Surgical outcomes in an improvised underground operating room during missile attacks

Armed conflict disrupts healthcare when hospital infrastructure is vulnerable to missile attacks. During a 12-day missile strike period, our hospital established an improvised operating room (OR) in an underground parking lot. This study evaluated perioperative and short-term outcomes among patients treated in the improvised OR compared with those treated in the hospital's fortified standard OR.

This retrospective cohort study included patients undergoing general or orthopaedic surgery during the 12-day conflict. Procedures identified via surgical logs were categorized by OR location (improvised or standard). Demographic, perioperative, and post-discharge data were collected from electronic records. Primary outcomes included operative time, estimated blood loss, transfusions, complications, hospital and ICU length of stay, ED visits, readmissions, and 3-month mortality.

Overall, 74 surgeries took place in the improvised OR and 77 in the standard OR. Patients in each group were comparable in age, sex, comorbidities, and anesthesia. Improvised OR surgery time was longer (mean 68.1 vs. 47.7 minutes, p < 0.001). There were no significant differences between groups in terms of blood loss, transfusions, postoperative complications, or hospital length of stay. After 3-month follow-up, there were no significant differences in readmissions or mortality rates.

Establishing an improvised underground OR during an armed conflict enabled maintaining surgical capacity without compromising short‑term patient outcomes. Prolonged operative time likely reflected logistical challenges in supply management.