Limits of aggressive surgical exposure in combat trauma: cricothyrotomy, left anterolateral and clamshell thoracotomy, laparotomy and REBOA

Modern combat trauma care has improved survival through damage control surgery and advanced resuscitation. However, contemporary battlefield experience shows that life-saving procedures may also cause substantial iatrogenic morbidity and long-term functional impairment. Cricothyrotomy, left anterolateral and clamshell thoracotomy, extensive laparotomy and resuscitative endovascular balloon occlusion of the aorta may be indicated in selected patients but carry significant physiological, reconstructive, infectious and functional consequences. This paper examines the limits of aggressive surgical exposure in Role 2 military trauma care, drawing on current evidence, clinical guidelines and contemporary combat experience. We discuss the indications, risks and potential overuse of highly invasive interventions, particularly in resource-constrained settings with prolonged evacuation times. Damage control surgery should remain physiology-driven and indication-based rather than a strategy of maximal intervention. When feasible, less invasive alternatives should be considered to reduce iatrogenic burden while optimising survival and long-term functional outcomes.