Unnecessary surgery
Unnecessary surgery refers to operative procedures performed without adequate clinical indication or expected net benefit for the patient, relative to less invasive or non-operative alternatives. The concept overlaps with medical overuse, low-value care, and defensive medicine, and is studied through evidence syntheses, practice-variation research, and evaluations of appropriateness criteria.
Background
Concerns about avoidable operations intensified with the rise of evidence-based medicine and studies documenting large geographic variations in procedure rates that could not be explained by patient need. The Institute of Medicine highlighted waste from unnecessary services as a major quality and cost problem in the United States. Internationally, the BMJ's Too much medicine initiative and the ABIM Foundation's Choosing Wisely campaign have sought to identify and reduce low-value interventions, including operations. The OECD has likewise called out wasteful spending related to overuse, including surgical care.Drivers
There are multiple, interacting causes of unnecessary surgery. Practice variation and local medical culture can lead to different procedure rates in different areas even when patient needs are similar. Studies and policy analyses have documented how local norms and clinician practices influence whether surgery is recommended or pursued.Defensive medicine driven by malpractice concerns can increase procedure use, as clinicians sometimes recommend interventions primarily to reduce perceived legal risk rather than because surgery is clearly indicated; national surveys and research have explored clinicians' views on defensive practices and their cost impacts.
Financial incentives in fee-for-service settings and supply-sensitive care, where greater local capacity correlates with higher use, can also drive unnecessary operations; health-economics analyses and OECD reports document how payment systems and resource availability affect utilization patterns.
Diagnostic uncertainty, limited shared decision-making, and outdated or contradicted practices further contribute to unnecessary procedures when clinicians and patients lack clear, evidence-based guidance and when historical practice persists despite newer evidence showing lack of benefit.
Prevalence and variation
Rates of common operations vary several-fold between regions and hospitals, even after adjusting for demographics. For example, Tonsillectomy in children showed a seven-fold variation across English local authorities in 2000–2005, illustrating the scale of geographic differences in some elective procedures.Hysterectomy for benign disease exhibits substantial small-area variation that has been documented in multiple countries and U.S. states, indicating that practice patterns and local factors affect the use of major gynecologic surgery.
The Dartmouth Atlas and related atlases describe such differences as "unwarranted variation" when not explained by illness, patient preferences, or robust evidence.
Examples debated in the literature
Arthroscopic knee surgery for osteoarthritis and degenerative meniscal tears has been debated because a sham-controlled trial found no better pain or function outcomes than placebo surgery, leading to reconsideration of its routine use for some patients.Percutaneous coronary intervention for stable coronary disease is another example under debate: the COURAGE trial showed no reduction in death or myocardial infarction versus optimal medical therapy, prompting calls to curb inappropriate elective PCI and to align indications with evidence and patient preference.
Cesarean section overuse has been highlighted by WHO statements emphasizing that cesareans should be performed when medically indicated; population rates above approximately 10% are not associated with further mortality reductions, prompting scrutiny of rising cesarean rates in many regions.
Ethical and legal issues
Unnecessary operations raise questions of informed consent, conflicts of interest, and potential health fraud. U.S. Senate investigators have reported patterns of questionable cardiac procedures and financial incentives that may encourage overuse in certain settings. News coverage has documented disciplinary actions for physicians who implanted unnecessary cardiac stents, illustrating harms to patients and erosion of trust.Responses and reduction strategies
Appropriateness criteria and clinical guidelines that prioritize non-operative care when supported by evidence, and "do-not-do" recommendations from professional bodies and health agencies, are commonly promoted to reduce unnecessary surgery and encourage practice aligned with current evidence.Shared decision-making for preference-sensitive care, supported by patient decision aids to align care with patient values and reduce unwarranted variation, is another key strategy that aims to ensure patients receive care that reflects their informed preferences and the best available evidence.
Second-opinion programs, which have been used since the 1970s to vet recommendations for elective surgery and may avert inappropriate operations, are implemented in some systems and insurers to provide additional clinical review prior to major procedures.
Safety checklists and perioperative pathways to curb non-indicated add-on procedures and improve reliability have been widely adopted; for example, the WHO surgical safety checklist has reduced complications in multiple settings, although its direct effects on procedure volumes vary by context and implementation.