Abstract Major surgical events/incidents onboard are rare but can be catastrophic to any mission. National Aeronautics and Space Administration (NASA) uses the Integrated Medical Model (IMM) to develop an integrated, quantified, evidence-based decision support tool useful for crew health and mission planners to assess risk and design medical systems. In 2017, the IMM of the NASA Human Research Program included a list of 100 medical conditions that could be anticipated during space flight. Of those conditions, 27 are expected to need surgical treatment. Consequently, there has been a continuing interest in surgical capabilities for exploration space flight. The surgical system capabilities aboard all space stations and analogue flights have been designed and implemented with an emphasis on stabilisation, medical evacuation, and ATLS capabilities. However, with future missions to the Moon and Mars, evacuation is not a possibility and astronauts will need to troubleshoot, adapt, and self-administer complex surgical care autonomously. This narrative review aims to examine the published work on surgical care in space, discuss the inherent challenges, and identify scope for future studies. The review evaluates and analyses results from several landmark experiments covering important technical aspects such as basic surgical skills, laparoscopic surgery, robotic surgery, and tele surgery. Relevant studies for the review were identified from the MEDLINE, PubMed, and EMBASE databases. Eligible studies were published between 1960 and June 2021 and were identified using the terms “space surgery”, “microgravity”, “zero gravity”, “weightlessness”, “parabolic flight”, “neutral buoyancy”, and “spaceflight”. Only articles in English were selected and references cited in the selected publications were followed up and included where appropriate. Documents available in the public domain and/or archives of National Space agencies were also included. The search yielded a total of 86 hits including review articles, commentaries, studies, meeting summaries and technical reports submitted to National Space agencies. Results were then filtered for eligible papers relevant to this narrative review. Challenges on a long-duration mission will be unique, unlike anything we have faced so far in the last 60 years of space travel. Despite the progress in space surgery in the last 40 years, there are several challenges to achieving a fully functional surgical care system on any mission outside Low Earth Orbit. The microgravity environment presents unique challenges related to altered physiology as well as mechanics and techniques pertinent to surgical care. Some of the challenges include but are not limited to crew selection, role of prophylactic surgery, adaptation to zero gravity, lack of ground support, training and maintenance of surgical skills and limitation of weight and volume for hardware. Ultrasound imaging, 3D printing and AI-based surgical assistance coupled with robotic surgery have shown promise, but their real efficacy and functionality remains to be tested.

    Highlights Inability to repatriate has highlighted need for autonomous surgical care. Adaptation to weightlessness for the patient and surgeon is important to consider. Crew selection, training and maintenance of skills will be critical. Conservative and minimal access management of surgical conditions is predicted. Ultrasound and 3D printing will play an important role in surgical care.


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