Surgery
rehabilitation programmes. In a conflict zone where prosthetic provision is inconsistent and physiotherapy access unreliable, limb salvage — even if imperfect — may provide greater long- term autonomy. This shift from purely anatomical assessment
to contextual decision making is instructive. It challenges high-resource surgeons to recognise how dependent our algorithms are on surrounding infrastructure. It also emphasises that ethical surgical practice must integrate societal and systemic realities, not simply operative feasibility.
Preserving function: the preference for fasciocutaneous flaps A consistent operative pattern observed in Gaza was the deliberate preference for fasciocutaneous flaps over muscle flaps where anatomically feasible. The rationale was functional preservation. In blast injuries with segmental bone loss, additional muscle sacrifice for coverage risked compounding long-term disability, particularly in paediatric patients. Fasciocutaneous flaps, designed on reliable perforators, provided stable coverage of exposed bone and hardware while maintaining muscle bulk and joint range. These flaps proved durable and technically
efficient. Their reliability underscores an important principle: in austere environments, reconstructive ambition must align with long- term functional sustainability and follow-up feasibility. The lesson extends beyond conflict settings.
Even within well-resourced systems, careful consideration of functional trade-offs remains essential, particularly where rehabilitation capacity is stretched.
Infection without microbiology Microbiological support was frequently unavailable. Antibiotic therapy was empirical, guided by contamination patterns and pragmatic renal safety considerations rather than culture sensitivity data. Despite this, infection outcomes were often acceptable. The explanation again lies in operative
discipline. Serial debridement reduced bacterial load mechanically. Surgeons relied on clinical judgement: tissue colour, bleeding characteristics, odour, systemic parameters. Reassessment was built into pathways rather than reserved for failure. This experience does not suggest that
microbiology is unnecessary. Rather, it demonstrates that laboratory support augments but does not replace surgical vigilance. In systems under pressure — whether due to
workforce gaps or delayed diagnostics — maintaining strong clinical assessment skills becomes even more critical.
Managing bone loss amid instability Blast injuries frequently resulted in complex segmental bone defects. In stable environments, distraction osteogenesis allows gradual regeneration over months. However, this technique demands reliable follow-up, patient compliance, and structured outpatient support. In Gaza, where patients were displaced
repeatedly and hospitals themselves were vulnerable, prolonged treatment arcs were often unrealistic. Surgeons therefore prioritised primary shortening to achieve union more rapidly. Definitive lengthening was deferred until stability could be assured. This sequencing, achieving biological union
before anatomical perfection, reflects a pragmatic doctrine of war surgery: stabilise first, refine later. For health systems facing resource strain, this principle has resonance. It emphasises prioritisation, realistic planning, and phased reconstruction rather than pursuit of immediate optimality at unsustainable cost.
Service delivery under displacement Infrastructure instability imposed operational constraints beyond the operating theatre. Hospitals were damaged. Supply chains were intermittent. Patient relocation was common. This forced procedural prioritisation. Where safe, single-stage reconstructions were favoured. Multi-stage microsurgical pathways were undertaken only when continuity could
be reasonably predicted. Every operative plan incorporated the possibility that follow-up might be interrupted. Such conditions sharpened decision making.
They demanded clarity of objectives and realistic assessment of deliverability. Documentation and communication became even more critical, ensuring safe transfer of care when patients moved between facilities. These service pressures echo, in less
dramatic form, challenges faced within strained health systems worldwide: capacity limits, delayed transfers, fragmented continuity. The Gaza experience illustrates how disciplined prioritisation and clarity of purpose can mitigate systemic disruption.
Transition to maritime humanitarian surgery: Nave Vulcano In January and February 2024, I joined the Italian Navy hospital shipNave Vulcano during a humanitarian evacuation mission responding to the Gaza crisis. The vessel functioned as a Role-2/2LM maritime hospital platform stationed off the Egyptian coast. Unlike Gaza’s collapsing infrastructure, this was a structured military- medical environment. However, capacity was finite, evacuation windows were fixed, and onward transfer to Italy required careful coordination. Daily transfers brought injured civilians,
predominantly women and children, requiring stabilisation prior to repatriation. Presentations included fractures, blast-related soft tissue defects, chronic infected wounds, and delayed complications following earlier damage- control procedures. Here, the challenge was
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