Management of intramuscular melanoma metastases to the psoas.

We detail a case of a woman in her 40s with isolated melanoma skeletal muscle metastasis (MSMM) to the right psoas muscle. This patient underwent R0 surgical resection through a novel pelvic approach. She received subsequent adjuvant immunotherapy with Braftovi/Mektov along with adjuvant radiation. She is currently disease free at 9 months post surgery. Here, we describe our novel surgical approach including description of the tumour pathology. We explain our multidisciplinary management of MSMM consisting of a multidisciplinary surgical approach by surgical oncology, gynecological oncology and urology as well as multidisciplinary medical management by oncology, radiation oncology and pathology. Finally, we discuss best current options for therapeutic management.

Rural Melanoma Patients Have Less Surgery and Higher Melanoma-Specific Mortality.

BACKGROUND: Melanoma causes most skin cancer-related deaths, and disparities in mortality persist. Rural communities, compared to urban, face higher levels of poverty and more barriers to care, leading to higher stage at presentation and shorter survival in melanoma. To further evaluate these disparities, we sought to assess the association between rurality and melanoma cause-specific mortality and receipt of recommended surgery in a national cohort. METHODS: Patients with primary non-ocular, cutaneous melanoma from the SEER database, 2000-2017, were included. Outcomes included melanoma-specific survival and receipt of recommended surgery. Rurality was based on Rural-Urban Continuum Codes. Variables included age, sex, race, ethnicity, income, and stage. Multivariate regression models assessed the effect of rurality on survival and receipt of recommended surgery. RESULTS: 103,606 patients diagnosed with non-ocular cutaneous primary melanoma met criteria during this period. 93.3% (n = 96620) were in urban areas and 6.7% (n = 6986) were in rural areas. On multivariate regression controlling for age, sex, race, ethnicity, and stage patients living in a rural area were less likely to receive recommended surgery (aOR .52, 95% CI: .29-.90, P = .02) and had increased hazard of melanoma-specific mortality (aHR 1.19, 95% CI: 1.02-1.40, P = .03) even after additionally controlling for surgery receipt. CONCLUSION: Using a large national cohort, our study found that rural patients were less likely to receive recommended surgery and had shorter melanoma cause-specific survival. Our findings highlight the importance of access to cancer care in rural areas and how this ultimately effects survival for these patients.

Modified oncoplastic lift, lymphatic excision, and reconstruction: Introduction of a novel technique in oncoplastic breast surgery with simple surgical principles.

INTRODUCTION: Oncoplastic surgery is an important component of the management of breast cancer. As prognosis has improved, the need for proficient techniques to achieve disease eradication while maintaining cosmesis for naturally appearing breasts has gained importance. This study describes an easy-to-learn modified oncoplastic technique for patients undergoing breast-conserving treatment. DESCRIPTION OF THE TECHNIQUE: Tumor resection is performed through different peri-areolar, inframammary, or radial incisions. To reduce the size of the surgical defect created after tissue resection, an internal purse-string is performed parallel to the chest wall or base of the wound with subsequent staggering in three or more layers as needed, while maintaining the parallel orientation of the needle. This is followed by the creation and overlapping of internal breast tissue flaps that are rearranged to decrease the dead space with the aim of improving cosmesis. The redundant skin is removed for the skin envelope to maintain shape. The wound is closed in layers. We also describe steps in performing sentinel lymph node and tumor extraction through the same periareolar, inframammary, or radial incisions for tumors located in outer quadrants. Following closure, contour and projection of the breast were maintained without indentation or loss of projection, with a symmetrical appearance to the contralateral side. CONCLUSION: This simplified oncoplastic (MOLLER) technique can be easily learned and used by surgeons who treat cancer patients and have limited oncoplastic training. It uses basic known surgical principles to decrease the size of the defect created while minimizing the need for larger incisions/pedicles.

Racial and ethnic minorities in lower income brackets are associated with late-stage diagnosis of non-ocular melanoma.

INTRODUCTION: Despite advances in oncologic care, racial and socio-economic outcome disparities persist in non-ocular melanoma patients. However, the unmet need is understanding the population at risk for late tumor stage at diagnosis. We sought to analyze the groups with an increased risk of unfavorable tumor stage at diagnosis. METHODS: Patients with non-ocular melanoma were reviewed using the 2000-2019 SEER Research Data (SEER*Stat) and grouped into early tumor stage at diagnosis (stage I-IIC) and late (stage III-IVC). Multivariable logistic and Cox regression examined the association of demographic, socioeconomic, and clinical factors with late-stage diagnosis and overall survival, respectively. Kaplan-Meier estimates were calculated with racial and county-level household income stratification to evaluate overall survival differences. RESULTS: Of 147,606 patients diagnosed with non-ocular melanoma, 38,695 cases were identified based on inclusion and exclusion criteria and separated into those with early-stage diagnosis (median 63 years) and those with late-stage (median 62 years). Male gender, Black race, Asian or Pacific Islander race, and Hispanic ethnicity were significantly associated with late-stage tumor diagnosis (p < 0.001). Receipt of surgery and a median county-level household income >$75,000 were protective for late-stage tumor diagnosis (p < 0.001). Additionally, male gender, Black, Asian or Pacific Islander, American Indian/Alaskan Native races, metastasis, and late-stage diagnosis were associated with factors significantly associated with decreased overall survival (p-value <0.001). Receipt of surgery and a median household income of $50,000-$74,999 and >$75,000 were factors associated with increased overall survival (p < 0.001). The median overall survival was 89 months, but Black patients (58 months) and <$50,000 income households (75 months) had significantly worse survival (p < 0.001). CONCLUSIONS: Hispanic ethnicity, Black and Asian or Pacific Islander race, and low-income households were associated with late-stage non-ocular melanoma at diagnosis. Black, Asian or Pacific Islander and American Indian/Alaskan Native races and lower-income households were associated with worse overall survival. Identifying addressable causal factors that link this at-risk population to poor cancer prognosis is warranted.

Coverage of Fertility Preservation and Treatment Among Surgical Trainees in the United States of America.

INTRODUCTION: Surgery trainees spend their prime fertility years in training, which leads to delays in childbearing, accompanying infertility challenges, and high-risk pregnancies. Literature report of institutional support for fertility preservation (egg/sperm freezing) and treatment is lacking. The cost is particularly prohibitive while receiving a resident physician salary. This study aimed to assess availability of fertility resources and institutional coverage of fertility services to US General Surgery Residents (GSR) and Breast Fellows. METHODS: We composed and distributed a 26-question survey to GS residency and fellowship program directors nationwide to survey residents and fellows. Summary and descriptive statistics were tabulated, and categorical variables were analyzed using Pearson's chi square test. RESULTS: A total of 234 US surgical trainees (male n = 75, female n = 155, unreported n = 4) completed the survey. Total of 12 % of trainees reported having been counseled on family planning/fertility treatment during training, and only 5.1% were counseled on fertility preservation. Perceived lack of support from program (p = 0.027) and counseling of fertility preservation (p = 0.009) were significantly associated with female gender. A minority (12.5%) reported having insurance coverage for fertility preservation and 26% had coverage of fertility treatment. In addition, 2.6% respondents pursued fertility preservation while in training and 33% reported they would pursue fertility preservation if it was covered by insurance. CONCLUSIONS: Fertility preservation is rarely discussed in US General Surgery residency programs. The large majority of GSR lacks awareness of insurance coverage of fertility preservation and treatment. Strong efforts are necessary to improve fertility education for GSR and insurance coverage to meet trainee's needs.

Association of Women Surgeons' Comprehensive Initiative for Healthy Surgical Families During Residency and Fellowship Training.

Importance: The lack of family-friendly policies continues to contribute to the underrepresentation and attrition of surgical trainees. Women in surgery face unique challenges in balancing surgical education with personal and family needs. Observations: The Association of Women Surgeons is committed to supporting surgical families and developing equitable family-friendly guidelines. Herein we detail recommendations for adequate paid parental leave, access to childcare, breastfeeding support, and insurance coverage of fertility preservation and assisted reproductive technology. Conclusions and Relevance: The specific recommendations outlined in this document form the basis of a comprehensive initiative for supporting surgical families.

Surgical and Oncologic Outcomes With Intraoperative Radiation Therapy for Early Breast Cancer.

BACKGROUND: For selected patients with early-stage breast cancer (BC), intraoperative radiation therapy (IORT) has emerged as a convenient alternative to standard whole breast irradiation (WBI). We report a single institution experience with IORT in terms of oncologic outcomes, toxicities, and cosmesis. METHODS: Clinicopathological and perioperative outcomes of patients who underwent IORT for early-stage BC at a public hospital from 2017 to 2020 were retrospectively retrieved. Toxicity was categorized to acute or chronic based on 6 months post-IORT cutoff. RESULTS: 85 patients underwent IORT and had complete data, aged 49-85 years (mean 62). Intraoperative radiation therapy added 23 minutes on average to the total operative time. Final stage was 0, I, and II in 40%, 58.9%, and 1.1% of patients, respectively. Mean tumor size was 0.8 cm (range .1-2.1), with ductal histology comprising 94% of cases. Surgical margins were positive in 2 patients, and adjuvant WBI was required in 5 patients. After a median follow-up of 17 months (range 3-41), none of the patients had local recurrence and no mortality was recorded. Early wound complications included wound dehiscence (n = 1), seroma/hematoma (n = 15), and re-operation with loss of nipple-areola complex (n = 1). Chronic skin toxicities were reported in 10 (12%) patients and good or excellent cosmetic outcome was reported in 93% of patients. CONCLUSIONS: Utilizing IORT among low-risk early BC patients may be a safe and more convenient alternative to traditional WBI, with low toxicity rate, acceptable cosmetic results, and good oncologic outcomes at 17 months. Longer follow-up and further prospective controlled studies are needed to confirm these findings.

Stalled at the intersection: insurance status and disparities in post-mastectomy breast reconstruction.

PURPOSE: Post-mastectomy breast reconstruction (PMBR) is an important component of breast cancer treatment, but disparities relative to insurance status persist despite legislation targeting the issue. We aimed to study this relationship in a large health system combining a safety-net hospital and a private academic center. METHODS: Data were collected on all patients who underwent mastectomy for breast cancer from 2011 to 2019 in a private academic center and an adjacent public safety-net hospital served by the same surgical teams. Multivariable logistic regression was used to assess the effect of insurance status on PMBR, controlling for covariates that included socioeconomic, demographic, and clinical factors. RESULTS: Of 1554 patients undergoing mastectomy for breast cancer, 753 (48.5%) underwent PMBR, of which 592 (79.9%) were privately insured, 50 (6.7%) Medicare, 68 (9.2%) Medicaid, and 31 (4.2%) uninsured. Multivariable logistic regression showed a significantly higher likelihood of not undergoing PMBR for uninsured (OR 6.0, 95% CI 3.7-9.8; p < 0.0001), Medicare (OR 1.9, (95% CI 1.2-3.0; p = 0.006), and Medicaid (OR 1.5, 95% CI 1.0-2.3; p = 0.04) patients compared with privately insured patients. Age, stage, race and ethnicity, and hospital type confounded this relationship. CONCLUSION: Patients without health insurance have dramatically reduced access to PMBR compared to those with private insurance. Expanding access to this important procedure is essential to achieve greater health equity for breast cancer patients.

Evaluation of Simplified Lymphatic Microsurgical Preventing Healing Approach (SLYMPHA) for the prevention of breast cancer-related lymphedema after axillary lymph node dissection using bioimpedance spectroscopy.

BACKGROUND: Lymphedema is a serious complication of axillary lymph node dissection (ALND) with an incidence rate of 20%. Simplified Lymphatic Microsurgical Preventing Healing Approach (SLYMPHA) is a safe and relatively simple method, which decreases incidence of lymphedema dramatically. Our initial study showed an 88% decrease in clinical lymphedema rate. In the initial study, we used arm circumference measurement for the diagnosis of lymphedema and median follow up was 15 months. The aim of this study was to confirm these results after a long-term follow up period and by using bioimpedance spectroscopy (L-Dex) technology in detecting lymphedema. STUDY DESIGN: All patients, undergoing ALND with or without SLYMPHA between January 2014 and November 2020 were included in the study. Patients with no postoperative L-Dex measurements were excluded. A L-Dex score outside the normal range (±10 L-Dex unit) or ≥10 L-Dex unit increase above patient's baseline was considered as lymphedema. The incidence of lymphedema was compared between patients with and without SLYMPHA. RESULTS: 194 patients were included in the study. 57% of cohort underwent SLYMPHA. Mean follow-up time was 47 ± 37 months. Patients, who underwent SLYMPHA, had a significantly lower rate of lymphedema (16% vs 32%; p = 0.01; OR 0.4 [0.2-0.8]). CONCLUSION: SLYMPHA is a safe and relatively simple method, which continued its efficacy after a long-term follow up period. It should be considered as an adjunct procedure to ALND for all patients during initial surgery.

Persistent and interdependent: Racial disparities and their mechanisms in postmastectomy breast reconstruction.

BACKGROUND: Racial disparities in accessing postmastectomy breast reconstruction persist despite expansion of insurance coverage. An updated examination with a broad assessment of mediating factors in a "majority minority" community is needed. METHODS: Data were collected on all patients undergoing mastectomy for breast cancer from 2011 to 2019 in a private academic center and adjacent safety-net hospital. Multivariable logistic regression was used to assess the effect of race on postmastectomy breast reconstruction, controlling for predetermined potentially mediating and confounding variables. RESULTS: Of 1,554 patients, 63.8% (n = 203) of non-Hispanic White, 33.4% (n = 102) of Black, and 47.9% (n = 438) of Hispanic patients underwent postmastectomy breast reconstruction. Multivariable logistic regression showed that Black patients (odds ratio [OR] 3.6, 95% confidence internal [CI]: 2.2-5.9; P < .0001) undergo significantly less postmastectomy breast reconstruction than White patients. Age, insurance status, stage, and hospital type mediated this relationship. CONCLUSION: Black patients have substantially reduced rates of postmastectomy breast reconstruction compared with White patients, which is mediated by socioeconomic factors.

Axillary Response to Neoadjuvant Therapy in Node-Positive, Estrogen Receptor-Positive, Human Epidermal Growth Factor Receptor 2-Negative Breast Cancer Patients: Predictors and Oncologic Outcomes.

BACKGROUND: One potential benefit of neoadjuvant therapy (NAT) in node-positive, estrogen receptor-positive (ER+), human epidermal growth factor receptor 2-negative (HER2-) patients is axillary downstaging to avoid axillary dissection. OBJECTIVE: The aim of this study was to evaluate axillary response to NAT with chemotherapy (NCT) or endocrine therapy (NET) and identify potential predictors of response. METHODS: A prospectively collected database was queried for node-positive, ER+, HER2- breast cancer patients treated with NAT and surgery from January 2011 to September 2020. Axillary response was categorized into pathologic complete response (pCR) versus no pCR, and was correlated to demographic and clinicopathologic parameters in a logistic regression model. RESULTS: A cohort of 176 eligible patients was identified and 178 breast cancers were included in the study. The overall axillary pCR rate was 12.3% (22/178). NCT and NET achieved response rates of 13.9% (19/137) and 7.3% (3/41), respectively (p = 0.232). A significantly higher axillary pCR rate was identified in patients with clinical stage II at diagnosis (12/60, 20%) compared with stage III (10/118, 8.4%; p = 0.03). NET patients with ypN0 were younger and were treated for a longer period of time (>6 months). Completion axillary dissection was omitted in the majority (73.7%) of NCT patients achieving axillary pCR. CONCLUSIONS: For patients with node-positive, ER+, HER2- breast cancer, a lower burden of disease at the time of diagnosis (stage II) is associated with a significantly higher axillary pCR, enabling those patients to be spared axillary dissection. Further studies are necessary to define the role of genomic profiling in predicting axillary response.

Relevance of sentinel lymph node biopsy for thick melanoma in the era of immunotherapy.

BACKGROUND: Sentinel lymph node biopsy provides prognostic information in patients with thick melanoma but is often underutilized. We examine regional lymph node evaluation (RLNE) in patients with thick melanoma and the effect on treatment and overall survival (OS). METHODS: Patients with clinical T4N0M0 melanoma were selected from the National Cancer Database (2004-2015). Binary logistic regression analysis was used to identify factors associated with RLNE and treatment. Overall survival analysis was performed. RESULTS: A total of 14 286 patients with clinical T4N0M0 melanoma were identified; RLNE was performed in 70.2% of patients, and positive LNs were identified in 27.1%. RLNE was more likely in males (OR:1.44, 95%CI: 1.32-1.56, p < .001), and patients treated at academic centers (OR:1.58, 95%CI:1.46-1.71, p < .001). Immunotherapy was more commonly used in patients with RLNE (13.9% vs 3.4%, p < .001) and was associated with positive LNs (OR:2.50, 95%CI:2.19-2.86, p < .001). The 5-year OS for RLNE was 56.9% and for no RLNE was 32.7%. Independent factors associated with better OS were treatment at an academic center (HR:0.88, 95%CI:0.84-0.93, p < .001), and immunotherapy use (HR:0.86, 95%CI:0.76-0.96, p < .001). CONCLUSION: The use of RLNE in patients with thick melanoma is important for prognosis and to risk stratify patients for selection of adjuvant therapies and clinical trials.

Inflammatory Breast Cancer in Pregnancy and Lactation.

Inflammatory breast cancer (IBC) represents only 1% to 5% of all breast malignancies and is an extremely aggressive subtype. At time of diagnosis, up to 85% of patients will present with regional nodal metastases and up to 30 % will have metastasis to distant organs. There is limited medical literature describing treatment guidelines for IBC during gestation. The best diagnostic tools are core needle and full-thickness skin punch biopsies to assess presence of dermal lymphatic invasion. Breast Ultrasound is preferred to mammogram, but mammography could still be done with proper fetal shielding. Ultrasound and Magnetic resonance imaging are used for staging. Pregnant patients should be managed with special attention to the health of the fetus by a multidisciplinary team. Treatment based on current guidelines consist of a sequence of systemic chemotherapy followed by mastectomy with axillary dissection (modified radical mastectomy), and even if good clinical nodal response to neoadjuvant therapy is obtained, sentinel node biopsy is not recommended. Radiation therapy is to be given once the baby has been delivered. Chemotherapy is not recommended in the first trimester, and anti-estrogen hormonal therapy, as well as targeted Her2-neu therapies are contraindicated during the length of the pregnancy. There is no evidence that early termination improves the outcome. However, given the poor prognosis of IBC, patients should be fully counseled on the risks and benefits of continuing or terminating an early pregnancy.

Triple-negative breast cancer in Peru: 2000 patients and 15 years of experience.

BACKGROUND: Epidemiological studies commonly identify the clinical characteristics and survival outcomes of patients with breast cancer at five years. Our study aims to describe the sociodemographic, clinicopathological characteristics and determine the long-term event-free survival (EFS) and overall survival (OS) of a Peruvian population with triple-negative breast cancer. METHODS: We reviewed the medical records of new cases treated at a single institution in the period 2000-2014. The survival analysis included patients with stages I-IV. Survival estimates at 10 years were calculated with the Kaplan-Meier method and compared with the Log-rank test. We further used multivariate Cox regression analysis to calculate prognostic factors of recurrence and mortality. RESULTS: Among the 2007 patients included, the median age at diagnosis was 49 years (19-95 years). Most patients presented histologic grade III (68.7%), tumor stage II (34.2%), and III (51.0%) at diagnosis. Local and distant relapse was present in 31.9 and 51.4% of the patients, respectively. The most frequent sites of metastasis were the lungs (14.5%), followed by bone (9.7%), brain (9.6%), and liver (7.9%). The median follow-up was 153 months. At 3, 5, and 10 years, the EFS of the population was 55%, 49%, and 41%, respectively, while the OS was 64%, 56%, and 47%, respectively. Moreover, an N3 lymph node status was the most important prognostic factor for both disease relapse (HR: 2.54, 95% CI: 2.05-3.15) and mortality (HR: 2.51, 95% CI: 2.01-3.14) at ten years. An older age and higher T staging were associated with a worse OS, while patients who received radiotherapy and adjuvant chemotherapy had better survival rates. CONCLUSION: The sociodemographic features of Peruvian patients with TNBC are similar to those of other populations. However, our population was diagnosed at more advanced clinical stages, and thus, EFS and OS were lower than international reports while prognostic factors were similar to previous studies.

Breast-conserving surgery vs. total mastectomy in patients with triple negative breast cancer in early stages: A propensity score analysis.

BACKGROUND: Breast-conserving surgery (BCS) as an alternative to total mastectomy (TM) in patients with early-stage triple-negative breast cancer (TNBC) is not widely spread. OBJECTIVE: We aimed to compare the overall survival (OS) and disease-free survival (DFS) between both surgical approaches in early-stage TNBC patients at 10 years. METHODS: We conducted a retrospective cohort study in TNBC female patients with stage I-IIa, treated at a single-center during the period of 2000-2014. We estimated and compared the survival rates with the Kaplan Meier and Long-rank test. Propensity scores were calculated with the generalized boosted regression model and were used in the multivariate Cox regression analysis with the covariate adjustment method. RESULTS: We included 288 patients, 111 in the BCS vs. 177 in the TM group. The median follow-up was 102 months. Moreover, the patients in the BCS group had superior OS (85% vs. 81%, p = 0.56) and DFS (83% vs. 80%, p = 0.42) at 10 years. In the multivariate Cox analysis, BCS decreased the mortality risk (HR: 0.79, 95% CI: 0.37-1.67, p = 0.538), and the locoregional or distant recurrence risk (HR: 0.67, 95% CI: 0.32-1.41, p = 0.294), albeit with no statistical significance. CONCLUSION: BCS is a safe alternative to TM in Latin-American patients with early-stage TNBC.

Evolving management of positive regional lymph nodes in melanoma: Past, present and future directions.

Sentinel lymph node (SLN) biopsy has become the standard of care for lymph node staging in melanoma and the most important predictor of survival in clinically node-negative disease. Previous guidelines recommend completion lymph node dissection (CLND) in cases of positive SLN; however, the lymph nodes recovered during CLND are only positive in a minority of these cases. Recent evidence suggests that conservative management (i.e. observation) has similar outcomes compared to CLND. We sought to review the most current literature regarding the management of SLN in metastatic melanoma and to discuss potential future directions.

The Role of Completion Lymphadenectomy in Positive Regional Lymph Nodes in Melanoma: A Meta-analysis.

BACKGROUND: The optimal management of melanoma with positive sentinel lymph node (SLN) remains unclear. Completion lymph node dissection (CLND) only yields additional positive non-SLN in 20% of cases and its benefits on survival remains debatable. METHODS: An online database search of Medline was performed; key bibliographies were reviewed. Studies comparing outcomes after CLND versus observation were included. Odds ratios (ORs) with the corresponding 95% confidence intervals (CIs) by random fixed effects models of pooled data were calculated. The primary endpoints were disease-free survival (DFS), melanoma-specific survival (MSS), and overall survival (OS). RESULTS: Search strategy yielded 117 publications. Twelve studies were selected for inclusion, comprising 7966 SLN-positive patients. Among these patients, 5306 (66.6%) subjects underwent CLND and 2660 (33.4%) patients were observed. Median Breslow thickness and ulceration were similar between groups (2.8 ± 0.6 mm versus 2.5 ± 0.8 mm, P = 0.721; and 38.8% versus 37.2%, P = 0.136, CLND versus observation, respectively). CLND was associated with statistically significant improved 3-y (71.0% versus 66.2%, OR 0.82, 95% CI 0.69-0.97, P = 0.02) and 5-y DFS (48.3% versus 47.8%, OR 0.75, 95% CI 0.59-0.96, P = 0.02) compared with observation. However, no difference was demonstrated in 3-y MSS (83.7% versus 84.7%, OR 1.09, 95% CI 0.88-1.35, P = 0.41), 5-y MSS (68.4% versus 69.8%, OR 1.02, 95% CI 0.88-1.19, P = 0.78), or OS (68.2% versus 78.9%, OR 0.93, 95% CI 0.55-1.57, P = 0.78). CONCLUSIONS: Based on this large-scale analysis, CLND improved both 3- and 5-y DFS, possibly because of increased rates of local control; however, this did not translate in improved MSS or OS. Efforts toward the identification of molecular markers associated with poor outcomes in SLN-positive patients who undergo observation are warranted.

Greening the operating room.

BACKGROUND: Climate change will affect most populations in the next decades and put the health of billions of people at risk. Health care facilities represent a significant source of pollution around the world and contribute to environmental changes. To address this topic, we performed a review of the available literature on tactics to reduce operating room (OR) waste and the potential of these strategies to impact the environment. DATA SOURCES: A literature search was performed querying PubMed, Web of Science, and Science Direct. No comparative data were found; most were opinion papers, white papers, and case studies. For this reason, we proceeded with a narrative review, which provides an overview of the evidence on this topic and identifies areas for future research. RESULTS: This systematic review summarizes the available literature on the 5 "Rs" of waste management: reduction, reusing, recycling, rethinking, and renewable energies. CONCLUSIONS: Surgery has a unique opportunity to transition to more environmentally-friendly operating room strategies, which may help decrease waste and lessen the impact of climate change.