Since the introduction of robot-assisted laparoscopic surgery, efforts have been made to incorporate force sensing technologies to monitor critical components and to provide force feedback. The advanced laparoscopic robotic system (AdLap RS) is a robotic platform that aims to make robot technology more sustainable through the use of the fully reusable shaft-actuated tip-articulating (SATA) instruments. The SATA instrument driver features electronics and sensors exposed to the sterile environment, which complicate the sterilisation process. The aim of this study was to develop and validate smart sensing in stepper motors using the back electromotive force in a newly developed Smart SATA Driver (SSD), eliminating the need for sensors in the sterile environment. Methods: The stepper drivers were equipped with TMC2209 ICs featuring StallGuard technology to measure back EMF. The tip was actuated up until a set StallGuard threshold value was reached, at which the resulting tip force was measured. This cycle was repeated ten times for a range of threshold levels. A regression analysis with a power series model was used to determine the quality of the fit. Results: The SSD is capable of exerting tip forces between 2.4 and 8.2 N. The back EMF force test demonstrated a strong correlation between obtained StallGuard values and measured tip forces. The regression analysis showed an R-squared of 0.95 and a root Mean squared error of 0.4 N. Discussion: The back EMF force test shows promise for force feedback, but its accuracy limits real-time use due to back EMF fluctuations. Future improvements in motor stability and refining the back EMF model are needed to enable real-time feedback. Conclusion: The strong correlation during the back EMF force test shows its potential as a low-budget method for detecting motor stalls and estimating tool–tissue forces without the need for sensors in laparoscopic instruments.

This book offers a comprehensive roadmap toward a circular and sustainable healthcare system, structured into three distinct parts.

Part I describes circular principles and policy tactics. Chapter 1 outlines the essentials of sustainable healthcare and designates the paradox in daily practice of sustainability and the circular economy. In Chapter 2 the impact of leadership on policy together with best practices is discussed. The legislation and infrastructural web, in which many stakeholders and circular economy initiatives are strangled, is described. Despite the fact that politicians and policymakers are motivated to encourage sustainability, the infrastructure is designed to discourage circular economy projects. This chapter shows examples of setting-up intrinsic motivated teams of hospital staff, green teams, industry leaders and scientific motivated research teams. Swimming against the current is about the legislation paradox. In chapter 3 described as how legislation should be redesigned to accomplish the goals as set out in the green deal and the climate law.

Part II serves as a practical guide to implementing circular strategies. In chapter 4 the reader is guided through the fundamentals of circular strategies by visualizing the circular economy. Chapter 5 reveals successful design strategies for products and processes which contribute to a zero-waste society. Using recycled materials by using waste as input for new products is described in chapter 6. In chapter 6 we will explore (surgical) waste as input for new products. Recycled should and could be used more. This is a fundamental concept within circular design principles but hardly used until this moment.

Part III explores circular economy design principles on basis of successful examples. This part dives into real-world applications and measurable outcomes. It showcases successful circular design concepts and business models that have reshaped the market. Chapter 7: Is about leading by design. Success stories of circular concepts which have effectively changed the market with circular products and services are designated. Also entrepreneurial success stories of circular economy business models are presented. Chapter 8 investigates how to measuring effectiveness and impact of circular economy products and processes. In particular how reliable some facts are which are used by many to sell products or introduce new policies or legislation. How trustworthy is data from life cycle assessments (LCA’s)? What are the pitfalls? Is it possible to manipulate these data? Why should we characterize one-sided data from an LCA as greenwashing? Circular Economy principles, sustainability and, in broader sense, the climate discussion seem to trigger emotions. Using fundamental and reliable data is essential in order to be able to judge whether a product or process indeed reduces CO2 emissions is essential in decision-making. Chapter 9 focusses on how universities can contribute to sustainable solutions by presenting different cases which resulted in actual results which were implemented or are ready for upscaling. The role of universities as innovation hubs is highlighted through case studies with proven impact. The final chapter offers a reflective and forward-looking analysis on how circular strategies in healthcare can shape future societal developments.

The authors reflect on the content in chapter 10. A final part in which a critical analysis is presented and the impact it could have on future developments and the society.

Objective: Cemented total hip arthroplasty (THA) demonstrates superior survival rates compared to uncemented procedures. Nevertheless, most younger patients opt for uncemented THA, as removing well-fixed bone cement in the femur during revisions is complex, particularly the distal cement plug. This removal procedure often increases the risk of femoral fracture or perforation, haemorrhage and weakening bone due to poor drill control and positioning. Aim of this study was to design a novel drill guide to improve drill positioning. Methods and procedures: A novel orthopaedic drill guide was developed, featuring a compliant centralizer activated by a drill guide actuator. Bone models were prepared to assess centralizing performance. Three conditions were tested: drilling without guidance, guided drilling with centralizer activation held, and guided drilling with centralizer activation released. Deviations from the bone centre were measured at the entry and exit point of the drill. Results: In the centralizing performance test, the drill guide significantly reduced drill hole deviations in both entry and exit points compared to the control (p < 0.05). The absolute deviation on the exit side of the cement plug was 10.59mm (SD 1.56) for the 'No drill guide' condition, 3.02mm (SD 2.09) for 'Drill guide - hold' and 2.12mm (SD 1.71) for 'Drill guide - release'. The compliant drill guide centralizer significantly lowered the risk of cortical bone perforation during intramedullary canal drilling in the bone models due to better control of the cement drill position. Clinical and Translational Impact Statement: The drill guide potentially reduces perioperative risks in cemented femoral stem revision. Future research should identify optimal scenarios for its application.

In de afgelopen decennia is het aantal medische wegwerpproducten significant toegenomen. Binnen het bedrijf GreenCycl en het GreenCycl Fieldlab worden oplossingen gezocht om de schaarste van grondstoffen tegen te gaan. Diverse methoden zijn onderzocht om medisch afval na gebruik opnieuw in te zetten als product, instrumentonderdelen of grondstof. De methoden volgen de strategieën van de Butterfly Diagram van de Ellen MacArthur Foundation. Een mix van deze strategieën is onderzocht en toegepast op vijf afvalstromen van de operatiekamer: complexe endoscopische instrumenten, herbruikbare instrumenten van roestvast staal, wegwerpinstrumenten van roestvast staal, instrumenten met inpakpapier van polypropyleen (PP) en verpakkingsmateriaal van polyethyleentereftalaat (PET). De vijf afvalstromen hebben hun eigen specifieke verwerkingsproces en verschillen in de benodigde hoeveelheid energie. Alle strategieën verminderen de CO2-uitstoot met 2,2-3 kg CO2 per kg afval. In alle gevallen blijkt het materiaal zijn eigenschappen grotendeels te behouden. Dit maakt de circulaire strategieën toepasbaar voor elk ziekenhuis.

Our world is the only planet, as far as we know, which harbors life. The number of humans on our planet has grown tremendously in recent centuries. In 1800 one billion humans occupied our earth; on 15 November 2022, this number reached 8 billion.

A result of this growth, the emissions of carbon dioxide (CO2), the primary greenhouse gas emitted by human activities, drastically increased. The increased concentrations of greenhouse gases in our atmosphere foster the long-term increase of our earth’s temperatures, also referred to as global warming.

While the earth’s population grew, so did our mass consumption society. After the Second World War humanity witnessed gigantic global economic development with great technological improvements. Computers, laptops, airplanes, tablets and Internet of Things connected humans all over the world. The hunger for plastics and steel grew as all products had to be manufactured in ever-increasing volumes. As the economy developed, our consumption grew apace.

The healthcare sector has seen the same increase of consumption. The number of patients grew, and so did the number of single-use medical products. As products become more complex and more different materials were combined., recycling became more difficult. Thus, hospitals transformed into waste factories with ever-growing waste streams. The consumption of (disposable) medical devices takes up scarce raw materials and contributes to the growing CO2 emissions.

In this book, Van Straten, Alvino and Horeman present their findings on how to create a sustainable healthcare economy by introducing different circular strategies. In 9 chapters, they present a wide variation of studies as practical cases to show what strategies and actions can be taken in order to implement sustainable strategies for a circular healthcare.

This book was written in line with the courses the authors developed at TU Extension School, the open online education edX platform of Delft University of Technology/TU Delft, a leading university in science and technology, recognized for its world-class research. This book is a manual for everyone who follows the online course ‘Circular strategies for a sustainable healthcare’, but certainly also for everyone who wants to discover more about circular strategies and wants to understand the principles and practices of circular economy and urban mining. This book is suitable for students, researchers, policymakers and practitioners in the fields of healthcare sustainability, management, business and economics.

De totale zorg draagt naar schatting voor 5 tot 8% bij aan de totale CO2-uitstoot in Nederland. Dit wordt mede veroorzaakt door het grote verbruik van medische wegwerpproducten, die na gebruik verbrand worden. Onderzocht is of gebruikte chirurgische mondmaskers gerecycled kunnen worden om nieuwe medische producten te maken. Recyclen kan ervoor zorgen dat de levenscyclus van een product circulair wordt, zodat de plastic afvalstroom afneemt. Dit artikel laat zien hoe het filtermateriaal van mondmaskers kan worden omgesmolten en verwerkt tot nieuwe grondstof. Tijdens dit proces zorgt een filtersysteem in de smeltoven ervoor dat metalen strips en elastiekjes grotendeels uit de mondmaskers verwijderd worden. Ook zijn de eigenschappen van het gerecyclede materiaal geanalyseerd, waaruit blijkt dat het materiaal brosser is dan de oorspronkelijke grondstof. Vervolgens zijn er productlabels voor instrumentsterilisatiecontainers gemaakt waarmee is aangetoond dat nieuwe medische producten kunnen worden gemaakt van gerecyclede mondmaskers. Een grootschalige pilot gaat in december 2021 van start om de haalbaarheid van het recyclen van chirurgische mondmaskers verder te onderzoeken.

Introduction: Disposable instruments in healthcare have led to a significant increase of medical waste. The aim of this study is to validate the recycling of disposable Zamak laryngoscope blades into new medical products by using a new ‘all-in-one’ affordable reprocessing setup as alternative for die-casting.
Methods: An “all-in-one” casting set-up was designed and built. Laryngoscope blades, recovered from two hospitals, were disinfected, melted and casted into dog-bones and into new instrument parts. The quality of the casted material was evaluated using X-ray fluorescence spectrometry. The mechanical properties were obtained by assessing the Ultimate Tensile Strength (UTS) and tensile tests.
Results: A recovery of 93% Zamak was obtained using a melting temperature of 420 0C for three hours. The XRF Spectro data showed higher Zinc and silicon concentrations when compared with Virgin Zamak. The dog-bones tests resulted in an average UTS, Yield Strength (YS) and Young’s Modulus (YM) of 236 ±61 (MPa), 70 ±43 and 9 ±3, respectively, representing 82%, 103% and 64% of the UTS, YS and YM of standard Zamak. Functional instrument parts with extensions and inner chambers were casted with a maximal shrinkage percentage of 1±1%.
Discussion: This study demonstrates that the created “all-in-one” reprocessing method can process contaminated disposable Zamak laryngoscope blades into new raw base material and new instrument parts. Although material and surface properties can deteriorate, reprocessed Zamak still has sufficient mechanical properties and can be used to cast complex parts with sufficient dimensional tolerances and minimal shrinkage.
Conclusion: A circular micro reprocessing method was designed and used to turn disposed laryngoscope blades into new basis material and semi-finished products. Follow up studies are needed to scale and optimize this process towards a functional alternative for die casting. It should be further investigated how this process can contribute to further medical waste reduction and a circular healthcare economy.

Hospital waste has a major impact on the environment. The worldwide growth of hospital waste is the result of the growing world population and the increase in use of disposables. A circular healthcare economy may contribute to the reduction of hospital waste. The circular economy is a system in which waste is prevented and where waste is reused. This thesis reports the findings of circular methods and strategies.

Background: Complications that occur in laparoscopic surgery are often associated with the initial entry into the peritoneal cavity. The literature reported incidences of Veress needle (VN) injuries of e.g. 0.31% and 0.23%. In a 2010 national survey of laparoscopic entry techniques in the Canadian General Surgical practice, 57.3% of respondents had either experienced or witnessed a serious laparoscopic entry complication like bowel perforation and vascular injury. As those complications are potentially life threatening and should be avoided at all costs, improving safety of this initial action is paramount. Methods: Based on a bare minimum design approach with focus on function expansion of existing components, a new Safety mechanism was developed for the VN that decreases the risks of VN overshooting. The mechanism works by preventing the puncturing acceleration of the tip of the VN by decoupling the surgeon’s hand from the VN immediately after entering the abdomen. Results: Based on a set of requirements, a first prototype of the VN+ with force decoupling safety mechanism is presented and evaluated on an ex vivo porcine abdominal wall tissue model in a custom setup. The experiments conducted by two novices and one experienced surgeon indicated a significant difference between the attempts with a standard, conventional working VN (41.4 mm [37.5–45 mm]) and VN+ with decoupling mechanism (20.8 mm [17.5–22.5 mm]) of p < 0.001. Conclusion: A new decoupling safety mechanism was integrated successfully in a standard VN resulting in a VN+. The results from the pilot study indicate that this new VN+ reduces overshooting with a minimum of 50% in a standardised ex vivo setting on fresh porcine abdominal wall specimens.

The Covid-19 pandemic led to threatening shortages in healthcare of medical products such as face masks. Due to this major impact on our healthcare society an initiative was conducted between March and July 2020 for reprocessing of face masks from 19 different hospitals. This exceptional opportunity was used to study the costs impact and the carbon footprint of reprocessed face masks relative to new disposable face masks. The aim of this study is to conduct a Life Cycle Assessment (LCA) to assess and compare the climate change impact of disposed versus reprocessed face masks. In total 18.166 high quality medical FFP2 face masks were reprocessed through steam sterilization between March and July 2020. Greenhouse gas emissions during production, transport, sterilization and end-of-life processes were assessed. The background life cycle inventory data were retrieved from the ecoinvent database. The life cycle impact assessment method ReCiPe was used to translate emissions into climate change impact. The cost analysis is based on actual sterilization as well as associated costs compared to the prices of new disposable face masks. A Monte Carlo sampling was used to propagate the uncertainty of different inputs to the LCA results. The carbon footprint appears to be 58% lower for face masks which were reused for five times compared to new face masks which were used for one time only. The sensitivity analysis indicated that the loading capacity of the autoclave and rejection rate of face masks has a large influence on the carbon footprint. The estimated cost price of a reprocessed mask was €1.40 against €1.55. The Life Cycle Assessment demonstrates that reprocessed FFP2 face masks from a circular economy perspective have a lower climate change impact on the carbon footprint than new face masks. For policymakers it is important to realize that the carbon footprint of medical products such as face masks may be reduced by means of circular economy strategies. This study demonstrated a lower climate change impact and lower costs when reprocessing and reusing disposable face masks for five times. Therefore, this study may serve as an inspiration for investigating reprocessing of other medical products that may become scarce. Finally, this study advocates that circular design engineering principles should be taken into account when designing medical devices. This will lead to more sustainable products that have a lower carbon footprint and may be manufactured at lower costs.

The Circular Economy faces a growing interest. The aim of this study is to determine the feasibility of a circular approach towards reusing discarded hospital instruments and stainless steel waste. Secondary, this study aims to identify if any cost savings can be realized by following a circular instrument repair and recycling approach. During 6 months SS waste from three hospitals was collected. Both repair as well as recycling possibilities were evaluated by analyzing the waste composition and by calculating the percentage of SS that could be recovered and turned into raw material. Cost savings were calculated for three categories: (1) extending the life cycle of instruments by repair instead of disposal, (2) recycling of instruments by means of melting it into raw material, and (3) savings on waste handling costs. A total of 1,380 kg instrument waste was collected of which 237 kg was refurbished and returned to the hospitals for being put in use, resulting in savings of € 38,868 (1). Of the 1,143 kg SS instruments, sheet material was made to manufacture components for new instrument baskets. The SS revenues of € 1,040 were sufficient, covering logistical and disinfection costs (2). The hospital savings on waste costs were € 316 (3). The total gain for the hospitals were € 39,184. These results indicate that circularity as a sustainable model could provide a basis for a new approach in surgical waste management, realizing cost savings and environmental benefits on the long run.

Background
Face masks, also referred to as half masks, are essential to protect healthcare professionals working in close contact with patients with COVID-19-related symptoms. Because of the Corona material shortages, healthcare institutions sought an approach to reuse face masks or to purchase new, imported masks. The filter quality of these masks remained unclear. Therefore, the aim of this study was to assess the quality of sterilized and imported FFP2/KN95 face masks.

Methods
A 48-minute steam sterilization process of single-use FFP2/KN95 face masks with a 15 minute holding time at 121°C was developed, validated and implemented in the Central Sterilization Departments (CSSD) of 19 different hospitals. Masks sterilized by steam and H2O2 plasma as well as new, imported masks were tested for particle filtration efficiency (PFE) and pressure drop in a custom-made test setup.

Results
The results of 84 masks tested on the PFE dry particle test setup showed differences of 2.3±2% (mean±SD). Test data showed that the mean PFE values of 444 sterilized FFP2 face masks from the 19 CSSDs were 90±11% (mean±SD), and those of 474 new, imported KN95/FFP2 face masks were 83±16% (mean±SD). Differences in PFE of masks received from different sterilization departments were found.

Conclusion
Face masks can be reprocessed with 121 °C steam or H2O2 plasma sterilization with a minimal reduction in PFE. PFE comparison between filter material of sterilized masks and new, imported masks indicates that the filter material of most reprocessed masks of high quality brands can outperform new, imported face masks of unknown brands. Although the PFE of tested face masks from different sterilization departments remained efficient, using different types of sterilization equipment, can result in different PFE outcomes.