Surgical tray optimization: a prospective and survey-based evaluation of environmental and economic outcomes

Background: Operating rooms are resource-intensive environments. While reusable instruments are more sustainable than disposables, sterilization and reprocessing of unused instruments in the trays generate unnecessary environmental and financial burdens. Surgical tray optimization—removal of rarely used instruments—may reduce these impacts. Current evidence is fragmented, with no standard method to identify unused instruments and limited integration of environmental and cost analyses. Methods: We prospectively recorded instrument use for the Major General Surgery tray (94 reusable instruments) in one academic hospital in the Netherlands during 162 surgical procedures across multiple disciplines (November 2023–May 2024). Instruments used in < 20% of cases were considered for removal by (1) prospective clinical observation and (2) retrospective staff survey (surgeons, residents, scrub nurses). Life cycle assessment (LCA) and activity-based costing quantified the carbon footprint and costs. Results: On average, 19 instruments were used per case; 10 were never used. Observation-based optimization reduced tray size and weight by 54%, lowering costs by 55%. Survey-based review achieved smaller reductions (22% in number, 18% in weight, 21% in cost), with surgeons supporting more removals than scrub nurses. The original tray generated 1.25 kg CO₂-eq per use. Optimization reduced emissions by 0.91 and 2.69%, corresponding to thresholds of < 10 and < 20% use, respectively. Conclusion: In multi-specialty settings, tray optimization offers substantial cost savings and modest but cumulative environmental benefits. Clinical observation identified greater reductions than staff reviews. Combining LCA with cost analysis can provide a transparent framework to guide sustainable surgical practice.