As modern battlefield preparations have shifted towards a focus on conflict against peer and near-peer adversaries, large-scale combat operations (LSCO) present challenges to casualty care on a scale not experienced since World War II. Medical evacuation capabilities are anticipated to be episodic. Prolonged casualty care will require massive consumption of far-forward medical resources and healthcare personnel, however, likely without access to protected medical facilities. LSCO will generate mass casualty events (MCE) requiring methods for triage to provide medical care for the “greatest good.” Blood product availability will continue to be a critical life-saving intervention as well as a constraint in an operational environment without prolific damage control surgical capability. Past and present experiences with LSCO combined with predicted future LSCO scenarios will challenge the feasibility and effectiveness of massive casualty response, triage, evacuation, logistics, surgical damage control, and hospitalization which will likely require the integration of civilian surgeons and trauma systems. In this paper, we will analyze challenges and discuss potential solutions to combat casualty care in modern LSCO.

The last 20 years of sustained combat operations during the Global War on Terror generated significant advancements in combat casualty care. Improvements in point-of-injury care, en route care, and forward surgical care appropriately aligned with the survival, evacuation, and return to duty needs of the small-scale unconventional conflict. However, casualty numbers in large-scale combat operations have brought into focus the critical need for modernized casualty receiving and convalescence: Role 4 definitive care. Historically, World War II was the most recent conflict in which the United States fought in multiple operational theaters, with hundreds of thousands of combat casualties returned to the continental United States. These numbers necessitated the establishment of a “Zone of the Interior,” which integrated military and civilian health care networks for definitive treatment and rehabilitation of casualties. Current security threats demand refocusing and bolstering the Military Health System's definitive care capabilities to maximize its force regeneration capacity in a similar fashion. Medical force generation, medical force sustainment and readiness, and integrated casualty care capabilities are three pillars that must be developed for Military Health System readiness of Role 4 definitive care in future large-scale contingencies against near-peer/peer adversaries.

Purpose of Review: The purpose of this review is to describe the advancements in combat casualty care from the prehospital environment, through en route care, and into damage control resuscitative and surgical care during recent military conflict. We also explore potential areas of future research needed to enhance survivability on the future battlefield during large-scale combat operations (LSCO). Recent Findings: In the prehospital space, the use of tourniquets has become standard practice for controlling severe hemorrhage, while techniques like Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) continue to be researched for managing hemorrhagic shock. Implementing whole blood transfusions and freeze-dried plasma enables hemostatic resuscitation. Pain management strategies are also evolving, with the use of ketamine, Penthrox, and fentanyl. During en route care, the concept of the “golden hour” emphasizes the urgency of delivering timely medical intervention, and critical care paramedics play an essential role in this setting. En route resuscitation and surgical teams enable rapid, lifesaving interventions during patient transport. Within damage control resuscitation and surgery, the focus has shifted towards hemostatic resuscitation with blood products to counteract coagulopathy and prevent further bleeding. Damage control laparotomy remains a critical intervention for severe abdominal injuries, while vascular shunting techniques are being utilized extensively to stabilize patients with limb-threatening injuries. Likewise, acellular vessel conduits are a novel, promising innovation, offering a bioengineered solution for vascular repair. For future LSCO, novel combat casualty care research must delve into anti-shock drugs aimed at enhancing hemodynamic stability, the use of Extracorporeal Membrane Oxygenation for severe combat trauma, and the development of novel antimicrobials to combat post-traumatic infections. Directed energy technologies, telemedicine, decision-assist tools, and autonomous systems are also being investigated, with the potential to transform trauma care by improving response times and treatment efficacy in remote or resource-limited environments. Summary: Recent combat casualty care advancements, such as hemorrhage control methods like tourniquets and REBOA, alongside innovations in resuscitation techniques like whole blood transfusions and freeze-dried plasma, exemplify improving prehospital and en route care. The golden hour policy, en route resuscitation, and improvement in surgical capabilities highlight the importance of timely interventions in saving lives. Novel research areas, including anti-shock drugs, ECMO, antimicrobials, directed energy technologies, telemedicine, decision-assist tools, and autonomous systems, could enhance survivability in future large-scale combat operations.

Background: Choledocholithiasis complicates 10–15% of patients undergoing cholecystectomy. While endoscopic retrograde cholangiopancreatography (ERCP) followed by cholecystectomy is common, access to ERCP is inconsistent in rural and military hospitals, highlighting the role for single-stage laparoscopic common bile duct exploration (LCBDE). Methods: We describe a technical approach for fluoroscopy-guided, wire-based transcystic LCBDE using standardized endovascular tools, the “Biliary Endovascular Toolkit”. We performed a retrospective review of five patients undergoing cholecystectomy and transcystic LCBDE at our military hospital between May 2024 and October 2025. The operative technique employed percutaneous micropuncture sheath access, fluoroscopy-guided transcystic wire cannulation of the ampulla, and balloon dilation with sphincteroplasty for stone clearance. Results: Five patients (mean age 35.4 years) underwent single-stage cholecystectomy with transcystic LCBDE. Transcystic cannulation, duodenal wire access, and ductal clearance were successful in all cases (100%), without conversion or postoperative ERCP (0%). Mean operative time was 208 min (range 161–275). No patient experienced postoperative pancreatitis, pleural complications, or other 30-day adverse events. Conclusions: The Biliary Endovascular Toolkit offers a standardized, wire-guided workflow for transcystic LCBDE using off-the-shelf equipment. This technical note provides a practical framework for general surgeons managing choledocholithiasis, particularly in resource-limited settings.