title: Providing surgery in a war-torn context: the Médecins Sans Frontières experience in Syria.
abstract: BACKGROUND
  Since 2011, civil war has crippled Syria leaving much of the population without access to healthcare. Various field hospitals have been clandestinely set up to provide basic healthcare but few have been able to provide quality surgical care. In 2012, Medecins Sans Frontieres (MSF) began providing surgical care in the Jabal al-Akrad region of north-western Syria. Based on the MSF experience, we describe, for the period 5th September 2012 to 1st January 2014: a) the volume and profile of surgical cases, b) the volume and type of anaesthetic and surgical procedures performed, and c) the intraoperative mortality rate.
  
  
  METHODS
  A descriptive study using routinely collected MSF programme data. Quality surgical care was assured through strict adherence to the following minimum standards: adequate infrastructure, adequate water and sanitation provisions, availability of all essential disposables, drugs and equipment, strict adherence to hygiene requirements and universal precautions, mandatory use of sterile equipment for surgical and anaesthesia procedures, capability for blood transfusion and adequate human resources.
  
  
  RESULTS
  During the study period, MSF operated on 578 new patients, of whom 57 % were male and median age was 25 years (Interquartile range: 21-32 years). Violent trauma was the most common surgical indication (n-254, 44 %), followed by obstetric emergencies (n-191, 33 %) and accidental trauma (n-59, 10 %). In total, 712 anaesthetic procedures were performed. General anaesthesia without intubation was the most common type of anaesthesia (47 % of all anaesthetics) followed by spinal anaesthesia (25 %). A total of 831 surgical procedures were performed, just over half being minor/wound care procedures and nearly one fifth, caesarean sections. There were four intra-operative deaths, giving an intra-operative mortality rate of 0.7 %.
  
  
  CONCLUSIONS
  Surgical needs in a conflict-afflicted setting like Syria are high and include both combat and non-combat indications, particularly obstetric emergencies. Provision of quality surgical care in a complex and volatile setting like this is possible providing appropriate measures, supported by highly experienced staff, can be implemented that allow a specific set of minimum standards of care to be adhered to. This is particularly important when patient outcomes - as a reflection of quality of care - are difficult to assess.
authors.affiliation: Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB), Surgery, Anaesthesia, Gynaecology, and Emergency Medicine Unit, Brussels, Belgium.
authors.forename: Miguel
authors.initials: M
authors.lastname: Trelles
authors.affiliation: Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB), Surgery, Anaesthesia, Gynaecology, and Emergency Medicine Unit, Brussels, Belgium.
authors.forename: Lynette
authors.initials: L
authors.lastname: Dominguez
authors.affiliation: MSF-OCB, Operational Research Unit, MSF-Luxembourg, Luxembourg, Luxembourg.
authors.forename: Katie
authors.initials: K
authors.lastname: Tayler-Smith
authors.affiliation: MSF-OCB, Emergency pool, Brussels, Belgium.
authors.forename: Katrin
authors.initials: K
authors.lastname: Kisswani
authors.affiliation: MSF-OCB, Logistics department, Brussels, Belgium.
authors.forename: Alberto
authors.initials: A
authors.lastname: Zerboni
authors.affiliation: MSF-OCB, Logistics department, Brussels, Belgium.
authors.forename: Thierry
authors.initials: T
authors.lastname: Vandenborre
authors.affiliation: MSF-OCB, Emergency pool, Brussels, Belgium.
authors.forename: Silvia
authors.initials: S
authors.lastname: Dallatomasina
authors.affiliation: MSF-OCB, MSF Syria project, Latakia Governorate, Syria.
authors.forename: Alaa
authors.initials: A
authors.lastname: Rahmoun
authors.affiliation: MSF-OCB, Emergency pool, Brussels, Belgium.
authors.forename: Marie-Christine
authors.initials: MC
authors.lastname: Ferir
keywords: Conflict settings; Minimum standards of care; Quality surgical care; Syria