Surgical Service Delivery in a Fragile State: A 10-Year Analysis of Volume and Burden at Somalia's Largest Tertiary...

Somalia represents a critical data vacuum in global health. While its surgical burden of disease is presumed to be high, the absence of empirical data hinders effective policy and humanitarian aid. This study provides the first large-scale, longitudinal analysis of surgical care delivery in this fragile state, offering a foundational dataset where none previously existed.

We conducted a 10-year retrospective analysis of 52,469 surgical procedures performed between January 2016 and June 2025 at Somalia's largest tertiary referral hospital. We analyzed trends in surgical volume, procedural distribution, and risk factors for 30-day postoperative mortality to characterize the disease burden and institutional capacity.

Surgical volume increased significantly over the study period, with General Surgery (22.3%), Orthopedics (14.7%), and Urology (12.5%) being the most common specialties. The procedural mix revealed a dual burden of trauma and obstetric emergencies alongside a growing capacity for elective surgery. Notably, Caesarean section was the single most frequent procedure among the top 10 indications, accounting for 32% of these high-volume cases. The overall 30-day postoperative mortality rate was 7.2%. Multivariate analysis identified ICU admission as the strongest independent predictor of mortality (AOR 7.28; 95% CI 6.75-7.85), followed by general anesthesia (AOR 4.67; 95% CI 4.02-5.43) and operative duration exceeding 4 h (AOR 1.69; 95% CI 1.42-2.00).

This foundational dataset provides the first empirical evidence of tertiary-level surgical needs in Somalia. The findings reveal the hospital's crucial role as an "island of capacity" in a fragile health system, absorbing a concentrated burden of risk from a vast, underserved region. The high volume of Caesarean sections functions as a barometer of systemic weaknesses in primary and district-level care. The identified predictors of mortality reflect a patient population with extreme clinical acuity, underscoring the urgent need for a National Surgical Plan to build a resilient referral system and address the country's immense unmet surgical needs.