Surgery
What can we learn from conflict zones?
In this article, Giovanni Dall’Amico discusses the delivery of limb reconstruction in resource-constrained healthcare systems. Healthcare providers under pressure can learn a great deal from conflict zones and Giovanni shares some valuable insights.
At the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) Winter Scientific Meeting in Belfast in December 2025, Mr Ahmed El Mokhallalati and I presented two complementary studies examining lower-limb reconstruction during the Gaza conflict and subsequent humanitarian evacuations aboard the Italian Navy hospital shipNave Vulcano. Although geographically and operationally distinct, these experiences represent two ends of the reconstructive spectrum: active bombardment within a collapsing civilian healthcare infrastructure, and a structured but capacity-limited maritime Role-2/2LM hospital platform operating under military-humanitarian governance. Together, they offer a unique lens through which to examine how reconstructive trauma care can be delivered when systems are under extreme strain. What emerged was not a narrative of
improvisation in chaos, but one of disciplined adaptability anchored firmly in surgical fundamentals. The lessons are not confined to conflict zones. They are increasingly relevant to modern health systems facing workforce shortages, supply chain disruption, infrastructure pressure, and rising demand.
Leadership under collapse: Mokhallalati’s experience in Gaza Mr Mokhallalati’s experience in Gaza occurred during periods when healthcare infrastructure degradation rapidly outpaced humanitarian supply. Hospitals operated with intermittent electricity, inconsistent sterilisation capacity, minimal imaging, no microbiological testing, and dwindling stocks of dressings and anaesthetic agents.
In this context, the instinct might be to assume a collapse of standards. Instead, what proved striking was the preservation of structure. Operative pathways were maintained. Senior oversight was non-negotiable. Complex cases were discussed collectively. Even in the presence of bombardment and structural damage, professional discipline was retained. Major limb salvage decisions were never
unilateral. At least two senior surgeons assessed severe injuries before committing to definitive pathways. Where communications permitted, remote consultation with international colleagues was sought. This maintenance of peer review and collective governance, even under threat, is arguably one of the most transferable service lessons. The absence of advanced wound adjuncts
required recalibration rather than abandonment of principle. Vacuum-assisted closure devices were unavailable. Modern antimicrobial dressings were exhausted. Laboratory confirmation of infection was impossible. Wound care therefore reverted to
physiologically rational fundamentals. Soap and diluted acetic acid (Vinegar) were used for irrigation. Granulated sugar was applied to infected cavities, leveraging osmotic effects to inhibit bacterial proliferation and desiccate necrotic tissue. Vinegar was used selectively to suppress Pseudomonas colonisation. These measures, while rarely encountered in contemporary UK practice, are grounded in basic microbiological science. However, they were effective only because
they were paired with uncompromising surgical debridement. Devitalised tissue was excised aggressively. Re-look procedures were routine. Operative thoroughness replaced technological dependency. This reinforces a central service message: adjunct technologies enhance care, but they do not replace fundamental surgical judgement.
Redefining the amputation threshold Few surgical decisions carry as much weight as proceeding to amputation in a young trauma patient. In Gaza, the ethical and functional implications were magnified by limited rehabilitation infrastructure. The reconstructive framework employed
was described as a “reconstructability triad”: l Can the limb be made painless? l Can it be made functionally useful? l Can it achieve stable, durable soft-tissue coverage?
If these criteria could not be satisfied, amputation was considered. However, context fundamentally altered the
threshold. In high-income systems, amputation may be followed by advanced prosthetics, specialist physiotherapy, and long-term
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www.clinicalservicesjournal.com I April 2026
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