Dmytro Mialkovskyi

Modern combat trauma care has improved survival through damage control surgery and advanced resuscitation. However, contemporary battlefield experience shows that life-saving procedures may also cause substantial iatrogenic morbidity and long-term functional impairment. Cricothyrotomy, left anterolateral and clamshell thoracotomy, extensive laparotomy and resuscitative endovascular balloon occlusion of the aorta may be indicated in selected patients but carry significant physiological, reconstructive, infectious and functional consequences. This paper examines the limits of aggressive surgical exposure in Role 2 military trauma care, drawing on current evidence, clinical guidelines and contemporary combat experience. We discuss the indications, risks and potential overuse of highly invasive interventions, particularly in resource-constrained settings with prolonged evacuation times. Damage control surgery should remain physiology-driven and indication-based rather than a strategy of maximal intervention. When feasible, less invasive alternatives should be considered to reduce iatrogenic burden while optimising survival and long-term functional outcomes.

Current civilian algorithms for penetrating neck trauma assume access to definitive vascular reconstruction, endovascular intervention, advanced imaging, and specialist multidisciplinary care. These assumptions may not apply to Role 2 military facilities, where neck exploration can commit the surgeon to procedures that cannot be completed under optimal conditions. This position paper was developed through a focused narrative review of contemporary recommendations and literature on penetrating neck trauma, vascular and aerodigestive injury, temporary hemorrhage control, and combat casualty care, supplemented by targeted PubMed searches addressing penetrating carotid injury, temporary vascular shunting, carotid collateral circulation, aerodigestive trauma, balloon tamponade, and Role 2-to-Role 3 evacuation. We propose a combat-specific framework distinguishing injuries requiring immediate surgery from those in which temporary hemorrhage control, airway protection, stabilization, and evacuation may better preserve definitive treatment options. The framework challenges automatic application of selected civilian indications for neck exploration in stable patients when hemorrhage is controlled and safe evacuation is feasible, extends this selective approach to aerodigestive injuries, and incorporates transport conditions and en-route rescue capability into the decision to operate. We also propose hypotheses regarding common carotid artery shunting, including the potential effects of collateral cerebral perfusion, shunt position, configuration, monitoring limitations, and thromboembolic complications on neurological outcomes. Role 2 decision-making should incorporate surgical capability, physiology, airway security, effectiveness of temporary hemorrhage control, and evacuation feasibility. Safe evacuation depends not only on transport time but also on the reliability of temporary control and the ability to manage deterioration en route. Rather than replacing civilian algorithms, this framework adapts them to combat casualty care while introducing hypotheses requiring prospective clinical and experimental validation.

Aim. To analyze modern approaches to the treatment of soft tissue defects of the extremities in military conflicts and to evaluate the role of synergy between Role 2 and Role 3 medical care levels as a key factor in effective functional wound closure and preservation of reconstructive potential. Materials and methods. A systematized search and critical analysis of relevant scientific literature published mainly between 2021 and 2026 was conducted. The search included publications indexed in major scientometric databases and electronic resources: PubMed, Google Scholar, and Web of Science. The analysis involved sources covering experience in treating combat extremity injuries, the principles of echeloned medical support according to NATO standards, modern methods of wound bed preparation, and soft tissue reconstruction technologies in conflicts in the Middle East, Afghanistan, Iraq, and during the full-scale Russo-Ukrainian War. Results. It was established that the primary factors complicating early soft tissue defect closure are biofilm-associated infections, the presence of devitalized tissues (“gray zone” of ischemia), and insufficient wound bed preparation. It was demonstrated that aggressive surgical interventions at the Role 2 level, specifically excessive debridement and disruption of vascular architecture, can significantly limit the options for applying local and regional flaps at Role 3. Conversely, a staged, tissue-sparing approach that preserves anatomical structures creates the necessary conditions for utilizing advanced wound bed preparation methods and effective reconstruction, ranging from simple local flaps to perforator flaps and, where indicated, free tissue transfers. Conclusions. Effective treatment of extremity soft tissue defects in military settings is only possible through close synergy between Role 2 and Role 3 and a clear delineation of their respective tasks. Focusing on the preservation of reconstructive options at the early stages, the application of modern wound bed preparation methods, and a staged approach to reconstructive decisions improve functional outcomes and increase the chances of returning the wounded to active life or military service.

Aim. To evaluate the feasibility, indications, and outcomes of laparoscopic surgery in hemodynamically stable combat casualties with abdominal trauma during the Ukrainian War of Independence. Material and methods. A retrospective observational study included 238 hemodynamically stable patients with combat-related abdominal trauma treated at the Zaporizhzhia Military Hospital between 2022 and 2025. Medical records, operative protocols, imaging examinations (e-FAST, computed tomography), and intraoperative documentation were analyzed. Results. Laparoscopic procedures performed included diagnostic laparoscopy (n = 78), foreign body removal (n = 60), hemostasis (n = 23), diaphragmatic repair (n = 19), hollow viscus suturing (n = 15), splenectomy (n = 5), and colectomy / colostomy (n = 12). Conversion to laparotomy was required in 28 cases (11.8 %), while secondary laparotomy was needed in 5 patients due to missed bowel injuries, intra-abdominal abscess, ileus, or bleeding. The best outcomes were achieved in American Association for the Surgery of Trauma (AAST) grade I–II injuries. Advanced bowel resections were technically complex requiring further validation for routine use. Barbed suture-based closure improved safety and efficiency in diaphragmatic and hollow viscus repair. Conclusions. Laparoscopy appears to be a safe and effective option for selected hemodynamically stable patients with abdominal combat trauma. It reduces rates of unnecessary laparotomies, postoperative complications, and recovery time, facilitating faster return of soldiers to duty. Complex bowel resections require further validation before routine implementation in military trauma surgery.

Aim: Penetrating blast injuries to the neck carry a high risk of mortality due to the presence of vital structures. Common carotid artery (CCA) injuries require urgent management to prevent exsanguination or ischemic complications. Temporary shunting is often preferred in ROLE 2 (NATO medical role system) military settings, as it reduces stroke and mortality rates. However, in cases where vascular ex-pertise is limited, CCA ligation may be a safer and faster alternative, as it minimizes the risk of distal embolization. This case report presents a combat-related CCA injury and the rationale for ligation over shunting in a ROLE 2 envi-ronment.Methods: A 35-year-old soldier sustained a blast injury to the neck and was evacuated to a front surgical team with signs of major vascular damage. Surgery identified injuries to the right CCA and vertebral artery. Due to the risk of em-bolization and limited vascular expertise, CCA ligation was performed instead of temporary shunting. The patient was stabilized and transferred to ROLE 3 for definitive repair, where autologous vein grafting was successfully performed.Results: Temporary shunting is the preferred approach for maintaining cerebral perfusion but requires vascular ex-pertise and carries the risk of embolization. In resource-lim-ited combat settings, ligation provides rapid hemorrhage control and facilitates faster evacuation. This case demon-strates that CCA ligation can be an effective damage control strategy when shunting is not feasible. The patient recov-ered well, with minimal postoperative complications.Conclusions: Combat-related CCA injuries require rapid de-cision-making based on available resources and expertise. While temporary shunting is ideal, ligation is a practical al-ternative in ROLE 2 settings where vascular specialists are unavailable. This case highlights the need for adaptive sur-gical strategies in military trauma care.

Introduction: High-energy combat trauma often results in injuries to both the radial and ulnar arteries, accompanied by extensive soft tissue loss and a low probability of sufficient collateral flow. Materials and Methods: A case series of 28 male patients with acute forearm arterial injuries from combat trauma was reviewed. Surgical approaches included ligation, end-to-end anastomosis, and autologous vein grafting. Temporary shunting was employed in select cases. The clinical outcomes were assessed. Results: Among 28 cases, 26 achieved successful hand salvage. Complications included one graft thrombosis (leading to amputation) and one death. Good late outcomes were achieved in 60% of cases. Conclusions: Repair of at least one forearm artery is essential in dual injuries. Autologous vein grafting is preferred for combat trauma. Mangled Extremity Severity Score may not reliably predict amputation. Temporary shunts can be effectively utilized with appropriate adjuncts

Aim: to demonstrate the possibilities and advantages of laparoscopic surgery in combat-related abdominal penetrating trauma with colon injury. Materials and methods. This case report presents the first experience of laparoscopic colon resection with primary anastomosis for combat-related thoracoabdominal trauma with through-and-through colon injury. A 47-year-old serviceman sustained an explosive penetrating thoracoabdominal injury (dropping explosives from a drone) operated 10 hours after. Initial management at Role 2 included chest tube drainage, surgical debridement, and wound sealing of the chest. CT: penetrating gunshot wound with internal and external damage to the lower lobe of the left lung, perforation of the diaphragm on the left, and transverse colon perforation with a retained metal fragment, pneumoperitoneum, drained hemopneumothorax, and a gunshot fracture of the posterior third of the 5th left rib. Exploratory laparoscopy revealed no free fluid in the abdominal cavity. Surgery: the diaphragmatic perforation was sutured with a 3-0 V-loc barbed suture, the segment of the transverse colon was resected using two Endo-GIA 60 linear staplers according to the severity of injury (AAST Grade 3) and non-viable edges of colon wound. To ensure mobility, a side-to-side antiperistaltic anastomosis was performed using an Endo-GIA 60 stapler (blue cartridge). The anastomosis site was reinforced with a single-layer 3-0 V-loc suture. The procedure was completed with abdominal drainage and port site closure. Results. Postoperative recovery was without complications. The abdominal drain was removed on the 2nd day, and the pleural drain on the 5th day after the control CT scan. Follow-up after 1.5 month – returned to military service. Our case demonstrates that laparoscopic surgery can be a useful option for combat-related colon injuries when tissue damage is minimal and the patient’s condition is stable. The absence of massive hemoperitoneum and contamination confirms the feasibility of primary repair or anastomosis. Conclusions. Laparoscopic surgery for combat-related penetrating abdominal trauma with colon injuries is feasible and safe in stable patients. If there are no multiple colon injuries or significant contamination, primary repair or stapled anastomosis is a suitable option.

Introduction and relevance: Penetrating neck trauma results in a 10% mortality rate for patients and management can be challenging, often requiring a multidisciplinary approach. Methods: This is a case report of a 33-year-old male patient who received a neck gunshot through the oral cavity during close combat on the south front of the Ukrainian-Russian war in January 2023. Clinical discussion: A CT scan revealed a foreign body in the neck on the right side, between the mastoid process and the right jaw angle. A CT scan with contrast revealed a foreign body in the neck – a bullet – and helped with observing relations to surrounding tissues and following the bullet’s trajectory. The multidisciplinary team performed surgery for foreign body removal. As a first step, carotid arteries and the internal jugular vein were dissected and looped to control potential bleeding. The bullet was 7.62 caliber. The patient recovered well with minimal postoperative complications, including hypoglossal and facial nerve neuropathy, which resolved in two weeks. Conclusion: The proximity gunshot resulted in unexpectedly moderate tissue injury, but regardless of the relatively low destruction of palate tissue, the location of the foreign body near carotid arteries made the surgery approach challenging.

With development of minimal invasive surgery ambitions to improve cosmetic outcomes after thyroidectomy led to invention of Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA). This technique implies port placement through the vestibulum of the oral cavity into the subplatysmal space. Robotic endoscopic thyroidectomy can be performed either. In contrast to open surgery TOETVA is not done in case of large thyroid gland, sub- and decompensated thyrotoxic goiter, prominent chin, retrosternal goiter, previous neck surgery/radiation; there are some limitations depending on size and histological type of the node. The rate of complication does not differ from conventional surgery. Specific complication for TOETVA is mental nerve injury. Transoral endoscopic thyroidectomy vestibular approach is feasible and safe surgery with outstanding cosmetical and clinical results for selected patients. Further researches are required to assess TOETVA. З розвитком мініінвазійної хурургії прагнення покращити косметичний ефект після резекції щитоподібної залози привело до розробки трансоральної ендоскопічної тиреоїдектомії вестибулярного варіанта (ТОЕТВВ). Дана методика передбачає встановлення портів через переддвер’я ротової порожнини в субплатизматичний простір. Ендоскопічна тиреоїдектомія може виконуватися за допомогою робота. На відміну від відкритої резекції щитоподібної залози ТОЕТВВ не виконується при великих розмірах залози, суб- та декомпенсованому дифузному токсичному зобі, високому підборідді, загруднинному зобі, попередніх операціях на шиї і/або радіотерапії, існують також обмеження щодо розмірів вузла залежно від гістологічного типу. Частота післяопераційних ускладнень не відрізняється від відкритої методики. ТОЕТВВ притаманне специфічне ускладнення — ушкодження підборідного нерва. Трансоральна резекція щитоподібної залози є доцільною і безпечною операцією з відмінним косметичнимта клінічним результатами для ретельно відібраних пацієнтів. Необхідні подальші дослідження методики.