Functional constraints on surgical care delivery in a besieged conflict zone: an observational study of 128 consecutive operations

Background: In besieged conflict settings, surgical activity is shaped by trauma burden, diagnostic scarcity, and system constraints rather than by conventional scheduling categories. The emergency/elective classification commonly used in peacetime health systems is misleading in such environments. Methods: We analysed an anonymised dataset of 128 consecutive operations performed in a conflict-affected hospital environment in Gaza during the 2025 conflict. Variables included patient demographics, diagnosis at time of surgery, surgical specialty, name of operation, operative duration, anaesthetic employed, imaging use, intraoperative blood loss, equipment or consumable issues, surgical outcome, reasons for non-completion, post-operative destination, and surgeon characteristics. Analysis focused on surgical specialty, operative task, and functional constraints. Results: Median patient age was 27 years (interquartile range 11.5 to 33), and 83 patients (64.8%) were male. Imaging was unavailable or not used in 91 cases (71.1%). Orthopaedic surgery accounted for 55 operations (43.0%) and plastic surgery for 43 (33.6%), together comprising 76.6% of all procedures. There was a preponderance of fracture stabilisations, soft-tissue reconstructions, debridements, foreign-body removals, and limb salvage procedures, indicating a workload overwhelmingly attributable to traumatic injury and its sequelae. Outcomes were completed as planned in 114 cases (89.1%), modified intra-operatively in 12 (9.4%), and cancelled mid-procedure in 2 (1.6%), giving 14 non-standard outcomes (10.9%). Thirty-six surgeons contributed to care, with the operative workload being highly concentrated among a smaller subset of consistently active surgeons. One surgeon performed 26.6% of all operations, and the ten most frequently operating surgeons accounted for 73.4% of cases. Conclusion: In this besieged setting, surgical care delivery was dominated by trauma-related operations performed mainly without imaging support and under equipment constraints. Classification by surgical specialty and operative task has direct implications for the development of future surgical teams deployed to conflict zones.