With Syria's medical infrastructure in tatters, many of its doctors in exodus and security conditions making parts of the country difficult to access, medics have been treating the war wounded across the border in Lebanon and Jordan.
Several international organisations have set up medical centres and operating rooms near the Syrian border to treat injuries caused by armed conflict.
In addition to performing life-saving surgery, teams provide follow up care and rehabilitation services, medics near the Syrian border told Al-Mashareq.
Some teams are based in Lebanon and Jordan and perform their work there because they cannot operate in the conflict zones in Syria, while others provide support and guidance to medics in Syria over the internet.
With the collapse of Syria's health sector, doctors from the Syrian American Medical Society (SAMS), a nonprofit medical relief organisation operating in Syria and neighbouring countries, have stepped in to help cover the shortfall.
SAMS currently provides medical services in Syria, Lebanon, Jordan, Turkey and Greece, said Dr. Mohamed Sekkarie, a US-based nephrologist and urologist who serves on the SAMS nephrology committee.
"SAMS doctors working in Syria examined three million cases last year and conducted war surgeries," Sekkarie said.
Because of the shortage of specialised physicians in Syria, "we are helping the doctors and medical students who remained in Syria with their surgeries remotely via telemedicine over the internet", he said.
"We perform surgeries remotely with doctors inside Syria, guiding them through the surgery to ensure its success," he said. "We help them in this way to save the lives of the wounded in many areas of Syria."
Lebanon-based ICRC operations
The war in Syria "is leaving a large number of wounded daily, while good medical care is not available, and this leads to complications and infections", said Fabrizio Carboni, head of the International Committee of the Red Cross (ICRC) delegation in Lebanon.
"Our inability to send specialised ICRC medical teams into many areas in Syria forced us to operate out of Lebanon, using its extensive experience in treating war-time injuries," he said.
"All we can do in Syria is support the medical facilities [in areas] under the regime’s control, and provide medical equipment to centres [in areas] under the opposition’s control," he added.
"We developed a reconstructive surgery centre three years ago in Tripoli and in the Rafiq Hariri Hospital in Beirut in partnership with surgeons from American University of Beirut Medical Centre (AUBMC), where we provide war-time surgery services, psychotherapy and prosthetics fitting," he said.
Carboni said the injuries vary, and are caused by "explosions, building collapse, delay in treatment resulting in inflammation of the wounds, as well as burns and loss of limbs. The injured are of all ages and include a large number of children".
ICRC centres treat hundreds of patients each year, he said, and follow up on their cases for at least six months, as some require multiple surgeries and rehabilitation.
War-time surgery programme
Injuries and disabilities caused by the war in Syria "are piling up and increasing due to the collapse of the health sector and mass emigration of doctors", said Dr. Ghassan Abu-Sitta, head of cosmetic and reconstructive surgery at AUBMC.
This has forced medics who remain in the country to focus their efforts on saving lives, he told Al-Mashareq.
To address the shortage of medical professionals, "international organisations became involved in performing war-time and reconstructive surgery", he said, which has helped to offset the loss of 50% of Syria's doctors and 60% of Iraq's.
A war-time surgery and rehabilitation programme is being implemented in partnership with AUBMC and other international medical organisations, he said.
The AUBMC is working to roll it out to conflict-stricken countries such as Iraq, Syria and Libya, to train doctors on war-time surgery, he said.
This work "is aimed at saving the lives of the seriously wounded who require surgery, and because the number of wounded is increasing", Abu-Sitta said.
The number of those wounded in Syria each year is six times the number of those who die, he noted.
Doctors Without Borders in Jordan
In Jordan, Doctors Without Borders (MSF) co-ordinator Dr. Rashid al-Samerrai, an orthopedic surgeon, spoke with Al-Mashareq about the challenges of war-time surgery.
"At Al-Mouwasat Hospital we have a team of orthopedic surgeons and specialists in facial cosmetic surgery and maxillofacial and corrective surgery who perform surgery on the wounded," he said.
"We are often faced with difficult and complex cases," he said, adding that every day brings injuries that are challenging to treat.
The rate of success of war-time surgeries varies depending on the injury and how quickly the intervention and treatment are started, al-Samerrai said.
War-time surgery is "demanding, given the complexity of the injuries and complications for the patient that could result from them", he said.
Al-Mouwasat Hospital treats a large number of wounded Syrians, Iraqis and Yemenis, he said, but its proximity to Syria means Syrian patients can get there faster, and consequently their injuries are easier to treat.
Common injuries are "loss of tissue, tissue contraction, severe burns and hand tendon injuries", he said.
"All these cases require us to perform corrective surgery and try to compensate for the loss of bone mass, tissue or nerves," he added.
MSF treats 60 cases of all ages per month, which increases during emergency situations, he said, adding that MSF doctors work hard to stay up to date on surgical advances to provide effective treatment for patients from war zones.