature of a training program is the building of team surgical skills.Carl H. Snyderman, Harshita Pant, Amin B. Kassam, Ricardo L. Carrau, Daniel M. Prevedello, Paul A. Gardne

Management of Complications of Endonasal Cranial Base Surgery

Endoscopic endonasal surgery of the cranial base is maximally invasive surgery and poses many of the same risks as traditional skull base approaches. Preliminary data demonstrates that serious complications can be avoided through a strong foundation in endoscopic skull base anatomy, adherence to principles of surgical dissection, and a dedicated surgical team with proper training and experience. Surgical complications may be categorized by severity, location, organ system or tissue type, and time period. Advances in reconstruction have decreased the incidence of CSF leaks to less than 5%. Major complications such as vascular injury are rare and can be managed using endoscopic techniques. Nasal morbidity is acceptable.Snyderman C.H., Pant H., Gardner P.A., Carrau R.L., Prevedello D.M., Kassam A.B