Introduction The full-scale war with Russia on the territory of Ukraine has revealed several problems related to care of the wounded. In this article, we summarize the mechanisms of injury and injuries sustained for the period February to April 2022, focusing on extremity injuries. Materials and methodsWe compared these to a period of lower-intensity warfare in 2014-2021. In both cases, we report patients treated by the National Military Medical Clinical Center (NMMCC) in Kyiv. We also sought to evaluate the care of the wounded from an organizational viewpoint, taking into account the four-level system of care also used by the North Atlantic Treaty Organization (NATO). Third, we sought to understand lessons learned that could improve the care of the wounded. Conclusion During the 2022 conflict, the percentage of patients with extremity wounds who had long bone fractures increased and the percentage of people with long bone fractures who had bone defects increased, compared with 2014-2021. This may be due to the higher blast energy from the weapons used in the current conflict. Second, we adapted the four-level NATO system of care. Level 2 (first level hospital) care was provided by civilian hospitals close to the fighting, rather than mobile military hospitals. Level 3 (specialized) and 4 (highly specialized) care were combined into one hospital (NMMCC). This is the first description of flexible use of NATO's four levels. Finally, a major lesson learned was the need to improve use of damage control surgery. Dedicated to the heroic deeds of Ukrainian doctors in the name of life!.

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Introduction The incidence of vascular damage in modern combat conflicts is 5 times higher than in previous military conflicts, with one in five wounded having uncontrolled severe blood loss. Treatment of gunshot wounds of the main arteries is a complex multi‐level process, which can be done only in the case of close cooperation of related surgical specialties. Case report This case report details treatment of a 40‐year‐old man who was admitted with a gunshot wound to the left shoulder with injury of the distal axillary and proximal brachial arteries. Primary surgical treatment consisted of venous interposition graft of the injured artery and debridement of the scapular wounds in a peripheral hospital. He was transferred to Main Military Medical Clinical Center in Kyiv with acute thrombosis of the vascular repair graft. Urgent reoperation was performed, with removal of the previously placed vascular graft and revascularization of the distal axillary and proximal brachial artery with reverse venous graft, with accompanying fasciotomy. Conclusion This case demonstrates the crucial role of rapid evacuation of wounded to a specialized level of care for complex cases such as arterial reconstruction.

Background The current war in Ukraine is associated with frequent applications of multiple-launch rocket systems and cruise missiles as well as other various high-energy weapons to cause severe injuries in military personnel including abdomen wounds, vascular injury, and limb amputations as well as genitourinary trauma. The aim of this report is to demonstrate a case of successful penile salvage by restoring its function in a combat patient with gunshot genitourinary trauma in conditions of an interrupted supply of medical equipment. Case presentation We describe a case of a 48-year-old male patient with a combined shrapnel gunshot wound to the penis with damage to the urethra and combined injury to the soft tissues of the left thigh. Several hours after the injury, the patient underwent primary surgical debridement of the left thigh, ligation of the great saphenous vein of the thigh, primary sutures on the penile urethra and navicular fossa, suturing of the rupture of the head and penis, drainage of the wound, catheterization of the bladder, and epicystostomy. An artificial erection was performed intraoperatively. The urethral catheter was removed 3 weeks after urethral suturing (May 4, 2022). The epicystostomy was removed 5 months after the injury (August 4, 2022) and 2 days after the restoration of spontaneous urination. At the follow-up of 7 months after the injury, the patient has normal urination with minor urinary dribbling, sufficient erection, and ejaculation. Conclusions We have shown that in a case of gunshot wounds to the penis and hanging part of the urethra, even in the presence of combined severe purulent lesions of non-urological localizations, it is possible to perform a primary reconstruction of urogenital injuries using a primary urethral suture and applying a negative pressure device. Findings from this case report shed new light on the management of penile gunshot injury in ongoing warfare as well as provide evidence of the possibility to perform adequate management for penile injury in conditions of limited medical resources, violation of international humanitarian law, and under frequent strikes of high-energy weapons.

The postoperative eventration is one of the severe complications of abdominal oncological surgery, which complicates of postoperative course and leads to long‑term inpatient treatment, repeated surgery and forming laparostoma, filled with hypertrophic granulations. In spite of the numerous of surgical methods proposed for anterior abdominal wall wound closure in such patients, the anterior abdominal wall reconstructive operations keep to stay the difficult and unresolved challenge for abdominal surgery.The aim — to improve the outcomes of surgical treatment of severe patients with postoperative anterior abdominal wall defects (eventration) with full‑thickness Keystone flap procedure.The case report of the closing of anterior abdominal wall defect after chemotherapy complicated by intestinal bleeding, perforation, peritonitis, repeated operations has described in the article. The possibility of the successful multimodal reconstruction of anterior abdominal wall defects in oncology patient with using perforating vessels flap has demonstrated in the case report. The identification of perforating vessels with satisfactory tissue perfusion of Keystone flap with using of combine method (infrared thermometry and Doppler velocimetry) had been conducted in the preoperative period. The surgical debridement of the anterior abdominal wall, wound cavitation with low‑frequent ultrasound, wound closure with Keystone flap had been performed as the first stage of treatment. The midline laparotomy, the adhesiolysis, the sanitation and drainage of intestinal interloop abscesses, the right‑side hemicolectomy had been conducted as the second treatment step. The third stage of the surgery was closing of the midline laparostoma by means of the repeated surgical debridements of the anterior abdominal wall wound, the wound plastic with Keystone flap formed from the soft tissue of chest anterior wall.Conclusions. The successful closure of anterior abdominal wall eventration with forming laparostoma filled by hypertrophic granulations must be based on dynamic control approach of soft tissue perfusion of anterior abdominal wall.