Cis-lunar and surface missions: Health risks and potential surgical conditions

The next goal of human space exploration is to return to the Moon to stay, and to establish a new, more advanced space station in lunar orbit: the ‘Lunar Gateway’. The authors aim to contribute to this goal through undertaking an ongoing comprehensive survey of relevant published scientific literature to seek information regarding the risk of medical conditions that might require operative or non-operative surgical solutions during long-duration spaceflight. The intended outcome is to create a roadmap for future mission planning. To date, we have identified more than 50 such potential surgical conditions. Based on disease severity and mission duration, these can be classified into: (Category 1) Time-critical conditions requiring immediate surgery; (Category 2) Urgent surgical conditions requiring minor temporising surgical intervention or conservative care (these patients can return to Earth for definitive treatment); or (Category 3) Non-urgent, as these conditions do not require immediate surgical intervention, and definitive treatment can be delayed. The proposed Lunar Gateway will be an international collaboration. Reaching Gateway is anticipated to take around three days. Gateway will operate in microgravity conditions, and include a communications lab (ground support from Earth is still available with minimal signal delay), a scientific lab, and a habitat for astronauts. Transfers to and from the lunar surface will allow astronauts to undertake extra-vehicular activities (EVA). Habitation on Gateway will present similar physiological and psychological challenges as experienced on the International Space Station (ISS), with the addition of a slightly increased communications lag. The Moon is only within Earth's magnetosphere for approximately 25 % of the time, which will increase space radiation exposure compared to the ISS. Gravitational conditions will range from microgravity on Gateway to ⅙ of the Earth's gravity on the lunar surface. Considering the duration and distance necessary in order to undertake a lunar mission, time-critical surgical interventions (Category 1) will likely be necessary, such as treating a bowel perforation, or fixation for musculoskeletal trauma. For urgent conditions (Category 2), antibiotic treatment of responsive appendicitis, drainage of uncomplicated cholecystitis, or other conservative measures might be acceptable as a temporising measure. If a return to Earth is possible within three days, delayed surgery can be undertaken if the conservative measures are unsuccessful, or the condition recurs. In the case of non-urgent procedures that can be delayed (Category 3), planned evacuation to Earth is expected to be available, for example, if a malignancy develops or is detected. Anticipating the medical and surgical challenges a lunar mission presents, and subsequent adequate planning and preparation for possible surgical emergencies, will help ensure mission success. Creating a system for triaging of surgical cases will be paramount in order to guide appropriate management.