Implementation and feasibility of telemedicine post-surgical follow-up clinics in Gaza during active conflict

Abstract

Introduction

The conflict in Gaza has devastated its healthcare infrastructure, leaving many hospitals nonfunctional and created a significant need for specialized medical care. Peripheral nerve surgery is one such subspecialty due to endemic nerve injuries caused by shrapnel and high velocity trauma, requiring timely intervention and long-term follow-up. The scarcity of specialists in Gaza presents a major challenge not only in treating these cases but also in monitoring patients after international volunteer surgical missions conclude. This study describes the feasibility of implementing an online telemedicine clinic to provide post-surgical follow-up care for patients in Gaza during an active war, and outlines the steps taken to ensure continuity of care for postoperative patients under severe system disruptions.

Methods

A remote telemedicine initiative was implemented to provide post-surgical care to patients operated on by a London-based volunteer surgeon during his surgical missions, thereby unburdening local teams. These follow-ups were conducted through online clinics with the assistance of local junior doctors, offering continuous care for patients after complex nerve surgery. During these clinics patients were monitored for clinical progress, surgical complications, and further management plans including physical therapy, diagnostics, or local referrals. Satisfaction rates from local staff and treated patients were also assessed.

Results

Six telemedicine clinics were held across northern and southern Gaza between September 1st to 31st 2024, with a total of 115 patients reviewed from 144 successful contacts (80% attendance rate). Most cases involved single nerve injuries (n = 69), brachial plexus injuries (n = 8), and complex fractures (n = 8). Patients were able to access postoperative review with the operating surgeon through telemedicine. Clinical investigations, medication prescriptions, and physiotherapy referrals were successfully coordinated through the service. Patient satisfaction responses were positive, with 85% reporting “very satisfied” and 15% “satisfied”. Local surgeons also reported the service to be useful.

Discussion

This experience suggests that structured telemedicine follow-up for complex surgical patients is feasible in a conflict setting despite major logistical barriers. Reliable local collaboration, communication systems, and basic digital infrastructure appear essential for successful delivery. These findings support consideration of structured follow-up pathways when visiting teams undertake complex surgery in conflict settings.

Introduction

The ongoing conflict in Gaza has led to the complete collapse of the healthcare system, with more than half of all hospitals now out of service and the remainder completely overwhelmed [1]. At the time of writing, 60,138 people have been killed, with a further 10,000 estimated to be missing under the rubble, and more than 146,269 injured by the end of July 2025 [1].

Several types of complex injuries have been described due to the deployment of a variety of explosive devices. These include extensive soft tissue injuries, complex open fractures, peripheral nerve injuries, amputations, spinal cord injuries, traumatic brain injuries, and burns [2]. The use of the latest weapon technology in this conflict has resulted in more devastating destruction and therefore more extensive injuries among survivors. This highlights the need for specialized care, including the management of peripheral nerve injuries which are particularly challenging to treat [3]. The scarcity of peripheral nerve specialists in Gaza means they must rely on visiting surgeons to address this shortage.

Medical missions to Gaza have provided essential surgical interventions for various complex injuries. These missions typically involve visiting surgeons who perform complex procedures under limited resource conditions. In our study, a peripheral nerve surgeon completed 290 peripheral nerve surgeries during a single three-month mission [4]. Under normal circumstances, many missions are short term, usually between two and four weeks. Although they address immediate surgical needs, long term care often remains a challenge. The lack of specialized care within Gaza presents a major obstacle to sustained follow-up, leaving patients without appropriate postoperative guidance regarding monitoring, complications, or rehabilitation. Failure to establish postoperative follow-up may compromise continuity of care and place additional strain on already burdened local services.

In peripheral nerve surgery it is particularly important to have both short term and long-term follow-up, as specialized rehabilitation is critical to successful outcomes [5]. Immediate postoperative follow-up is usually managed during surgical missions, but access to specialized care after surgeon’s leave is virtually nonexistent. Local surgeons are overburdened with acute trauma and lack both the subspecialty training and the time. To unburden colleagues and monitor our surgical cases, we explored alternative solutions such as telemedicine to offer safe follow-up in both the short and long term.

Telemedicine has already proven its value in conflict areas around the world. Studies have shown its importance in maintaining healthcare services where access to physical facilities is limited due to security threats, damaged infrastructure, or geographic barriers [6, 7]. Previous studies have demonstrated that telemedicine is acceptable and feasible for both patients and healthcare professionals [8, 9]. In Afghanistan, telehealth programs have supported mental health services for patients and healthcare workers amid ongoing violence. They also allow remote diagnosis, treatment, and continuity of care [6, 7]. More than 60,000 telemedicine visits were completed within the first 18 months of the Russia Ukraine conflict [7]. Recently, an international initiative led by physicians around the world used telemedicine to assist local doctors in Gaza in guiding care for complex trauma cases [10]. This initiative demonstrated the effectiveness of such systems and highlighted the need for similar interventions to support the heavily damaged healthcare system.

This paper describes our experience organizing remote online clinics for a specialized surgical service as a method of delivering postoperative care by the operating surgeon. This played a crucial role in ensuring continuous care under the extreme conditions of an active war zone. As far as we are aware, this is the first example of structured and regular telemedicine clinics used to monitor complex postoperative care in the Gaza population.

Methodology

Study design

This study is a retrospective descriptive report of implementation and feasibility of a telemedicine postoperative follow-up service using routinely collected service data. Outpatient clinics were conducted between 1st and 31st September 2025 at Al Aqsa Hospital in the south of Gaza and at the Public Aid Hospital in the north. The sessions were conducted using video conference platforms such as Zoom or Google Meet.

All patients assessed for surgical intervention by our visiting peripheral nerve surgeon, or those operated on, were included. They were organized into separate follow-up sessions for the south and north of Gaza. The telemedicine service was coordinated between two teams: an international team including the peripheral nerve surgeon, and a local team consisting of volunteer medical students and a resident doctor.

Patient appointments were scheduled to allow sufficient time for consultation regarding their medical condition. This included history taking by the senior surgeon online and examination performed by the local medical team under the surgeon’s instruction. The surgeon also communicated instructions for investigations including laboratory tests and radiological imaging. Due to the absence of an electronic medical record system, a WhatsApp group was created to allow real time sharing of test results, radiology images, and medical reports.

Feasibility

Feasibility was assessed using predefined service indicators: (1) number of clinics successfully delivered, (2) number of patients contacted, (3) attendance rate, (4) range of conditions reviewed, (5) ability to coordinate investigations, prescriptions and physiotherapy referrals, and (6) patient and clinician satisfaction.

Routine clinical assessments were undertaken during follow-up consultations to guide patient management, including review of pain, function, wound healing, complications, and progress of rehabilitation. These data formed part of clinical care. Formal analysis of clinical outcomes is outside the scope of this manuscript and is being reported separately.

Satisfaction

Following consultation, patients were asked one standardized question by a local medical student independent from the operating surgeon: “How satisfied were you with this telemedicine follow-up clinic?” Responses were recorded immediately after the consultation using five options: very satisfied, satisfied, neutral, unsatisfied, very unsatisfied. One response per patient was recorded at first attended consultation. Five local surgeons were separately asked whether the service was useful.

Ethics

This study was approved by the Research Committee of the Health Information Systems Directorate, Palestinian Ministry of Health. This project was undertaken as a retrospective service evaluation of a telemedicine follow-up pathway using anonymised routinely collected operational data. Verbal consent was obtained from patients for telemedicine consultation and anonymised use of service data. No experimental intervention was performed and no identifiable patient information was included. The study was conducted in accordance with the principles of the Declaration of Helsinki. Local governance processes available during the conflict were followed. Formal research ethics committee review was not locally available because of disruption to institutional infrastructure during the war.

Results

The visiting surgeon had completed two missions in Gaza at the time of this study, performing 290 complex surgeries and more than 1000 consultations. Of these, 159 patients required long term follow-up. A total of 144 patients provided contact details and were successfully reached to arrange follow-up sessions, while the remainder could not be traced due to war conditions. Six remote clinics were held in Gaza between September 1st to 31st 2024, with three in the southern region and three in the northern region.

Of the 144 patients contacted, 115 attended (55 in the southern region and 60 in the northern region), an attendance rate of 80% despite dangerous conditions. Of those attending, 82.6% were male and 17.4% were female (n = 95 and n = 20), with a mean age of 30.3 years. These attendance rates demonstrated the practical ability to organise and deliver remote follow-up despite active conflict, transport barriers and unstable connectivity. The predominance of male attendees may reflect barriers affecting access to follow-up during active conflict and may not represent the wider operated population. Table 1 summarizes attendance across the clinics.

Table 1.

Attendance numbers for telemedicine clinics in southern and northern Gaza

Clinic	South		North
	Total	Attendants (%)	Total	Attendants (%)
1	25	15 (60%)	33	28 (84.8%)
2	35	32 (91.4%)	26	23 (88.4%)
3	14	8 (57.1%)	11	9 (81.8%)
Total	74	55 (74.3%)	70	60 (85.7%)

Diagnostic investigations including imaging and laboratory tests requested as needed. Some patients reported symptomatic improvement during follow-up consultations. Formal analysis of pain outcomes has been reported separately [13]. Those with ongoing pain received analgesic prescriptions. At this point, not enough time had passed to reliably measure motor outcomes post nerve reconstruction. Patients stable enough for rehabilitation were referred for physiotherapy.

Postoperative complications, including infections and increased neuropathic pain, were identified and treated. Completion of investigations, prescriptions and referrals was recorded as an indicator that telemedicine consultations could generate actionable postoperative management plans in Table 2. Diagnostic categories reviewed are presented to demonstrate the breadth and complexity of cases managed through the telemedicine model in Table 3.

Table 2.

Post-consultation actions generated through telemedicine clinics

Outcomes	South	North
Complications	n = 1: Increased neuropathic pain after sciatic nerve neurolysis (later settled)	n = 3: 2 infections (treated with antibiotics) 1 increase in neuropathic pain median-radial nerve transfer (later settled)
CT	5	3
X-Ray	21	7
US	1	1
Analgesics Prescription	10	6
Referral for physiotherapy	47	60

Table 3.

Case mix reviewed through telemedicine follow-up clinics

Nerve	N	(%)
1. Single Nerve Injuries ( n  = 69)
Radial	18	15.65%
CPN (or branches)	16	13.91%
Ulnar	15	13.04
Sciatic	14	12.17%
Median	5	4.35%
Lateral cutaneous nerve of the forearm	1	0.87%
2. Combined Nerve Injuries (n = 8)
≥ 2 Ipsilateral upper limb nerve injuries	5	4.35%
≥ 2 Nerve injuries involving the upper and lower limbs	3	2.61%
3. Major Nerve Trunk and Plexus Injuries (n = 9)
Brachial Plexus Injuries	8	6.96%
OBPI	1	0.87%
4. Fractures +/- Nerve Injury (n = 11)
Fracture fixation	8	6.96%
Fractures with associated nerve injuries	2	1.74%
Non-union	1	0.87%
5. Tendon and Soft Tissue Cases (n = 14)
Tendon injuries	7	6.09%
Multiple tendon + nerve injury (spaghetti wrist)	7	6.09%
6. Tumors, Pain, Amputation-Related Cases (n = 4)
Bone tumors	2	1.74%
Phantom limb pain	2	1.74%
Total	115	100%

All patients and surgeons surveyed responded. Most patients reported high satisfaction with the telemedicine clinic. All five local surgeons expressed very high satisfaction, noting that this service relieved a burden they were expecting to carry (Table 4).

Table 4.

Patient and surgeon satisfaction rates with telemedicine clinic

Response	Patient	Surgeon
Very satisfied	98 (85%)	5 (100%)
Satisfied	17 (15%)	0
Neutral	0	0
Unsatisfied	0	0
Very Unsatisfied	0	0

Discussion

Peripheral nerve injuries, especially those caused by high velocity penetrating trauma from explosive devices, represent significant clinical challenges. These injuries often transect or destroy nerves and require specialized reconstructive surgery [11]. The need for timely nerve reconstruction due to the risk of permanent disability without reinnervation, combined with the extreme scarcity of nerve surgeons in Gaza, highlights the difficulty of providing adequate care in such environments [12].

Our surgeon also treated complex fractures, tendon injuries, and combined injuries. Follow-up is a standard and essential component of surgical care. In nerve surgery specifically, follow-up aims to minimize complications such as worsening muscle atrophy, joint contractures, or failure of nerve repair [12]. In the case of nerve reconstruction, we also monitored for a progressive Tinel sign indicating nerve regeneration. If absent, patients were highlighted for distal nerve transfers to prevent permanent paralysis.

Some patients with preoperative neuropathic pain described symptomatic improvement during follow-up, although formal outcome analysis is reported separately. A study from this same patient group showed that neurolysis procedures resulted in measurable improvements in both pain and function, emphasizing the importance of surgical technique and structured follow-up [13].

Long term follow-up is vital, as nerve regeneration may take several months or years [5]. It is also essential for the surgeon to evaluate the success or failure of their interventions. Since returning to Gaza is extremely difficult for international surgeons, in person follow-up may be delayed or impossible. This can worsen outcomes and leave patients uncertain about their progress. Remote clinics may help address this gap where in-person review is not possible.

During the clinics, the surgeon recorded notes in a shared Google document and the local team implemented the follow-up plan. Patients were referred to physiotherapy with protocols aligned to international practice. Local physiotherapists received remote guidance from international specialists, including a center in South Africa, to support rehabilitation planning.

Despite the extreme conflict conditions, the local team successfully facilitated six remote clinics across Gaza, providing care for more than 115 patients. The process was not without challenges. A major issue was unstable internet and frequent disconnections. Similar difficulties were observed in a telemedicine initiative in Syria, where power outages and poor internet disrupted consultations [14]. Noise from drones and airstrikes also interfered with communication. Logistical barriers such as dangerous roads and the high cost of travel also created obstacles. Similar challenges were noted among Syrian refugees using telemedicine [14]. We therefore covered travel, medication, and physiotherapy costs for some patients.

There were also challenges related to the limited availability of essential medical resources. These included difficulties obtaining controlled medications for severe neuropathic pain and intermittent unavailability of radiological equipment such as CT and MRIs. A review by Parkes and colleagues highlighted similar issues in Gaza before the recent conflict, noting shortages of diagnostic tools, medications, and infrastructure for telemedicine [15]. These problems have only worsened since October 2023.

Despite these challenges, the team adapted effectively. When live consultations were disrupted, videos and images were recorded and forwarded through WhatsApp for review. When conversations were interrupted, local staff ensured that patients fully understood their care instructions through direct follow-up.

Despite all obstacles, the service was deliverable and well received despite major operational barriers. Patient satisfaction was very high, and local surgeons welcomed the initiative. Virtual consultations allowed urgent concerns to be reviewed, progress to be discussed, and complications to be identified for onward management. Many patients continued rehabilitation with physiotherapists, while others were placed on waiting lists for future interventions.

The experience in Gaza demonstrates that telemedicine can support ongoing specialist follow-up in conflict settings. However, it also emphasizes the need for reliable connectivity, adequate equipment, and strong logistical support. Partnerships with local providers and hospitals are essential for such programs to succeed.

Limitations

This study has limitations. It is a descriptive observational report without a comparator group. Satisfaction measures were simple and non-validated. Selection bias is possible, as patients with connectivity or transport barriers may not have attended. Clinical outcomes were not the primary focus of this paper and are being analysed separately. Findings may not be generalizable beyond similar conflict settings.

Conclusion

In any institution across the world, surgeons must monitor their surgical outcomes and complications. Adherence to this fundamental constitutes a basic tenet of delivering clinical care. Structured telemedicine follow-up clinics for postoperative surgical patients were feasible in Gaza during active conflict using locally supported digital systems and multidisciplinary collaboration. Such models may help maintain continuity of care where in-person specialist follow-up is not possible. Further studies should evaluate long-term clinical outcomes, cost-effectiveness and scalability.

Author contributions

R.M. and A.A.-K.S. led the study design, data analysis, and manuscript drafting. M.T. critically revised the manuscript for submission. D.M, R.AD, N.A., F.B., M.Ta., E.L., and A.A.-S. contributed to data collection, writing, and interpretation of results. All authors reviewed and approved the final manuscript.

Funding

Not applicable.

Data availability

No data are available for sharing.

Declarations

Ethics approval and consent to participate

This project was undertaken as a retrospective service evaluation of a telemedicine follow-up pathway using anonymised routinely collected operational data. Verbal consent was obtained from patients for telemedicine consultation and anonymised use of service data. No experimental intervention was performed and no identifiable patient information was included. Local governance processes available during the conflict were followed. Formal research ethics committee review was not locally available because of disruption to institutional infrastructure during the war.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.