There is an ongoing trend across the United States (US) to move surgeries from more expensive, high-acuity facilities to less expensive, low-acuity facilities, prioritizing outpatient surgical care over inpatient care whenever possible for elective surgeries.1 In just the past two decades, an abdominal aortic aneurysm that was once repaired open in a tertiary care facility can now be managed closed in an endovascular suite.2 Total hip and knee replacements, which were surgical cases routinely performed on an inpatient basis in hospitals, are now being performed more and more frequently on an outpatient basis in ambulatory surgical centers (ASCs).3 ASCs have become commonplace in the surgical world since the late 1990s with their demonstration of increased efficiencies, decreased costs, high patient satisfaction, and comparable or even improved surgical outcomes for many surgical specialties.4,5

Following the spirit of surgical cases moving from high-cost to low-cost centers exemplified by the increasing number and type of cases being moved from hospitals to ASCs, there is now an increasing movement of surgical specialties to the office setting. Specialties such as ophthalmology and plastic surgery have led the way for years. More recently, surgical specialties such as orthopedic surgery and its subspecialties such as hand surgery have begun following suit.6,7 The basis is the obvious cost savings to the patient, the payers, and the healthcare system in general, while also yielding greater efficiency and opportunity for increased productivity to the surgeon.8–10 Starr et al. in 2023 demonstrated that moving hand surgical cases performed under only local anesthesia from the ASC to an office-based surgery (OBS) suite resulted in a time and cost savings of $931 per case or an 82% reduction in case cost.11 Moreover, multiple studies have demonstrated additional savings in surgeons’ time and improved efficiencies.11–13

Limitations in moving surgical cases from the ASC to OBS are often based on the need for anesthesia services, surgical case equipment demands (i.e., complex surgical trays and scope towers) and the need to maintain and process them, implant reimbursement challenges outside a certified facility (i.e., fracture implants and joint replacements), surgical site infection potential, and the management of unexpected intraoperative surgical complications. Yet, there are many surgical specialties (i.e., hand surgery and podiatry) that are ripe for OBS where surgeries can be performed under local anesthesia with field and tumescent anesthesia, surgical equipment is minimal, supporting equipment such as scope towers is often not necessary, surgeries not requiring implants are plentiful, and the risk of surgical site infection and intraoperative complications is very low.

Relative to concerns for surgical site infection, there is often a surgical cultural bias to assume that the same level of surgical sterility is needed for all types of surgery. For instance, are the sterility demands the same for a total hip or knee replacement as a carpal tunnel release? The literature is replete with evidence confirming that field sterility is more than adequate for the vast majority of low-acuity and non-implant-related surgeries.14–18 Field sterility has been routinely demonstrated to show equal rates of surgical site infection risk, which is very low in fields such as hand surgery and plastic surgery in general, as compared to standard surgical preparation in hospital and ASC settings.

However, a common barrier to adopting OBS is navigating the required equipment, workflows, and operational overhead. Using the 2025 launch of an independent hand and plastic surgery clinic as a case study (“Heritage Hand and Plastic Surgery”, Lansing, MI, by co-author JWC), this paper provides an itemized, data-driven framework for establishing an OBS suite inside a standard procedure room. While clinical specifications naturally vary by discipline, this model utilizes hand surgery to illustrate universal principles of lean setup and cost efficiency.

THE ROOM

Any typical examination room in a doctor’s office can potentially be converted into a procedure room or surgical suite to perform OBS. The necessary equipment includes: a comfortable place for the patient to sit or lie, a stable surface to perform the surgery, a stand or table to hold the surgical equipment, adequate lighting, and a comfortable rolling stool for the surgeon (if / when surgeon is seated during surgery). Like purchasing furniture for a home, there is a wide range of preferences, tastes, and options available. Ultimately, what is selected should be based on the size of the procedure room, type of surgeries to be performed, and budget. [Table 1]

Basic considerations:

  • Patient position: Positioning depends on the case, though a supine position is generally preferred, as it is familiar, comfortable, and protective against fainting and falls. A treatment table that is easy to mount and dismount is ideal. Although a motorized table may be desired, a standard static treatment table is adequate. A standard static treatment table can cost $300-1000 when purchased new.

  • Surgical surface: In cases where the hand or upper extremity is being operated on, a mobile hand table that provides a stable surgical surface and can also be rolled into position and then rolled away after a procedure is ideal. A mobile hand table can cost $100-2000 when purchased new. A cost-effective alternative that also allows height adjustment is a mobile adjustable-height desk.

  • Surgical field: Like the hand table, a stand or table that can hold the surgical instruments and be rolled into a convenient position for the surgeon to access during the procedure and rolled away afterward is helpful. Alternatively, if there is a fixed surface such as a fixed counter that can also accommodate the surgical instruments and is conveniently positioned, it can also be feasible. A mobile stainless steel back table can cost $100-500 when purchased new.

  • Lighting: Optimal lighting during surgery is imperative. This can be achieved (in increasing costs) with the use of a headlamp by the surgeon, free-standing surgical lights on wheels that can be maneuvered into position as needed, or surgical lights attached to the ceiling. A headlamp can cost $10-100, while a mobile free-standing procedure light can cost $1000-5000, when purchased new.

  • Stools: Depending on the surgery and surgeon preference, a comfortable stool for the surgeon and assistant, if applicable, is useful when the surgeon is seated to operate. A rolling exam stool can cost $50-150 when purchased new.

Table 1.Furniture & ancillary
Item / Description Units Unit Cost (USD) Origin Total Cost (USD)
Mobile standing desks (hand tables) 2 $107.00 Europe $214.00
Cotton sterile towel drapes, 15″ × 26″ 40 $2.37 Europe $94.80
Neck pillow (OR table) 1 $21.00 Europe $21.00
Positioning pillow 1 $17.15 Europe $17.15
Office camera 1 $69.99 Europe $69.99
Vinyl Padded Mobile Shop Stool 1 $85.00 Europe $85.00
Large stainless steel back table 1 $150.00 Europe $150.00
Subtotal — Furniture & Ancillary $651.94

USD=United States Dollar

EQUIPMENT

Surgical equipment needs will be predicated upon the types of surgery being performed. For example, with OBS hand surgery, the recommended minimum instruments to consider include: scalpel handle, Adson toothed forceps, Senn-Miller retractors, Iris scissors, Stevens tenotomy scissors, bandage scissors, mosquito hemostat, needle driver, Freer elevator, stainless steel cup, and two towel clamps. Instruments may be wrapped in a sterile towel for autoclaving in lieu of a tray [Table 2]. Other optional instruments can be purchased and individually packed for use on a case-by-case basis [Table 3]. Similarly, the number of these instruments will be based on the anticipated number of cases to be performed per surgical schedule and the necessary processing time. A basic set of surgical instruments can cost $50-100 when sourced from overseas manufacturers through online bulk vendors, and $500-1500 when purchased new through US medical-supply distributors.

Table 2.Core operating set instruments (10 complete identical sets)
Item / Description Units Unit Cost (USD) Origin Total Cost (USD)
T/C Adson Tissue Forceps, 1×2 teeth, 4.75″, gold handle 10 $10.99 Asia $109.90
Iris Scissors, 4.5″, curved 10 $5.00 Asia $49.99
TC Mayo-Hegar Needle Holder, 5″, cross-serrated 10 $9.99 Asia $99.90
Supercut Stevens Tenotomy Scissors, 4.5″, curved 10 $9.99 Asia $99.90
Knowles Bandage Scissors, 5.5″, straight 10 $5.83 Asia $58.33
Bard Parker Scalpel Handles #3, with ruler 10 $4.50 Asia $44.99
Mosquito Hemostat Forceps, 5″, straight + curved 10 $1.50 Asia $14.99
Senn-Miller Retractors, 6 3/8″, sharp & blunt 10 $8.50 Asia $84.95
Freer elevators (mean unit cost across three sub-lots) 10 $9.45 Europe $94.53
Towel clamps, 3.5″ (2 per set) 20 $3.24 Europe $64.82
Stainless steel 6 oz cups 10 $1.91 Europe $19.07
Subtotal — Core Operating Set Instruments (10 complete identical sets) $741.37

An autoclave will be necessary to maintain sterilized equipment, and the type and size will be predicated on the size and volume of surgical equipment necessary. Depending on the size, a steam-based autoclave can cost $1500-5000 when purchased new.

For OBS hand surgery, cautery is not routinely necessary as the use of epinephrine in the local anesthetic should mitigate surgical site bleeding. However, having cautery in an OBS suite is a reasonable selection. Options include standard electrosurgical units that support both monopolar and bipolar cautery, as well as battery-operated thermal cautery pens. A standard electrosurgical unit costs $1000-5000 when purchased new. Alternatively, the cautery pens cost $15-100 per pen. Also, rather than opening a cautery per case, they can be opened and applied on a case-by-case basis.

Table 3.Individually-packed specialty & reserve instruments
Item / Description Units Unit Cost (USD) Origin Total Cost (USD)
Adson Dressing Forceps, 6″, straight serrated 5 $9.99 Asia $49.95
Adson forceps, non-toothed 5 $10.58 Europe $52.89
Heiss retractors, sharp, 4″ 5 $4.24 Europe $21.19
Heiss retractors, blunt, 4″ 2 $10.60 Europe $21.19
K-wire removers, tungsten inlays 2 $22.49 Europe $44.98
K-wire cutters, 6″ 2 $21.09 Europe $42.17
Weitlaner Self-Retaining Retractor, 4.5″, 2×3 prong 4 $9.49 Asia $37.98
Joseph Skin Hook, 6.25″, single sharp prong 3 $7.99 Asia $23.97
Joseph Skin Hook, 6.25″, two sharp prong, 10 mm 2 $7.99 Asia $15.98
Bone Reduction Forceps, 8″, long ratchet, gold handle 1 $24.99 Asia $24.99
Blumenthal Bone Rongeur, 6″, 90° angled tips 4 $15.99 Asia $63.96
Slim Weingart Pliers, 5.5″ 3 $9.98 Asia $29.94
Subtotal — Individually-Packed Specialty & Reserve Instruments $429.19

X-RAY IMAGING

X-ray imaging in the office is highly desirable, particularly in specialties such as OBS hand surgery. This can be achieved (in increasing cost) with the use of a tabletop mini C-arm fluoroscope, a small C-arm fluoroscope, a large C-arm fluoroscope, or a radiology suite built into the OBS suite. The choice of system should be predicated upon anticipated patient and case needs and space availability. The range of fluoroscopic units can cost $10,000-50,000 when purchased new. However, there is a large market for used and aftermarket fluoroscopes with significantly decreased costs.

PREPPING & DRAPING

Field sterility is sufficient for the majority of low acuity OBS, including OBS hand surgery. This can be achieved by either normal soap and water or chlorhexidine washing of the surgical site by the patient, followed by application of chlorhexidine or iodine/betadine by the surgical team when the patient is positioned.

Full draping and concealing of the limb is not required in OBS. A drape on the surgical table and towels, if desired, over the forearm is sufficient draping for OBS hand surgery. Ultimately, the extent of surgical draping is based on surgeon preference.

Also, as the patient is awake, they can hold their own limb up and manipulate it during prepping and draping per the surgical team’s instructions. As such, additional team members to hold an extremity while prepping and draping is generally not necessary.

GOWN & GLOVES

Sterile gloves are necessary while prepping, draping, and during surgery. For OBS hand surgery, beyond the use of sterile gloves, the use of gowns, masks, and hair cover is surgeon preference and can be used as personal protective equipment more so than for infection control. A cost-effective alternative is to use sterile surgical sleeves, which allows the surgeon to rest their forearm on the surgical field for longer cases without the need for more costly standard surgical gowns.

MEDICATIONS

Local anesthesia will be required per case, and should be secured at the volume necessary to support the anticipated surgical schedule. For OBS hand surgery, 1% lidocaine with 1:100,000 or 1:200,000 epinephrine is recommended, with an anticipated volume of 3-50cc per case. The addition of 1cc of 8.4% Bicarbonate to a 10 cc syringe of local will buffer the solution to reduce injection pain. Bupivacaine is not recommended for OBS due to its cardiac affinity.19,20

Antibiotics can be administered orally as needed. In general, specialties such as hand surgery and others that do not involve an implant do not need antibiotic prophylaxis. However, some surgeons prefer it, and plasma levels are acceptable 30 minutes after oral administration of cephalosporin.

DISPOSABLES

Certain single-use items will likely be required per case, including: scalpel blades, syringe, and needles. Specifics will be predicated upon the surgical cases being performed. For OBS hand surgery, 15 blades, 10 cc syringes, 25 g and 27 g needles are recommended.

SUTURES & DRESSING

Sutures and dressing will be required per case and will be predicated upon the surgical cases being performed. Adequate inventory should be maintained to support the anticipated surgical schedule, taking into account the time necessary for replenishing supplies, cost differences between purchasing in larger quantities at lower frequency versus smaller quantities at higher frequency, and related storage capacity.

EQUIPMENT PROCESSING

Equipment sterilization is often the biggest challenge in maintaining an OBS practice, as this represents a major ongoing processing burden normally managed by hospital and ASC staff. Processing steps include (1) manual wiping and rinsing of equipment, followed by enzymatic immersion and manual scrubbing to remove bioburden, (2) packing the instruments either individually in their sterilization packet or as a set appropriately wrapped in towels or on a tray, and (3) autoclaving the instruments. A consistent workflow with the OBS team should be established for reliable and adequate equipment processing and sterilizing. Team members should be advised of the Centers for Disease Control (CDC) sterilizing guidelines. Routine use of indicators and regular servicing of the autoclave is also good practice to confirm adequate sterilization [Table 4].

Table 4.Capital equipment
Item / Description Units Unit Cost (USD) Origin Total Cost (USD)
Midmark M11 cassette autoclave 1 $4,060.00 US $4,060.00
Operating table — Sibella Spa Luxe IS240 electric exam/facial chair 1 $2,393.00 US $2,393.00
Surgical hand drill 1 $539.07 Europe $539.07
Surgical loupes with headlight 1 $800.00 Europe $800.00
Subtotal — Capital Equipment $7,792.07

EMERGENCY EQUIPMENT

Maintaining resuscitation equipment is good practice, although highly unlikely to be necessary. Recommended equipment includes smelling salts, phentolamine for epinephrine reversal, and an automated external defibrillator. In addition, maintaining basic life support training by the surgeon and relevant surgical team members is always good practice.

Although not in a hospital or ASC, maintaining a formal surgical consent process with procedure-specific documentation is good practice. Similarly, performing a formal timeout prior to commencing the surgery is recommended even with OBS.

DOCUMENTATION

Formal documentation in the patient’s electronic health records after an OBS is good practice. This OBS documentation should be similar to a formal operative report as would be documented in a hospital or ASC, and should be its own dedicated encounter in the patient’s records. As there will not be associated nursing staff notes that would normally accompany a hospital or ASC operative report, details of the prep, drape, local injection type and amount injected, and any other associated medications administered should be included in the OBS operative report. Similarly, the surgical consent signed before the OBS should be uploaded as well. Best practice is to complete all documentation the day of OBS.

OFFICE ENVIRONMENT & PATIENT EXPERIENCE

Well-established hospitality industries have long since used environmental cues to put guests at ease and provide a sense of comfort, luxury, and experience. OBS has every opportunity to excel in providing an experience as well, differentiating itself from traditional sterile ASC and hospital settings. For instance, Dr. Jean Paul Brutus in Montreal was inspired by the hospitality industry and focused on providing a luxurious experience for his patients by adding music and a light show during surgery.21 At Heritage Hand, author JHWC has enhanced the waiting room with surgical heritage antiques, a narrative of personal family history in surgery spanning over 150 years, and added virtual reality (VR) experiences during the procedure through Wide Awake VR.22–24 An OBS practice gives the surgeon complete freedom to express and differentiate themselves, with an authentic patient experience without compromise by the corporate nature of big healthcare, and patients notice.

SETUP COST: A Case Study

Tables 1–4 itemize the setup cost for the case study OBS hand surgery practice (Heritage Hand). Items mentioned in the body text but not deployed (i.e., electrosurgical cautery, dedicated procedure lights) were not purchased and thus excluded. Also, the fluoroscopic unit used, which was purchased second-hand, has the largest and most variable capital expense and is excluded due to its high-cost variability. Instruments are organized into a core operating set of ten identical trays and a smaller reserve of individually-packed specialty instruments. Recurring supplies (sutures, local anesthetic, splinting, sterilization consumables, personal protective equipment (PPE)) are excluded as ongoing operational costs. Subsequently, the total setup cost was identified as: $9,614.57.

The source regions were noted in the Tables. When Asia was noted, the country of origin for the surgical equipment was Pakistan, although other countries can be used to source surgical equipment as well. Table 5 represents an analysis of the cost of sourcing the same equipment from US distributors versus the Asian (Pakistani) distributors. US prices were cumulatively identified as over 11 times greater for surgical equipment. [Table 5]

Table 5.Per-instrument cost comparison: Pakistani-manufactured versus equivalent US-distributor list pricing for a representative basket of common hand-surgery instruments (n = 86 instruments). US comparators are OR-grade German surgical stainless steel reusable instruments; sources accessed June 2026.
Instrument Asian seller unit (USD) US distributor range (USD) Ratio range
Adson Tissue Forceps, 1×2 teeth, 4.75″ $10.99 $30.00–$77.00 2.7–7.0×
Adson Dressing Forceps, 6″, serrated $9.99 $27.00–$70.00 2.7–7.0×
Iris Scissors, 4.5″, curved sharp/sharp $5.00 $35.00–$123.00 7.0–24.6×
Mayo-Hegar Needle Holder, 5–6″ $9.99 $13.00–$109.00 1.3–10.9×
Stevens Tenotomy Scissors, 4.5″, curved (basic ↔︎ Supercut) $9.99 $10.00–$152.00 1.0–15.2×
Scalpel Handle #3 $4.50 $16.00–$42.00 3.6–9.3×
Mosquito Hemostat, 5″, curved $1.50 $30.00 20.0×
Senn-Miller Retractor, 6¼″ $8.50 $68.00–$100.00 8.0–11.8×
Weitlaner Self-Retaining Retractor, 4.5″, 2×3 prong $9.50 $32.00–$329.00 3.4–34.6×
Joseph Skin Hook, 6¼″, single sharp prong $7.99 $58.00 7.3×
Blumenthal Bone Rongeur, 6″, 90° $15.99 $317.00 19.8×
Basket aggregate at Heritage purchase quantities (n = 86 instruments) $680.58 $7,919.14 11.6×

CONCLUSION

Launching an OBS represents a natural evolution of the ongoing movement of surgical care from high-cost and high-acuity centers to low-cost and low-acuity centers, whenever a surgical specialty or surgery is appropriate for it. Setting up an OBS suite can be daunting, but when broken down into its fundamental steps, it is very doable without being prohibitively expensive. Like any purchase, there is a range of features, size, and quality to choose from. An OBS suite is no different. In the case study provided here, an OBS hand surgery suite was established for under $10,000, excluding the cautery, fluoroscope, medications, and disposables.

Declaration of conflict of interest

The authors declare that they have a financial relationship with Walant Surgical Solutions, Inc.

Declaration of funding

The authors received NO financial support for the preparation, research, authorship, and publication of this manuscript.

Declaration of ethical approval for study

The institution does not require ethical approval for the review papers.

There is no information (names, initials, hospital identification numbers, or photographs) in the submitted manuscript that can be used to identify patients.