Background During the Syrian civil war, patients were initially treated on-site in Syria and later transferred to medical centers in Israel. Relevant details concerning the exact nature of injury and medical/surgical care received in Syria were unavailable to clinicians in Israel. Many of these patients required abdominal re-exploration for obvious or suspected problems related to their injury. Our aim is to present our approach to abdominal trauma patients who survived initial on-site surgery and needed subsequent abdominal re-exploration abroad, in our medical center. Methods Clinical data from all medical records were retrospectively analyzed. Each patient underwent total body computerized tomography on arrival, revealing diverse multi-organ trauma. We divided the patient population who had abdominal trauma into 4 sub-groups according to the location in which abdominal surgical intervention was performed (abdominal surgery performed only in Syria, surgery in Syria and subsequent re-laparotomy in Israel, abdominal surgery only in Israel, and management of patients without abdominal surgical intervention). We focused on missed injuries and post-operative complications in the re-laparotomy sub-group. Results By July 2018, 1331 trauma patients had been admitted to our hospital, of whom 236 had suffered abdominal trauma. Life-saving abdominal intervention was performed in 138 patients in Syria before arrival to our medical center. A total of 79 patients underwent abdominal surgery in Israel, of whom 46 (33%) required re-laparotomy. The absence of any communication between the surgical teams across the border markedly affected our medical approach. Indications for re-exploration included severe peritoneal inflammation, neglected or overlooked abdominal foreign bodies, hemodynamic instability and intestinal fistula. Mortality occurred in 37/236 patients, with severe abdominal trauma as the main cause of fatality in 10 of them (4.2%), usually following urgent re-laparotomy. Conclusions Lack of information about the circumstances of injury in an environment of catastrophe in Syria at the time and the absence of professional communication between the surgical teams across the border markedly dictated our medical approach. Our concerns were that some patients looked deceptively stable while others had potentially hidden injuries. We had no information on who had had definitive versus damage control surgery in Syria. The fact that re-operation was not performed by the same team responsible for initial abdominal intervention also posed major diagnostic challenges and warranted increased clinical suspicion and a change in our standard medical approach.

Background: During the Syrian civil war, casualties were treated on-site and only later transferred to foreign medical centers. Significant number needed abdominal re-operation. Our aim is to present our approach to abdominal trauma casualties who survived the on-site surgery and needed abdominal reoperation abroad.Methods: Medical data from all medical records were retrospectively analyzed. Each patient underwent total body computerized tomography on arrival, revealing diverse multi-organ trauma. We divided the casualty population involving abdominal trauma into 4 sub-groups according to the location of abdominal surgical intervention, focusing on missed injuries and post-operative complications in the re-laparotomy sub-group. Results: By July 2018, 236 casualties suffering abdominal trauma (among 1331 trauma casualties) had been admitted to our hospital. Life-saving abdominal interventions had been done in 138 subjects in Syria before arrival to our medical center. Seventy-nine underwent abdominal surgery in Israel, of whom, 46 (33.3%) needed abdominal re-laparotomy. Indications for re-exploration included severe peritoneal inflammation, neglected abdominal foreign bodies, hemodynamic instability and intestinal fistula. Mortality occurred in 37/236 patients, with abdominal trauma as the main cause of fatality in 10 of them (4.2%), usually following urgent re-laparotomy. Conclusions: Clinical presentation of the Syrian casualties following emergency medical care outside our borders, and the fact that re-operation was not done by the same team responsible for the initial abdominal intervention posed major diagnostic challenges and necessitated increased suspicion and changes in our medical approach.