German Team: Quininde District Hospital, Ecuador

24-28 OCTOBER 2011

Members of the German Team: Dr. Karl Moser (surgeon), Prof. Dr. Markus Heiss (surgeon), Dr. Andreas Kremer (anesthetist), Marion Koell (photographer)
Organizing Team in La Concordia: Kathia Tinixaray, Sandra Ocampo and Theresa Butron (Madrid)
Scientific Support: Samuel Shillcut

Andreas Kremer the Anesthesist
Andreas Kremer the Anesthesist

When we arrived after our 16-hours journey from Düsseldorf to Quito, we were heartily welcomed by Sandra and her brother. They brought us in very comfortable cars within 4 hours to La Concordia, where we stayed in the nice Hotel Atos. On the same day we saw around 50 patients in the nearby area de salud 23 which was run by Kathia. This preoperative consultation was very well organized by Kathia and Samuel, who did also an excellent paperwork.

Situation at the Quninde District Hospital
The next day Sandra and Kathia took us to Quininde to the local district hospital, which was 40 minutes drive away. We were welcomed by the leading surgeon and led to the operating area. There we were left alone and really nobody took any notice of us. The whole crew including the surgeon in charge was lying on the patient´s stretchers and was not really willing to help us. A little bit puzzled about this situation we tried to start with the first operation. As we did not bring along drapes and gowns (we were informed by Theresa, that this would be provided) we asked a nurse. She said that we are not allowed to change the gowns between the operations - only the gloves. When we told her that we won´t accept this, she suddenly managed to get enough gowns for us. When we asked for a scrub nurse this was refused and between the operations the floor was not cleaned or the waste taken out. After 6 operations totally working on our own, while the local staff enjoyed a lazy day, we stopped working and complained to Kathia. She took care of this by bringing a nurse from the area de salud 23 to the hospital on the next day. During the week the support from the hospital staff got better and on the last 2 days it can be named good. They crew helped us with the patient transport, cleaned the operating theater and brought us the instruments. This was probably due to the pressure of Kathia and some thankful patients, who complained very forcefully to the manager of the hospital, about how we were treated.

Security
Unfortunately on 2 days parts of our equipment were stolen, although we left it in a locked room in the operating area. I was missing 3 of my 10 hernia sets, 2 presents for Kathia and Sandra  and Andreas Kremer 5 bottles of local anesthesia and 3 precious clamps. Even the locks were cut. This was reported by Sandra to the local police, which is still investigating. According to Sandra the hospital is now willing to pay for the stolen hernia sets.

Patient details
64% of patients were male, with patient ages ranging from 10-72 and a median age of 41. Average family size was 4 people - 28% of patients were fathers.
The average years lived with hernia was 8.4 (6 median, 0-36 range). 67% of patients were in pain before surgery and 6% had vomiting. 88% of patients with inguinal hernias received mesh.

Operation details
In total we operated 43 Hernias: 24 inguinal hernias, 2 femoral hernias, 6 incisional hernia, 10 umbilical hernias and 1 epigastric hernia. Three patients (8%) had bilateral hernias, and 5 patients (14%) had two hernias that were not bilateral.
Inguinal hernias were reducible in all but one patient, who had a large inguinoscrotal hernia. 80% of all hernias repaired were primary.
Of 25 inguinal hernias, 24% were H1, 48% were H2, 24% were H3, and 4% were H4. Of the 6 H3 and H4 hernias, the inguino-scrotal component was <10cm in 50%, 10-20cm in 33%, and <20cm in 17%.
Of 54 inguinal hernias evaluated, 28% were direct, consistent with an expected 25%-30%.
One lady with a huge incisional hernia was operated with a modified Ramirez procedure

Anesthesia
72% of patients received spinal anesthetic, 22% received local anesthetic, and 6% received general anesthetic. Due to a leak in the anesthetic machine it was one time very dangerous for one of our patients receiving general anesthesia. But Dr. Kremer was able to lead the patient through this difficult time.

Postop Course
Three patients were hospitalized, one for six nights (the lady with the huge incisional hernia). Antibiotic prophylaxis was not used in keeping with European Hernia Society (EHS) recommendations.
In the so-called ICU no nurse took really care of our difficult case. Therefore Dr. Kremer had to keep an eye on this case the whole day. As he was very busy, we had to cancel some of our patients on this day.  As we did not want to risk the live of our patients we did not operate 3 additional patients with huge incisional hernias as planned.
Up to now all patients do fine and according to our knowledge no infections occurred.

Summary
Despite the trouble we experienced we had a marvelous time, because our patient were so grateful and Sandra was such a wonderful host. However in accordance with Kathia we advice not to send more teams to this hospital. We think that it is a very good idea to perform the next mission in the Centro de Salud La Concordia, where Kathia is in charge. We will definitely do another mission to La Concordia after this is arranged. We also want to thank Samuel for his excellent record keeping and wish him the best for his wedding next month with the his ecuadorian fiance.

Markus Heiss, me and a local surgeon
Markus Heiss, me and a local surgeon