What started as an uprising in 2011 has now developed into a full civil war with multiple regional and international stakeholders. The war has been described by the United Nations as the worst humanitarian crisis in recent times with around 220,000 people, mostly civilians being estimated to have died, with many more people having been forced to leave their homes and become refugees.  In this context, the surgical needs of the population have greatly increased, leaving a large proportion of the population in need of urgent surgical assistance. At least 388,000 surgical procedures were required for forcibly displaced persons in Syria in 2014, a figure that is likely to have risen as the conflict has continued. 
Exacerbating the unmet surgical need in Syria is the destruction of medical infrastructure that has taken place during this conflict.  Medical facilities and personnel have become targets of war in many conflicts around the world in recent times, particularly in the Syrian conflict.  These clear breaches of International Humanitarian Law make providing surgery in conflict areas such as Syria both difficult and dangerous for medical staff.
In the context of the Syrian conflict, international assistance providing surgery is vital to meeting the healthcare needs of the population. Surgery is often overlooked in global health as an intervention due to the misconception that it has high costs and limited benefits for population health.  In terms of disability-adjusted life years (DALYs), general surgery is $82 per DALY versus $52 per DALY for the BCG vaccine and $454 per DALY for antiretroviral drugs.  With the onset of conflict, the requirement for safe affordable surgery becomes even greater.
One example of surgical provision in Syria by a Non-Governmental Organisation (NGO) is the work of Medecines Sans Frontieres (MSF). MSF have provided emergency surgical care for over 40 years in humanitarian crises all around the world.  MSF found in Syria that trauma surgery was the most frequently required intervention with half of their cases being injury related.  Young males suffered the most injuries requiring surgical intervention and road traffic accidents were the largest cause of injury with almost 30% of injuries being indicated as traffic related.  Paediatric cases made up one third of their case load and again in this group, trauma and infection were the most prevalent pathologies.  Despite the evident prevalence of trauma injuries in the conflict setting, MSF found that it was important to provide a full range of surgical interventions as well as just trauma surgery. The conflict increased the need for nearly all types of surgery but most of all trauma surgery.  Obstetric surgeries made up a large proportion on non trauma related surgeries and provision for them was crucial.  MSF’s very stringent quality control measures led to a very low intraoperative mortality rate of patients.  Surgery by NGOs in conflict settings is vital to meeting the increased health care needs of the population and it can be done cost effectively and with good outcomes.
Another approach to helping Syria with its increased surgical burden due to the conflict has been that of the David Nott Foundation. Dr. David Nott runs war surgery education programmes for surgeons in conflict affected countries.  He has run five day programmes for Syrian surgeons in Turkey to teach them the ‘art of war surgery’. This is particularly important as many medical schools and teaching facilities have been closed down due to the conflict so external teaching is greatly appreciated.  War surgery is complex as it often requires dealing with every region of the body whilst managing massive loss of blood and other physiological constraints. One thing that Dr. Nott tries to impart is that trauma textbooks are to be ignored to some extent as the critical skill is being able to think fast on the spot and make the right decisions, a skill that he has acquired with many decades of experience.  In conflict settings, sometimes the most important thing is knowing when to not operate due to limiting factors such as not having the material resources like available blood for transfusion. 
Our research group will be carrying out a scoping review of the literature on surgery in conflict scenarios such as has been described above. This will create an effective research agenda for future research into conflict surgery. “A 2012 systematic review of surgical care in humanitarian crises collected studies too heterogeneous to provide actionable quantitative data”.  A scoping review will inform future authors of where their research might be directed to have the most impact on global surgery in conflict settings.
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Alexander West is a third year medical student with a passion for global surgery and its application to help people all around the world.