3rd Annual Mission

June 2012
Magdi & Professor Narmandakh
Magdi & Professor Narmandakh

As a Specialist Registrar in General Surgery, I was extremely fortunate to join the 2012 Operation Hernia mission to Mongolia through the great generosity of the Pitts-Tucker Fellowship. This Fellowship was kindly donated by the JPT charitable trust, which provides opportunities for young adults to travel in the exchange of cultures and to bring delivery of medical facilities in difficult to reach foreign areas, and awarded through Association of Surgeons in Training.

The Mongolian mission was led by Professor Juri Teras (Estonia), together with Magdi Hanafi (British), Fennie Wit (Dutch) and Kristjan Kalling (Estonian Anaesthetist). The Mission was also joined by Vahur Laiapea, a film-maker making a documentary on the Mission for Estonian television. Fortunately the filming predominantly focused on the Estonian speaking members of the trip!

We all met in Ulaan Baatur by Mrs Enkhtuvishin of the Swanson Charitable Foundation, who was again the tireless local co-ordinator for this third Mongolian mission, together with the Chief of the department of Surgery Professor Tsagaan Narmandakh. There was momentary anxiety as Magdy, together with all the meshes, sutures and local anaesthetic for the mission had missed the flight- he did finally make it a day later (minus the local anaesthetic, confiscated by customs). We immediately headed out to the Khustain National Park, a short distance but very long and bumpy drive from the Soviet-style sprawl of Ulaan Baatur into the vaste grassland steppes. Here, the Przewalski's horse, once extinct in the wild and limited to 12 animals in captivity, was reintroduced via Dutch conservationists. They now number more than 300 in the wild, mostly in Khustain, and we were fortunate to be given a tour of the park by Piet Wit (Fennie’s father) who managed the reintroduction program for many years in Mongolia.

Przewalski's horses in Khustain
Przewalski's horses in Khustain
The hosts and Operation Hernia Team in Hospital #2
The hosts and Operation Hernia Team in Hospital #2

We returned, inspired and enthused, to the capital for the first part of the mission, in the capital’s Teaching Hospital #2. This hospital has been host to two previous missions, and we were pleased to hear that they have regularly been performing tension-free inguinal hernia repairs in the intervening period, and had almost finished the stock of mesh left over from the last visit. They had arranged a pre-assessment clinic on Sunday afternoon, and we recruited a large number of patients for surgeries over the coming days. Most of these were very large incisional hernias, with many of the inguinal hernias having being performed by the surgeons prior to our arrival. We had access to two theatres with monitoring for general and regional anaesthesia, and a third more basic theatre for local anaesthetic repairs. Parallel cases allowed training to be provided to a wide range of staff, from medical students and residents to staff surgeons. The theatre equipment was very adequate, but all team members commented on the scrub nursing staff who were exceptional. Interestingly, there were some new laparoscopic stacks, and largely re-sterilised disposable laparoscopic instruments which are being used for laparoscopic cholecystectomies.

For the second half of the mission, we headed north, to the town of Erdenet, just a short distance from the border with Russia. This industrial town is centred on the fourth-largest copper mine in the world, and is the second largest city in Mongolia, with around 90,000 population. One specific local problem was that most local community healthcare workers would refer patients presenting with a hernia directly to Ulaan Baatur, an 8-hour journey each way, rather than to the local hospital. As in Ulaan Baatur, we were interviewed on local television which advertised our presence (increasing recruitment) and we hope ultimately serving to validate the surgical department in Erdenet. Unlike Teaching Hospital #2, the preoperative clinic was unscreened, and so we saw a number of interesting and varied non-hernia pathologies, such as penile hypospadias and undescended testes in adults. The hospital in Erdenet was well equipped, with a state-of-the-art high-definition laparoscopic stack in one theatre, whilst one of our patients became the first patient to undergo an abdominal scan in the newly installed CT scanner. The bulk of the surgical workload was inguinal hernia repair, predominantly paediatric. Again, we performed a large number of cases training both staff surgeons and residents. Perhaps the timing of the mission immediately prior to the Naadam festival, a three-day national holiday which sees almost every Mongolian taking to their horse and riding to their local village, limited adult recruitment, explaining the high percentage of children treated!

Wresters warming up at the Naadam Festival
Wresters warming up at the Naadam Festival

Alongside the surgery, we were very well entertained by our always generous hosts and included a concert featuring traditional Mongolian throat-singing. Dr Sanchin, a staff surgeon from Hospital #2, took us to visit his uncle’s ger camp where we sampled fermented mare’s milk beer and cheese, while elsewhere we gorged on an entire stewed goat. The highlight was a visit to the Naadam festival, where we watched Mongolian wrestling (the rules of which I am no clearer about now) and long-distance horse racing over a course of 40km with jockeys aged between 5-8yrs old.Overall it was an excellent mission to a rapidly developing country. The work that Operation Hernia has performed on previous trips was evident, and it is clear than in Teaching Hospital #2 use of tension-free meshes is becoming routine part of practice. Meanwhile I hope that we have provided some teaching and training to surgeons in Erdenet which can be built on during future missions. The success of the mission was due to the extensive planning and organization, both by Mrs Enkhtuvishin and the hosting surgeons, especially Professor Narmandakh- many thanks once again!

Adam Stearns