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ICRC expertise in war surgery

26-05-2009 Interview

ICRC war surgeon Chris Giannou explains the scope and objectives of the new publication, "War surgery: working with limited resources in armed conflict and other situations of violence". As co-author, Giannou provides some insight into the ICRC's war surgery policy and practices in general as well as the new content featured in the book.

What is the basic thinking behind this new publication?  

War surgery involves working in an austere environment under precarious circumstances: a situation usually defined as one of under-development (in terms of the infrastructure, the lack of human resources and sophisticated technology); harsh working conditions due to the physical environment of an isolated location and exposure to the climate; and the stress and danger associated with a zone of armed conflict.


The ICRC has acquired considerable expertise in caring for the victims of armed conflict in an austere environment, particularly in settings where the healthcare system has been severely disrupted. This know-how derives from three different, but related programmes in various countries afflicted by armed conflict and other situations of violence around the world.

1. Independent ICRC-run hospitals.

2. Support to local hospitals through the short-term presence of expatriate surgical teams, with a strong focus on training and capacity building; the provision of supplies and equipment; the renovation of infrastructure and water and sanitation facilities; and financial incentives and salaries for local staff when necessary.

3. Organization of war surgery seminars, which provide opportunities for colleagues to exchange experiences and expertise.

This new publication gathers together the experience derived from these three types of programmes in defining ICRC clinical protocols and procedures. A great deal is predicated on the discussions and exchange of experiences between ICRC surgeons and those colleagues who have attended the more than 120 war surgery seminars that have been organized in over 30 conflict-affected countries.

 What is new in this book?  

To meet the challenge faced by surgeons who face war wounded patients for the first time under these extreme conditions, our predecessors in the surgical department of the Medical Division of the ICRC produced a basic reference manual: Surgery for victims of war. The first three editions of this book have been extensively distributed and received wide acclaim the world over.

Originally intended as a fourth edition of this classic work, developments in ICRC surgical practice and questions and requests during war surgery seminars soon made it clear that an entirely new book, to be published in two volumes, was necessary.

A significant amount of new material has been added to this Volume 1, particularly in the non-surgical chapters that deal more widely with general topics concerning the coordination, logistics, and principles underlying the ICRC approach. These include:

  • Special Characteristics of Surgery in Times of Conflict

  • Applicable International Humanitarian Law

  • Wound Ballistics

  • The Epidemiology of the Victims of War

  • The Chain of Casualty Care

Recent developments in the field of trauma surgery (emergency room resuscitation, damage control surgery, the fatal triad of hypothermia, acidosis and coagulopathy) have also been included, and the surgical chapters entirely rewritten.

 What are some of the lessons that the ICRC has learned from these many years of war surgery programmes?  

The philosophy behind the ICRC approach is based on the concept of appropriateness; what is appropriate in one context does not necessarily apply to another, and the key to operational success is to define the correct – appropriate – response to a given situation.

Thus, we may describe a spectrum of " surgeries " for war wounded depending on the human resources and technology available. There are four basic levels of organization and sophistication of the surgical care available for war wounded patients:

  1. classical army of an industrialized country where the soldier can expect the same level of care as offered to a civilian trauma victim at home;

  2. country with an emerging economy where sophisticated care may be available in the major cities, but this is not often the case in remote rural areas where most modern armed conflict takes place;

  3. low-income country where, even in peacetime, basic medical services are stretched thin and the public health system is one of the very first victims of armed conflict;

  4. non-state actors and belligerent civilian populations where the availability of surgical care may be close to non-existent.

The pathology is similar in all of these cases; however, the diagnostic and therapeutic means available differ widely. Sometimes, the technology is relatively sophisticated and trained staff numerous. In most contexts where the ICRC is involved (levels three and four), what is appropriate is often a question of making the best of very limited resources. ICRC experience has shown that a great deal can be accomplished for the war wounded by using very simple, but scientifically adequate and appropriate, means. This approach has proven to be very cost effective, especially important in a country with limited financial resources where every penny spent on curative care is at the expense of preventive measures.

Who will benefit most from this publication?  

ICRC practice in most instances does not differ greatly from that of a public hospital in a rural area of a low-income country that faces the extra health burden of caring for those wounded by the weapons of war. The explanations of techniques are geared to the level of knowledge and practice of general surgeons in a rural hospital . These surgeons are often the first to see patients wounded in conflict and they know that, under the circumstances, referral to more sophisticated facilities – far away in an inaccessible capital city – is impractical or impossible. This book attempts to provide surgeons in a conflict-affected country – civilian and military – who do not have specialized training with basic advice about the treatment of various weapon wounds, describing the types of operations that have proved successful in ICRC and other comparable practice.

Secondly, those surgeons from National Societies of the Red Cross and Red Crescent or from non-governmental organizations, who go out on a humanitarian mission for the first time and face the challenges of a totally new pathology under extreme conditions and precarious circumstances will profit from reading through this book prior to their deploy.


Chris Giannou, ICRC war surgeon 

Chris Giannou, ICRC war surgeon

Djebel Mara region, Sudan. A medical group based in Nyala performs an emergency operation in a field clinic. 

Djebel Mara region, Sudan. A medical group based in Nyala performs an emergency operation in a field clinic.
© ICRC / B. Heger / sd-e-02138

A doctor at Keysaney Hospital in Mogadishu, run by the Somali Red Crescent and supported by the ICRC, operates on a patient wounded in shelling. 

A doctor at Keysaney Hospital in Mogadishu, run by the Somali Red Crescent and supported by the ICRC, operates on a patient wounded in shelling.
© ICRC / V. Louis / so-e-00302

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