The development of surgery at sea practice guidelines (SeaPG) for naval surgeons deployed on US Navy warships using modified Delphi methodology

BACKGROUND: US Navy general surgeons deployed on naval warships routinely provide a wide spectrum of surgical care—a vastly different experience compared with military and civilian hospitals. The Maritime Surgical Quality Improvement Program gathers and analyzes case log data; however, no specific clinical practice guidelines exist for deployed naval surgeons and their chains of command. We sought to close this gap by seeking the consensus of experienced maritime surgeons. METHODS: A modified Delphi method with three rounds was used. A cohort of physician leaders and surgeons with warship deployment experience was asked to state their level of agreement for statements involving elective and emergency surgical care using a 5-point Likert scale. In the first two rounds, open-ended comments were used to generate additional clarifying statements. Consensus was defined as 70% of respondents answering strongly agree/agree or strongly disagree/disagree. Statements not reaching consensus were repeated in subsequent rounds. RESULTS: Of 91 participants, 90% were surgeons. Across all rounds, a final list of 76 statements was evaluated; 58 (76%) reached consensus. Of these, 52 (90%) had a strong agreement between respondents based on median Likert scores with narrow interquartile ranges. There was broad consensus on the management of urgent/emergent conditions and on nongeneral surgery and systems factors, but less consensus on the elective management of surgical conditions. CONCLUSIONS: A consensus regarding the management of surgical conditions was reached for many disease processes. Despite the varied strength of that consensus, this is an important first step to developing guidance for surgery at sea aboard a naval warship. The iterative nature of the process elucidated situational nuances within specific disease processes, increasing its applicability. These statements will be used to create a comprehensive, expeditionary surgery at sea guidelines (“SeaPG”), aiding surgeons and their chains of command in ensuring a safe, reasonable approach to expeditionary surgery at sea. ( J Trauma Acute Care Surg 2026;00:000–000 Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.) LEVEL OF EVIDENCE: Therapeutic Care Management; Level V.