Dutch Team. Takoradi, January 25-1 February 2010

For the second time a Dutch Hernia Society team spent a week in Sekondi-Takoradi fulfilling activities according to the ¨Operation Hernia¨-terms. This team was proceeded by another Dutch team (M.Simons, F.Garssen and D.Boerma) that might send a separate report about their week (10 - 15 January 2010).
The team consisted of 4 surgeons (G-J. Clevers, R. Schmitz, E-J. Verleisdonk and R.Simmermacher), 2 surgical registrars (M. Blussé van Oud Alblas, A.Schiphorst) and one anesthesist (R.Schapendonk), who were divided in 3 teams that rotated in 3 hospitals that were served (the ¨Hernia-wing¨, GPHA and Dixcove).
In this period 92 patients were treated that received 99 treatments, mostly inguino-scrotal hernias but also hydroceles and one incisional hernia. Most of the days 8 patients were on every list but during the pre-operative ward-round some patients, for different reasons, were cancelled. Working-hours were very acceptable running from around 8.00 am till 4.00 pm, except on Tuesday when there was an important football-match, all Ghanaian wanted to watch, leaving enough time to have a après-work at one of the beach-clubs. Unfortunately registration of the patients outside “the wing”, due to the great enthusiasm of the Dutch docters, for sure is insufficient which is regretted by everybody and attempts have been done to correct that. The next time the groupsleader will have to take more responsibility on that.
Transportation to and from the hospitals was very well organized and rather speedy. Introduction and service at the hospitals excellent and to the point, guaranteeing smooth working for everybody. The teams brought their own clothes and materials for the operation. Biggest problem appeared to be drapping where there was a lack of material. Dixcove appeared to have the smallest stock.
Hernia-wing and GHPA functioned as usual and everybody, from all sides, enjoyed working there. Dixcove, too was a very pleasant place to stay and work. Nurses are very much committed to the task and continued to work as quickly as possible. In the beginning there was no diathermia but that was fixed by one of the surgeons, indicating that the machine standing there can be used.
In all places some teaching of basic cautions to be taken for sterility-reasons to nurses and docters might be useful. Education of the local docters could hardly be executed due to their busy work-scheme. Due to the excellent local support by anaesthesist-nurses the contribution of our “own” was less than hoped for. However this did not disturb his mood.
Accommodation and in-and out-house support by Kate and her friends was excellent which made the stay very relaxed.
Anyway the organization of all activities was excellent and could not be better, thanks predominantly to Bernard.
In summary, therefore, the members of this Dutch team had a very satisfactory week professionally and leisure-wise and very much hope that this was mutual and that their patients will do well.

Roger Simmermacher





Anglo-Irish-Swiss Team, Aliade, Nigeria, 17-27 February

Annyar – You’re welcome. With a touch to the forehead and chest followed by a slight bow, each colourfully dressed greeter would then take our hand and shake it. Regardless of social or financial station, the heartfelt greeting was the same – annyar.

Four European surgeons (Richard Stephens, Shorland hosking, Peter Nussbaumer, Andrew Kingsnorth) and one anaesthetist (Richard Salam) bumped for six hours in a very full minibus from the airport to our hospital base for the next week. Presentation of flowers, singing and dancing greeted us as we stepped into the 41°C heat. Posters around the town (photo) had heralded our arrival – ‘Operation Hernia by Professor Kingsnorth and team’. Boxes of instruments, diathermy machines, gloves and sutures were hoisted onto porter’s heads and taken to the operating theatre for unpacking and sorting. No electricity for 24 hours a day is normal, necessitating a new generator being installed to provide continuous (African style) power for theatres.

And so we started. By dawn patients with hernias started arriving; young, old, fit, HIV negative, HIV positive, pregnant, curious. Following confirmation of a hernia(s) they made their way to the theatres where they waited their turn. Nobody seemed to mind waiting for as long as it took – word on the street came back that this was a small price to pay for a well performed procedure as a day case. Like the children of Israel they kept coming and we kept operating – two tables on the go from 8 ‘til 5. Eighty patients and one hundred hernias later we reached full time and still they kept coming. Names were taken with the promise that the next hernia team arriving three months later would see to their hernia.

By day two an important discovery was to change our approach in a significant way. Initially, the hospital’s medical officers came to theatre for training but it quickly became apparent that their surgical skills were considerably less than those of the theatre scrub nurses. Furthermore, these nurses’ interest and enthusiasm to learn the mesh repair (they were familiar with the Bassini technique) was impressive. And so they began to assist, progressing naturally into performing under supervision. As they were taught (see photo), their enthusiasm visibly increased, work rate and efficiency improved further and the whole team worked so well. What a difference empowerment makes. It needed to, for it was the Europeans who began to wilt by mid-afternoon. Despite three air conditioners, theatre temperatures reached 30°C during the afternoon session.

Armed with mesh generously donated by several companies the pile of mesh nonetheless shrank rapidly at the rate of 20 hernias per day. The solution was simple but brilliant. Mosquito net was cut to size and sterilised. Initial attempts at high temperatures were rapidly modified when the net melted in the autoclave. The right temperature was found and the problem of sterile mesh was solved easily and cheaply.

Stepping outside the theatres onto the wards revealed a much bigger problem. HIV. Sub-Saharan Africa has been devastated by this virus. In our area of Nigeria forty per cent of the population are affected. In our hospital eighty per cent of the work load is HIV related. Thanks to huge inputs by overseas charities, antiviral drugs are now available free of charge. The effort in education and community is impressive.

As we said our goodbyes at the Hospital, "annyar” came at us from all directions. How strange, until we learnt that annyar not only means welcome; it means thank you.


Shorland Hosking






The Spanish, Puerto Rican and Andorran team, Eruwa, 18-27 March.


“It was incredible!” is all we can say . We began our project when I first came to Eruwa, in june 2009, when we decided to undertake part of our work after talking with Dr. Awojobi. The Foundation Dr. Ramon Vilallonga has been involved in many projects, but since we met Dr. Awojobi, we cleary decided to continue this colaboration. On this ocasion, we met, a group of five people, from three diferents countries, Puerto Rico (Dr. Vangie Teixidor), Andorra (Mr. Josep Maria Puy) and Spain (Dr. Candy Semeraro, Miss Cristina Andreu and myself, Dr. Ramon Vilallonga), at the airpot of Lagos.

We arrived late in the evening and we were met at the airport by the team from the Clinic who took us in the clinic’s bus to Eruwa the next morning after spending the night in Lagos. The same day of our arrival, we began surgeries. Hernias of course. Baba, the person in charge of the theater and assistant for us, has been working a lot, and in a very efficent way. Accomodation was very changed since the last time. We did not stay at the town’s hotel anymore, but at the clinic. Two houses were fixed for us. Perfect! We have repaired many hernias. Cristina, our srub nurse, has teached Shakira, a local nurse who helps with the surgeries. Candy and I have teached some trainee residents and specially Daso, who is now perfectly able to perform a hernia repair with mesh. We were very pleased about that. The Awojobi familiy, as usual, has been very helpful and kind. No need to say that again. We have been treated like kings. Vangie even wanted to taste the local food… we did.

As ususal , we did a nice visit to the neighbourhood school. All the kids were so happy and excited. It was a great experience and we enjoyed it a lot. Sweets, pencils and a ball were offered to the kids. We can still hear the shouts of happiness.
We have continued treating Kundus, the little boy who got burnt almost one year ago. With material from our hospital, we changed the dressing every two days and he is improving but it is going to be very slow, as the burns are so extensive. Candy made a fantastic doll for him and Joe, an ambulance.

We also had the oportunity to assist Dr. Awojobi in his elective and emergency surgeries: testicular torsions, recurrent laparotomy hernia repairs, humerus realignement, thyroidectomies… an experience.

Finally, we also laid the first stone of the future Ramon Vilallonga Puy Ibarapa Hernia Center. An incredible experience. We wish to continue in this way, trying to improve heath care in Nigeria. We hope to come back soon.

Dr. Ramon Vilallonga.








UK-Israeli-USA-Slovenian Team, May 1-15, Mongolia

Mongolia is a country situated on the central Asian plateau wedged between China and Russia. It is classified as a low-income country, providing a healthcare system with poor infrastructure, old equipment and little money for basic supplies. The country has an average elevation of 1600 meters, a land mass the size of Western Europe and is situated at the headwaters of river systems that flow to Siberia, the Arctic, China and the Pacific. It has a dry climate yet affords 250 sunny days a year and is known as “Land of the Blue Sky”. Only 3 million people live in Mongolia and half of these reside in the capital Ulaanbaatar. Travel is best undertaken in a four wheel drive or by horse since there are only 1500 kilometres of paved road and most travel is via an improved earth surface or earth tracks. This gives wonderful opportunities to meet the hospitable herdsmen who tend the 40 million horses, goats, sheep and cattle that roam over the fenceless and treeless steppes. It is an exotic experience to visit a ger (a traditional round felt tent) and enjoy the hospitality of a nomadic family, which may include mutton stew, horse meat, goat’s milk tea and khoomis (fermented mare’s milk).

Our two week mission from 30th April to 15th May 2010, was undertaken with the very able assistance of the Swanson Family Foundation (SFF) represented in Ulaanbaatar (UB) by Mrs M Enkhtuvshin (Enkhee). Planning had begun more than six months earlier. Surgery and teaching took place during the first week in the central Teaching Hospital #2 in UB (under the leadership of the Chief of Surgery, professor Tsagaan Narmandakh) and during the second week at the central hospital in Moron, a distance of 800km to the north in Khuvsgol province. Surgeons from district hospitals attended for teaching and lectures in Lichtenstein inguinal hernia repair, incisional hernia repair with mesh and components separation, and some paediatric surgery. To reach Moron involved an unforgettable drive across the steppes and taiga to the still-frozen Khuvsgol lake adjacent to Siberia.

Our team consisted of myself, Professor Motti Gutman from Israel, Dr Todd Heniford and Dr David Earle from the USA (the first representatives of the American Hernia Society) and Dr Juriy Gorjanc from Slovenia. We arrived at the Chinggis Khan airport early on the morning of Saturday 1st May and were met by Enkhee, the Chief of Surgery and the Director, of Hospital #2. The remainder of the day was spent orientating in the city of UB and adjusting to the cheerful faces of Mongolians dressed in their exotic and colourful deels (three-quarter length gown that buttons at the right shoulder to a high round-necked collar), hats, scarves and sashes. Our clinical work began the following evening (Sunday) with pre-assessment of 20 or so patients who had a variety of hernias. On the Monday morning we attended a dignified official opening ceremony with appropriate speeches and then set to work. In 2 operating theatres we completed 10 cases, surrounded by up to 20 curious surgeons seeing modern techniques of hernia surgery for the first time. During the following week we were able to take several of these surgeons through hernia operations and then proceed to teach them under direct supervision. In the meantime we had a guided tour of the hospital, made occasional visits to the emergency room and on one occasion witnessed the expert treatment of a bleeding liver tumour. In the evenings Mongolian entertainment was laid on, including a visit to the Naran Tuul black market and a glimpse of ancient Mongolian culture at a presentation of the National song and dance Ensemble. We gave TV interviews to the national network which were broadcast during the evening and vastly increased the recruitment of patients. By the end of the first week over 50 patients had been treated and we celebrated with a farewell well dinner in a restaurant that had a copy of the famous painting of “One Mongolia” by Sharav, as a backdrop.

In Moron each morning began with an 800 meter walk to the hospital from our small hotel, rubbing shoulders with colourfully-dressed school children on their way to lessons and ordinary citizens going about their business. During four working days we completed another 50 cases and taught the surgical staff techniques of mesh repair. We operated on fifteen children, some as young as 4 months. By doing this, we would have saved each family two days travel each way to UB, plus a 2 or 3 day stay in the capital during the hospital admission. The cost of a journey such as this would often be beyond the means of a herdsman living a hand-to-mouth existence. Finally, the hospital staff entertained us to an evening meal in a ger camp when the whole delicious carcass of a goat cooked by traditional methods was consumed with vast quantities of Chinggis Khan vodka, which greatly assisted the content of subsequent “spontaneous” speeches.

On return to UB and prior to our departure we visited the Zanabazar fine art museum to view the long history of Mongolian art outlining the history of this interesting and fast-developing country. The hospitality had been enormous, and the surgeon’s thirst for surgical knowledge enviable. An invitation to return has been accepted. We departed with a rudimentary knowledge of the Mongolian language, including the phrase of greeting when approaching a nomadic ger - “nokhoi khor” (hold off the dogs!)

The Operation Hernia team members wish to express their deep admiration of the Mongolian doctors with their high level of professionalism, their committment to the traditional values of the art of surgery, their recognition that medicine in low-income countries is still a vocation,.and their appreciation that the craft of surgery is a continuous learning process. We also wish to thank them for: preparing the mission with Enkhee, recruiting the patients, being attentive and willing learners, looking after our patients postoperatively and providing a sustained and entertaining social and culinary programme. The Mongolian doctors who were involved in the success of the mission were: (i) At Hospital #2: G. Bayasgalan (Director), Ts. Narmandakh (Head of Surgical Department); the following surgeons – B. Onon, U Sanchin, Ya. Altanchineg, S. Ulambayar, G. Bilguun, P. Tseden-Ish, Ya. Batsumber; A. Khandaa (OR nurse); and the following anaesthesiologists: Z. Tumenjargal, A. Saranbaatar, J. Munkhzul. (ii) At Khuvsgol Central Hospital: D. Erdenebaatar (surgeon), D. Chuluunbaatar (Head of Surgical Department); D. Chuluunbat (surgeon) and Tumenjargal (anesthesiologist). We salute them all!

Andrew Kingsnorth






Leighton Hospital team, 24-31 July, Eruwa, Nigeria

This year we had a relatively large team comprising a consultant surgeon (Magdi Hanafy), consultant anaesthetist (Andy George), operating department practitioner (Paula Hynes), surgical registrar (Nicola Eardley), two senior scrub practitioners (John Pickering and Ginny Long), and a senior ward nurse (Michelle Hawkes). We met at 5.30am on Saturday 24th July and loaded a minibus with numerous boxes and bags of medical supplies and luggage. At Manchester Airport, British Airways opened a counter specifically for us. We flew to Heathrow Airport and then Heathrow to Lagos. We were met at the airport by Dr Yombo Awojobi and we uploaded all our boxes and luggage to another minibus and went to a hotel to spend the night.

The following morning we woke early and set off for Eruwa straight after breakfast. On arrival we were shown to our villas, where we unpacked. We then went to the hospital and unpacked our medical supplies to enable us to start work promptly the next morning. We met up with a medical student from the University of Sheffield, Christina, who had arrived three weeks earlier, and had spent the time prior to our arrival helping Dr Awojobi. Later in the day Dr Awojobi took us to see the latest developments to the area before we sat down to dinner.

We awoke on Monday morning after a night’s sleep made more difficult by the heat and the noise of insects and frogs! We had breakfast and went to the clinic where we started seeing the patients. We would examine them, mark them and give them identification wrist bands. We treated eight patients on that day with large and small hernias and one with a hydrocoele. Most had local anaesthesia but some had spinal anaesthesia for repair of the larger hernias. The experience of Ginny and John was apparent in the way that they set up instruments and equipment, ensuring a high turnover of patients. Everything went smoothly and we finished relatively early because there were no more patients for us on that day, mainly due to the heavy rain. As last year, Karim, Dr Awojobe’s theatre assistant, helped in organising the patients and the staff and to him we are very grateful.
On Tuesday morning we started with a ward round, reviewing any of the patients who had stayed over night. Karim brought us many more patients, young and old and we had another busy day. Andy and Paula were fantastic given that there was no scope for performing a standard general anesthetic as would be routine in the UK, taking everything in their stride. Today, and for the rest of the week, we had with us Sayo Idowu, a young Nigerian surgeon who was keen to learn more about hernia repair.
The following day we had a long list of patients for us to see and operate upon. Whilst we were busy operating, Michelle took good care of all the patients on the ward giving medication, changing dressings and helping with personal care. She got to know every patient very well and her quiet hard work did not go unnoticed.
Thursday turned out to be a more eventful day than we were hoping for. Unlike here in the UK, when patients are seen we know very little about any co-morbidity. Risks of the hernia versus risks of the anaesthetic/surgery have to be weighed up. We decided to cancel a man with a recurrent inguinal hernia who claimed to be 110 years old as we felt that the risk of surgery was likely to be too great to him. The next patient was a 75 year old lady with a recurrent femoral hernia. We decided that she should have surgery but after anaesthesia she became unresponsive and hyoptensive. She required a period of cardio-pulmonary resuscitation and IV adrenaline before her blood pressure improved and she regained consciousness. She recovered well and was admitted to the ward for close observation overnight. It goes without saying that we were extremely pleased to see her looking well the following morning. After performing the last few cases, we packed our belongings and started the long journey back home. We are all extremely gratefully to Dr Awojobe who made us feel very welcome and gave us a bit of an insight into surgery in Africa.

Nicola Eardley




UK-USA team, 17-31 July, La Independencia, Ecuador

On our first visit to the Hospital Padre de Damian in La Independencia, Ecuador, we encountered a very good sign. As Samuel Shillcutt, our organization liaison or “fixer,” was leading us on a tour of the multi-building, rudimentary space, we ran into Jopita, the head nurse. There she was crouched in the dressing room of the Operating Theater, dressed in jeans, flip-flops and paint spatters, with a brush in her hand, laying a new coat of paint on the locker doors. . . . On her day off. If there ever was an image that could sum up our experiences in Ecuador, the smiling and shy Jopita crouched on the floor of the dilapidated hospital floor, doing her very best to gussy up the old hospital and make us feel welcome does a nice job. The people we encountered in Ecuador were the heart of this adventure. Their sense of pride in community and “make-do” attitude are certainly what made our journey such a success.

We arrived in Quito in pairs on a Saturday evening; everyone tired and cranky after delayed flights or long lines through customs, and desperate to lie down. We were greeted at the gate by the eager face of Samuel, smiling broadly (and at least a head and a half taller than the crowd at the gate!), and we made our way to the Airport hotel across the street. Over a breakfast in the hotel cafe the next morning the group introduced ourselves. Our ranks included Samuel, our fearless leader; Professor Andrew Kingsnorth (whose wife Jane, a GP, joined us a week later), and senior registrar Mr. David Sanders, a veteran of 2 OH trips to Ghana. The neophyte OH surgeons were Dr Brigid Glackin of Springfield MA and Dr. David Oberdorfer of Kansas City, KA. Dr. Glackin travelled with myself, her daughter, Deidre Murphy and my father Michael Murphy. Our anaesthesiologist, Dr Lorenzo Dimpel of the UK joined us later that day, trailing along his son Toby.
After a fairly brief introduction, the team decided to fast-track getting to know each other by cramming ourselves into a van and zooming off on the journey to La Concordia. The Concordian cabbie “Otto”, who shepherded us across the Andes, pointed out places of interest as we rose and fell out of the breathtaking rain forests, stopping for photo ops. He also managed to slip into conversation that his father had a hernia and was hoping we could help him. It was a very common occurrence to meet people, have them treat you like family, then slip into the conversation that a friend or family member was suffering from some type of hernia. The people in Ecuador always seemed to have some friend who could help us as well as someone who needed our help. During this 5.5 hour trek we all had quite a bit of time to ponder what our destination would be like; this being the first Operation Hernia trip to Latin America, no one knew quite what to expect.

La Concordia is a town of “between 50,000 and 100,000” inhabitants- there is no real census there, nor any type of street map beyond Google Earth- but it does exist and it is bustling. It has two main roads and a market abutting the main square, surrounded by a grid of dirt, alley-type streets and, beyond that, small slum-like rows of houses. La Concordia is situated about midway between Quito and the Pacific coast in a lowland rain forest region that is mostly used for the farming of Palm Oil. Our hotel, Atos, was owned by Sandra De Campo, the very sweet and friendly mayor’s sister. We found our stay there to be very comfortable and accommodating, as well as an air conditioned and be-cabled escape from our very dusty and chaotic surroundings at the end of a long day.

Initially, we operated in two locations: Clinica Guayaquil, run by Dr. Morantes in La Concordia, and El Hospital Padre de Damien, located in the neighboring village of La Independencia. Every morning those of us who made the trek to the hospital ambled down the 4 blocks to the main square, through the dusty chaos of La Concordia’s main drag, and attempted (sometimes successfully, sometimes not) to negotiate the local buses. After the first week, all surgical procedures were done at El Hospital Padre de Damian, and it’s been adopted by the project as the main base of operations for future missions. Used mostly for gynecological surgeries and as a clinic devoted to a day to day changing schedule of visiting doctors for many different purposes, the Hospital Padre de Damian sits down a narrow bumpy gravel road off the main highway that travels from La Concordia to the coast. It houses one operating theater, and several rooms for patients to stay during preparation and recovery. In the past, this theater has been used mainly for cesarean sections; a surgery much in demand in a country with a 40% cesarean rate. The electricity is run by generator and the running water is stop-start, the back-up water supply was contained in large barrels of rain water that the nurses would bale over surgeons’ hands during scrub-in.

Samuel had been working out of the hospital previous to our arrival, on his own research as well as preparation for our project. His research determined that the actual cost of Hernia Repair including the fabrication and laundering of new OR sheets and gowns, electricity, and nurse/staff wages, was thirty dollars per patient, excluding costs for surgeons or anaesthesia staff. Locally in La Concordia, there is no public hospital, and private clinics there are offering Hernia Repair, usually without the use of mesh, for $300-600 U.S..

In total we operated on 72 patients to repair 79 hernias and one cystic lesion. 79% of hernias were inguinal, 10% bilateral, with one triple hernia. 80% of patients received local anesthetic. The mean length of time with hernia was 9.8 years. 75% of patients were in pain before surgery, 8% had vomiting, and 63% had daily living activity limitations. Based on the number of untreated hernias in the area despite the availability of surgeons and operating theatres, many probably would not have received surgery otherwise. 76% of our patients with inguinal hernias received mesh, as opposed to 80% of surgeons in Ecuador opting for use of Bassini technique without mesh normally. Patients don't fully understand the benefit of mesh, and saving $100 is the dominant decision making factor usually. Many of the surgeons in the area are focusing on cesareans, which is more urgent and amenable to supplier-induced demand than hernia.

The local political atmosphere was a bit turbulent during our stay in La Concordia. A visit by the president, Rafael Correa, was spurred by a land dispute in the region. Prof K and several team members were able to meet Correa , who stayed in our hotel for one evening, and hear of his desire to establish a public hospital in La Concordia (The Prof.even has photographic evidence of the meeting!). We got an up-close-and-personal view of security necessary to protect a national leader in such turbulent times. Security guards, police, and military filled the lobby of the hotel and spread out across the front entrance and street for much of the duration of our stay. On the evening of the President’s public address the street in front of the hotel was filled with protesters.

The disparity of wealth in the country is glaring; we met doctors and business owners who seemed to be “Upper Middle-Class” by U.S./European standards, and farmers suffering greatly from something so simple to treat as athlete’s foot. Lack of infrastructure is an enormous issue for the poor of the region. Sewers, storm drainage systems, and drinkable water are nowhere to be found in the poorer parts, resulting in a lot of preventable illness. As almost the only health care available to people in the region is private, a lot of simple medical care is out of reach to the majority of people. Many of the clinics seem to run like businesses, and patients seemed very skeptical of the quality of care we must be providing for the $30.00 US that the program was charging.

Dra. Kathia Tinizaray, the local Public Health Doctor, shared with us at our farewell dinner that she had her own initial skepticism about the project and its prospects. She expressed great satisfaction that the initial hectic start had been followed by “the unbelievable” overall success of the effort. She is prepared to bring an Ecuadorian Government mobile surgery unit to Hospital Padre de Damian for the next Operation Hernia Project. This expanded technological capability should enable the project to include services for children under 10 and patients with incisional hernias who couldn’t be served in the initial project.
The people in the area were extremely excited about the idea of our return, and the nurses of the hospital buzzed around with a new life and energy as their empty, forgotten hospital filled with patients and bustled with activity. Gifts were bestowed upon us and we tried our best to reciprocate—some of the doctors even left their theater shoes for the nurses of Damian (If you’re looking for a good present to bring along on future missions, a nice woman’s pair of Crocs is hard to beat). I can think of nowhere else in the world where the people are more deserving of good care nor more grateful to have it, and consider myself a very lucky person to be included in this mission.

Deidre Murphy