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





SPANISH MISSION TO ALIADE (NIGERIA)
MAY- 2010

Fears to travel to an unknown place for us, fears to leave our families to start a new adventure, but we have to thank Prof Kingsnorth for advising us to go to Aliade, in Nigeria. It has been a great experience, we can say again that we have had that feeling of coming back home with a smile on our face. This is our third year of working together with “Operation Hernia” and we can say that the “Spanish team” is a group with a deep experience in this type of Projects, and we feel so proud to have the chance to support “Operation Hernia” and to help local people to improve their quality of life by repairing their hernias.
This is a noisy group, we like to enjoy while we are working and we are able to say that we are prepared to end up living for a week in a calm place in which people work at their own rhythm. We are aware of the difficulties to local people to get use to our way of just being, but we feel very happy when they tell us, after just three days, that they are going to miss us when we leave and that we are making then happy during our stay in that place.
We have met many nice people during our stay in Aliade. We have the chance to sit and just talk to them, to laugh, to share a beer or a soft drink, to work while we are sweating, not because the heat but the humidity is very high, and at the end, all what it is left in our heart is that we can say we have had the chance to meet many nice people who work in a part of the world very close to our place, just 5 hours by plane, but very far in terms of opportunities, items availables, possibilities of being attended properly by a correct health systems and water and light canalization. We just hope we can reduce that distance with projects like this one.
As we were saying, many new faces in our hearts: the team of the five doctors of St Vincent´s Hospital, very interested in learning the different mesh techniques and anything we can teach them. Specially, we have to mention Dr Austin Ella, the program coordinator of Operation Hernia at Aliade, it was a real challange for him to manage his first real group of Operation Hernia after the visit of Prof Kingsnorth. He did a great job organizing everything for his first time and, you could say, he was anxious to know how he could improve his effort to maintain the project. We have had many conversation with him, and based on our previous experince in Operation Hernia, we tried to support him with new ideas for the success of future missions. We also have to make a special mention to Dr Charles, always smiling, always happy and anxious to learn the different techniques of mesh repair and the way to perform a spinal anesthesia. He wants to be part of the Spanish team next year anywhere we go, we are going be very happy to have him with us as part of the team.
The nurses at the theater, Peter and his team, nice people, they tried to understand every single step we made in the operating rooms, just to learn and to be able to do it by themself a week later. It was a great happiness for us to see their interests on our way of working, and it was even more important to see how, after just two days, they trusted us. As Peters said “overall results are more important that the number of cases we are able to perform”, and they were happy because we did many cases and the results were excellent. We were really proud and happy when the team of the theater walked together with us, after the party of the last night, from the hall to the convent, it was a sign of friendship between Peter´s team and the Spanish group, respect as professionals, and a way of rendering thanks to us as teachers of theirs team and as human being that came to help the local people of their own town.
On the other hand, we have to mention the Sisters of Nativity, they all took care of us, they really wanted us to feel confortable and we can say that their hospitality was well appreciated by the team. They moved out of their own rooms at the convent so we could feel more comfortable. They adapted their own way of living to us and their own way of cooking to our preference. They did not stop any single day of our stay with them to say thanks for our help and to express how happy they were with our visit. They organized a welcome ceremony with a typical dance and a “goodbye party” with music, dancing, food and even fireworks, just to say “see you soon” .
And the local people, you could tell in their faces how happy they were of our work. “Well done doc”, that was the sentece that we heard everyday while we were walking through the open halls of the hospital. Sisters told us how happy they were walking back home by their own feet right after their surgery. Different cultures, tribal chiefs, little boys, families of the staff of the hospital, very poor people, from 12 month to 86 years old, all of them express, one by one, their gratitude for our visit.
The Spanish team, our 3 surgeons, Salva, Antonio and Juan, the two anesthesiologist, Ana and Hilario, our 2 nurses, Patricia and Manolo, and our general doctor, Virginia, have loved this experience and want to support once again this missión to the heart of Africa, because it is necessary for local people. We felt very good with ourselves since we had the feeling that we solved many problems in just five days, 90 surgeries in 75 patients, we teached how to repair hernias using a mesh and how to perform properly a local and a spinal anesthesia to the local doctors and nurses..
Of course, the last thanks, which is very important, to our Hospitals, three in Sevilla, University Hospital Virgen del Rocío, University Hospital Virgen Macarena and USP-Clínica Sagrado Corazón, and two en Huelva, Hospital of Río Tinto and Hospital “Infanta Elena”, that support this project by covering our work during five days and offering instruments, meshes and sutures. And we also want to thanks to Atlanta-Agencia de Viajes, to Helvetia, to Entrearte Enmarcaciones, to Arena Publicidad and to Estudio Buenavista for their support with the different aspects of this project.
We will continue with our contribution to this mission in order to set the basis of a Project that is a reality, trying to search a better world, continuing what Prof Kingsnorth has already done.

Salvador Morales-Conde





German Team from Cologne 20.6.- 2.7.2010 – Nalerigu (Team 1 – first week) and Takoradi (Team 2 –second week)
We went with two teams this year to Ghana – and as you can expect for a German team during the soccer world championship. It was our first trip to Africa and we were very excited.
In order to raise money for the whole crew we organized two charity concerts. We were lucky to get a world class pianist like Mrs. Sheila Arnold, who was born in India and supported us right away. The biggest amount of money was spent from the Rotary Club of Cologne. With further help of the industry we were able to pack 7 big boxes full of medical equipment.
We landed in Accra and were afraid to get problems at the border control as our anesthetist has brought a lot of “medical-opiates” with him. But as Chris Oppong had told us - there will be no problem when a sticker with “Operation Hernia” is on the boxes – and he was right.
The trip to the Baptist Hospital was excellent organized by Jimmy . We decided to drive to Nalerigu by car. Whereas the south seems to be very developed, we were very astonished when we saw the first clay huts in the North. The area was very rural and luckily there where none of the annoying ads of the telephone companies like in the south. The people where very colorfully dressed in their traditional cloth.
We had a warm welcome by Greg and his wife Wendy, who made our stay in Nalerigu very comfortable. We stayed in 2 very well equipped houses with hot shower, kitchen and air conditioning in a park area belonging to the hospital. We could watch the soccer games in the evening on TV and had WIFI with internet access in a school nearby.
The hospital crew was wonderful and very professional. The hygienic standard in the hospital was acceptable but not comparable to Takoradi. Fot instance one nurse in Nalerigu always tried to keep flies away from the open wounds during the operation. Nevertheless we had no wound infections. We think this was due to the fact that we decided not to implant mesh on a regular basis.
The two teams performed 137 operations in 2 weeks. The operations where sometimes very challenging. Most of the Operations in Nalerigu were performed in spinal anesthesia and local anesthesia. The children got Ketamine, as there was no oxygen.
We took part also in emergency operations like cesarean sections or operated a small bowel perforation of a child with typhoid.
It was a wonderful and most impressing experience for all team members. Not only that we met people who do excellent work under really difficult conditions, this humanitarian mission was really life changing for all of us.
Karl Moser
Team 1: Karl Moser, Markus Heiss, Andres Kremer, Philip Metz, Marion Koell
Team 2: Karl Moser, Jürgen Meyer, Rainer Müller, Silke Simanowsky, Sadiye Öner, Marion Koell




Leighton Hospital Team. Eruwa, Nigeria, July 2010

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 early in the morning of Saturday 24th July and loaded a minibus with numerous boxes and bags of medical supplies and luggage before travelling to Manchester Airport. British Airways had opened a counter especially for us and our luggage which made checking in very straightforward. We flew to Heathrow Airport and then from Heathrow to Lagos. On our arrival we were greeted warmly at the airport by Dr Yombo Awojobi. He helped us to upload all of our luggage on to another minibus and then we went to a hotel to spend the night before our journey to Eruwa the following morning.
We woke early and set off for Eruwa straight after breakfast. When we arrived we were shown to our accommodation, where we unpacked. We then went to the hospital and unpacked our medical supplies to enable us to start work promptly the next morning. During that afternoon we had the opportunity to observe Dr Awojobe perform a Caesarian Section, assisted by Christina, a medical student on her elective from the University of Sheffield. We were extremely grateful to both Dr Awojobe and his patient for this experience. Later in the day Dr Awojobi took us to see the developments to the area since our last visit before we sat down to dinner. We were very impressed at the work that had happened and his plans for the future.

We awoke on Monday morning after a night of being serenaded by 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 anaesthetic 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. He was a good student and by the end of the week he was pleased to be able to perform hernia repairs from start to finish.
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 all came away with a feeling of wanting to do more to try to help to support Dr Awojobe’s efforts for the local people. As a result John Pickering is hoping to arrange funding from BMI Healthcare to provide solar panels for the hospital in order to be able to generate electricity with the aim to have enough electricity to run an autoclave. The team have also discussed raising funds for an oxygen concentrator which would mean that more patients would have access to supplementary oxygen. We are all extremely gratefully to Dr Awojobe who once again made us feel very welcome and gave us a bit of an insight into surgery in Africa.

Nicola Eardley
SpR in General Surgery






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

On our first visit to the Hospital Padre 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 Jovita, 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 Jovita 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 Ocampo, 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. Morante in La Concordia, and Hospital Padre Damian, 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 Hospital Padre 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 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 Hospital Padre 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




Belgian Team, 4-13 September, Takoradi

The second visit of a Belgian team to Takoradi has been postponed from April until September due to the eruption of the Eyjafjallajökull vulcano in Iceland. With two surgeons (Marc Huyghe and Casper Sommeling) and one nurse (Pina Orlando) we tried to plan our trip as well as possible with the forwarded information and the experience of our visit in 2008. We took meshes (kindly donated by B. Braun Medical NV Belgium and Covidien), gloves (Cardinal Health), disposable drapes (Mölnlycke Belgium), suture material (Johnson & Johnson), local anaesthetics (Astra Zeneca and BBraun), analgesics, syringes and needles, and two big bags of small gifts and sweets. After arriving at Takoradi on Saturday afternoon we were picked up by the driver of the GPHA-hospital and brought to the Doctor's Transit Lodge where we stayed the whole week. The ladies team (Kate, Grace and Benedicte) took very good care of us (as they are used to) and like last time we gained some weight again, due to the nice meals they served us. Also the bedrooms were more comfortable than they were two years ago; a hot shower needed some patience or some luck. On Sunday we made a trip to Nzulezo (the stilt village) and in the evening we had a swim and dinner in Green Turtle Lodge (where the waves of the Atlantic rock the shores).
After arrival at the hospitals (GPHA and Hernia Wing Takoradi Hospital) on Monday morning we could immediately start working. After getting acquinted again (and some introduction for newcomer Marc) we started in both hospitals for a long week, with long working hours and challenging groin hernias. No hernia operation was a routine operation; in contrast to the 2008 mission we did not really have the opportunity to spend our nights in downtown Takoradi.
With two surgeons we operated on 54 patients, most of them with groin hernias. In all this patients (except the children) we performed a Lichtensteinrepair (with standard middle weight polypropylene). In one female patient with a huge ventral hernia I performed a more extensive repair with a retromuscular mesh. The operation-theatres were better equiped (a new light in GPHA-hospital, with batteries), but a shortage of sutures was felt at the end of the week. Also more loco-regional anaesthesias were performed, contributing to a better comfort of the patients (in the sometimes timeconsuming repairs).
Pina “the rock” Orlanda helped us out in the operation theatres, but also managed to visit friends she made in her previous missions to Ghana. Apart from a nurse she is our “public relations” officer.
After a long week hard work we had a refreshing swim and nice dinner with Dr. Boateng and his wife at the Planters Lodge at Friday-evening. On Saturday we left for Accra and made a stop at Elmina Castle as all groups do. For me as Dutchman this visit reveals a part of our history we should not be proud of. But I also explained Marc that at that time the Netherlands included most of the northern part of Belgium… In Accra we changed car and driver and set of to the Volta-lake, were we spend the night. At Sunday morning a nice view of the lake was our reward. After visiting the Shai hills, were we, unfortunately due to the rain season, apart from bats and baboons, saw no wildlife, we drove back to Accra. After a stop at the local art market and a lunch at the Golden Tulip Hotel we left Ghana by plane again to arrive in Brussels the next morning.
Advise for the next missions: bring enough sutures, local anaesthetics, drapes and gloves. Gowns are no problem.

Marc Huyghe states: To call yourself a real hernia surgeon one should have operated on hernias in Africa



Leighton Hospital Team Report Carpenter, Ghana, November 2010
Fifth Mission
Magdi Hanafy, Perry Board, Janet Burrows, Sara Watson, Katy Griffiths, Natalie Weeg, Cristina Frezzini.
Ali Stout, Dee Richards and Julie Green. (Plymouth)
The team has been preparing for this mission for over a year. Tens of boxes filled with donated and purchased medical equipment were collected and distributed in 25 boxes to fly with us this year.
We received support this year for the team and Mission from:
 Leighton Hospital: Vaccination booster doses again, Annual/Study leave, Letters of support to Customs & Excise from CE, Posters from PGMC. Main Theatre (PAT), Treatment centre (Dawn), Orthopaedic Theatre (Jackie), Linen room, Occupational Health, Pharmacy...etc.
 South Cheshire Hospital Theatre & CEO.
 Residential Homes (Vera)
 British Airways. Waiving fees for 12 extra Bags as well as special fares for the team.
 BARD and Ethicon. 150 Free meshes and sutures.
 Eschmann: two “little sisters” autoclaves.
 Previous recognition of our work by Surgery and Cancer Department “The Judges Award”.
 Each and every person who kept wishing us good luck.
 Sallis Healthcare Ltd 27/01/2009 200 scrotal supports
 Mr Bill Love 05/02/2009 Donation of surgical instruments to the Ghana Project.
 Manchester Netcare Hospital. Theatre equipment on closing down.
Our work was recognized and broadcasted in the local TV. www.itv.com/granada/doctors-in-ghana75296/
Departure:
Always efficient and on time, the team arrived in two minibuses to my home at 7:00 am sharp. All the boxes were loaded in ten minutes, 25 of them, and off to the airport. BA as usual opened two counters for us this time and did not weigh any of the items as the weight was already written on each box. We have already paid for three more bags over our allowance which was generously increased by BA from 10 to 22 bags. Half of the stress was relieved when all check in was completed without problems including the two autoclaves. We flew to Heathrow Airport terminal five on the last voyage of a Boeing 757. The crew was proud of its twenty five years service.
At terminal five we met the Canadian team and the rest of the British team from Plymouth and Margate (Ali Stout, July Green, Sarah Hastead and Natalie Weeg). Hugs and kisses and photographs. Last year did not seem to be that far away. We were all looking forward to this year knowing we have a lot to do. The Canadian team was led as usual by Dr Jennifer Wilson, a GP from Toronto who is a brilliant doctor and leader, as well as a mother of five; the youngest are six year old twins. She introduced us to the new members of the Canadian team. We did the same. We also met the British team from the south going to Takoradi, led by Chris Opong a colorectal surgeon from Plymouth and one of the pioneers of Operation hernia.
Arrived to Accra:
In Accra airport Chris Oppong waved his magic stick and the customs and excise officers parted on either side to let the queue of 50 volunteers through with 155 boxes and bags full of equipment without inspection. Our trucks and buses were waiting for us outside the terminal. We went to the hotel in Accra where we spent the night after a quick dinner. The next morning we were up at six a.m., had breakfast and started our journey to Carpenter, taking 12 hours including three stops.
Arrived to Carpenter:
We arrived in a big compound next to the village. Dr and Mrs Mensah and the local team had prepared our accommodation AND OUR DINNER. We stayed this year in Akwaaba house. A compound with African style huts, security and all facilities in constant supply, electricity, water, and an open air shower etc. We went to our rooms. Each one had two beds, each with a mosquito net and a fan. Rooms and toilets were clean. The area was calm. It rained twice on that day.
Preparing for work:
We had been communicating with the Mensah’s long before this year’s mission. As a result each theatre was already prepared with a new air conditioner, new lights, operating tables in place as well as enough tables for equipments. We started opening the boxes and distributing the equipment to both theatres. We gave Mrs Mensah, three boxes of children’s school equipment, 50 footballs and toys we brought as gifts to the community. We started screening patients and listing them for an appropriate operation, i.e. local or general, and started operating immediately.
From the first morning, Professor Giampiero Campanelli and his assistant Dr Marta Cavali from Milano, started in Brenda’s theatre with a Local Anaesthetic list. Perry, Ira and Katy were preparing David’s theatre for General Anaesthesia, but still allowed me (Magdi Hanafy ) and Natalie Weeg to use the theatre for a few local cases. This time as well we have been blessed with an outstanding team of operating nurses, from Plymouth and Leighton, as well as Ali Stout the inpatient and recovery sister.
Start Working:
Patients were waiting for us under the tree early next morning. A quick ward round, yesterday’s patients were seen and discharged, new patients were allocated to their rooms, Alison started to excel as a ward sister, in organising the local helpers and the flow of patients. Theatres were prepared by Julie, Sara, Dee, Sarah Hasted and Janet. We started a General Anaesthetic list for children.
We performed 26 procedures on 20 patients on that day. Afterwards, we started screening patients for the next day and allocated lists for both theatres. By the end of the first week both Professor Campanelli’s team and my team had managed to operate on 100 patients.
Drama on the second week.
We were only two main surgeons in the first week. Professor Campanelli and Marta flew back to Milano on Friday afternoon after operating on three patients in the morning. I had to continue the rest of Friday and all Saturday on my own operating in two theatres. We were expecting plenty of surgical support on the second week. Mr. John Chester from Devon, Mr. Richard Dalton from Plymouth, Cristina Frezzini the medical student from Sheffield, were all travelling from London on Saturday and expected to arrive in Carpenter on Sunday night. Chris Oppong having finished a week’s work in Takoradi in the South was scheduled to meet the team coming from London in Accra and join them with the travel to Carpenter. The flight from London was cancelled due to engine failure and the first available flight was 48 hours afterwards, on Monday. John Chester cancelled his trip as it was not worth the effort to travel all that way for only two days operating.
Chris had to travel alone to Carpenter and arrived early Monday morning. Still he wanted a full list on Monday and I found myself operating on Monday and Tuesday with Chris rather than helping the Canadians in the villages.
Visiting villages with the Canadians:
Because of that the surgical team could not contribute this year to the usual efforts of joining the Canadian team in their trips to the villages (except for Sarah Hasted). We managed to sneak out of theatre for an hour or two when the clinic was in the compound for the Carpenter people. The Canadians were sending referrals all the time for us to treat or give an opinion. The Canadian team was prepared for the invasion by all the local population with and without any illnesses. But many of them have already been triaged by David Mensah, so those with genuine complaints were allowed to be examined. Medical, dental, tropical, infections and common diseases were all seen, and treated with the help of effective supporting teams of lab technicians, physiotherapists and pharmacists. At the end of the day, we gathered to be greeted by the chiefs who offered us gifts of vegetables and a ram as a token of their gratitude.
Conclusion:
Yet another “Life Changing Experience”. The life of both providers and recipients of care will never be the same again. This mission has seen our reputation extended not only to neighbouring villages but also people started arriving from Côte D’Ivoire and Burkina Faso. The lists of patients for next year and the year after are already full. The idea of building a permanent Hospital is brewing. The following table shows a comparison between last year and this year’s work.
Surgical team of GB 2009 2010
Number of procedures 191 206
Number of patients 151 160
Number of days 8.5 10
Number of surgeons 2-3/day 1-2/day


God Bless you

See you next year

Magdi Hanafy, Leighton Hospital Crewe, Cheshire, UK.




SPANISH TEAM MISSION IN THE “CORPORACIÓN DE SALUD PADRE DAMIÁN”, LA INDEPENDENCIA, ECUADOR.

We were already in the airport, it was 8 p.m. on 19th November and five of us (3 surgeons: T Butrón, JA Pascual, MA Vaquero and 2 anesthesiologists: O Aramburu, ML Vizcayno) as the other two members of the group (S Alonso, M Donat) had left in the morning. We had left behind the whole preparatory work carried out since at the end of July Prof. Kingsnorth, president of Operation Hernia Foundation, confirmed to us the mission, which was the starting gun for us to begin with the project and allowed us to ask several institutions for financial help and medical companies for medical material. We received financial cooperation from Obra Social Caja Madrid, Covidien, Gore SA, Smith&Nephew and Ricardo Viera (as a personal contribution), and medical and pharmaceutical material from Braun Surgical SA, sutures division and pharmaceutical division, Covidien sutures division and electro-scalpels division, Prim, Smith&Mephew, Menarini, Dr. P Castillo (Hospital Universitario Santa Cristina), Hospital Universitario Santa Cristina and Hospital Universitario 12 de Octubre, for whose help we want to thank them from here as it allowed us to carry out our mission to a happy end. We also thank our work companions in our several hospitals as they took care of our work while we were in Ecuador. We wrapped in plastic coverings the five great bags of medical material we had prepared and we marked them with red crosses to facilitate customs in Quito.
After a flight that took fifteen hours, we arrived at Quito airport at 8:35 of the 20th, six hours ahead of Spain time. Haydee, an Ecuatorian young girl who had already collaborated actively with the first mission in Ecuador, was waiting for us with a van and its driver. We proceeded to La Independencia with a stop at the Museo de la Mitad del Mundo. After several hours we arrived at the Corporación de Salud Padre Damián, a small health complex in that small place, made up by several simple one-storey structures, one of them with an operation theatre preceded by a hall with a washing stand and lockers room, a maternity room, several rooms with 2-3 beds each for the admitted patients, infirmary control, sterilisation room, and storeroom; another house with 4-5 consulting rooms and a third facility with a small laboratory and the administration area. There we unloaded our medical material, and Nidia, the administrative head, showed us the operation theatre with an old surgical table and lamp, where they were putting up an auxiliary lamp with four halogenous bulbs, she showed as several stretchers for us to choose the table we would use as a second operation table and the cloth screen that would divide the operation theatre into two spaces in order to be able to operate on two patients at a time. We finally went to La Concordia, a city four kilometres distant, where we were taken to the Atos Hotel, our small but friendly lodgings situated at the crossing of the two main streets of the city, with a heavy traffic of lorries, cars, autotaxis, and motorcycles. After a quick look at our rooms, we came down to meet doctor Kathia Tinizaray, the head of health services in the area, who would be our help the next days, as well as doctor Miguel Bunces, in charge of CSPD, who combined that work with his job in public health since a short time before. We finished our first day with a supper at a grill on the main street.
On Sunday at 7 in the morning we were ready to go to the CSPD, we bought some fruits in a stall in front of the hotel (pitahajas, bananas, mangoes, ananas,…) and we breakfasted on our way to the CSPD. Santiago and Miguel went with Dr Bunces to the local radio station to be interviewed so that people would know of our arrival and our beginning with examinations and operations that same day; the rest of us finally began our work: we unloaded all the material, shifted some shelves inside the operation theatre, Olatz and later Miguel too placed all the anaesthetic material at the back, and the rest of us put in place the sutures, meshes and all the other things, among them the toys (which had been given to us by Dr Martínez Montiel and nurses from the Department of Digestive Medicine of the Hospital 12 de Octubre), leaving the operation theatre ready for operations. We then came to the consulting room to examine the patients that came to the CSPD. We did it in three rooms, dividing the work between us. We confirmed those who had hernias and incisional hernias, etc, and identified those who needed laboratory tests. We worked in a chain. Haydee would take their data, we examined the patients and filled up the data sheets, then we ordered them and lastly we wrote the surgical patients lists for every day. By then it was time for the midday lunch and we had finished; so we decided to begin operating that same day, Sunday, after lunch. We operated upon four patients, we tested the stretcher and the auxiliary halogenous lamp, what a heat! There was one diathermy which, together with the one brought by us, provided one for each table. Everything went without any special incident and with much joy. We had gone far beyond what we had planned beforehand. At the end of the day, and after checking most of the patients on the list, we realised that some of them had no pathology, so that maybe the number of patients could be insufficient to occupy us the second week. We had to think what to do! Speaking at table during dinner we thought we could perhaps make some publicity on the local TV stations.
The following days we kept our routine, we bought fruit at 7 in the morning, took the bus to La Independencia, sat down for twenty minutes to take our fruit and our coffee and we started with the operations. On Monday we operated upon 13 patients, one of them a difficult case which took almost 4 hours, so that we finished almost at 7 in the evening with only 35 minutes break to eat in the bar-shop by the side of the CSPD. We realised that could not happen again as we came to know that the water supply was cut at 6 pm. Jovita told us about it, a very efficient and charming nurse who helped us most of the time and told us she had a daughter in Spain. On Tuesday and Wednesday we finished earlier, which allowed us to take supper one day with the chief of police, Mayor Luna, Kathia, and Sandra Ocampo, the owner of the hotel, whom we met that night and who from that moment helped us in all our needs. On Wednesday we were called from the Efe Agency while we were operating, and we spread the news of our work thinking that we could attract more patients that way. We had already operated upon some children between 4 and 11 years. We could not include smaller patients because the respirator was not working and the anaesthetists told us it was not possible to operate without them. All the children were happy as we gave them toys which we also distributed among the children of the workers in the centre. On that day at 7 pm we went to the local TV station whose owner was Sandra’s brother and on whom we operated a few days later. Haydee and doctor Bunces accompanied us. They interviewed us in the news programme and they gave us the opportunity to announce our work, so that the following days more patients came to our consult.
We daily increased our work: consultation, operation theatre, incoming register in sheets specially prepared by us which Haydee wrote out and printed in her computer. In that way, all the patients had ready a sheet with their data with information about their clinical situation and about the cost; besides, we filled in a database with all the information of each patient, and we completed the report we gave the patient together with a prescription for the medication they had to take. Thus the first week passed fast; a few days at night we went to a cyber centre to look at our e-mail in Internet, and we planned what to do on the weekend. How to make the announcements that would bring us more patients. Haydee got printed a thousand copies of an informative sheet in a printing press with details about our presence and our activity and where could those interested come. During the weekend we split into two groups and we went through different places giving out the information sheets and sticking up posters in pharmacies and other establishments. Sunday 28 was census day in Ecuador, which means that the whole country was paralysed as everybody had to remain at home since the previous midnight so that the officials could come and collect the data. How well we slept that night! No lorries or street noises to disturb us.
We too were censed, but as we were foreigners we were allowed on the streets. It was surprising to see La Concordia turned into a ghost city without any bustle, traffic, people as it would have been unthinkable a few hours before. That morning some of us went with Mayor Luna in a police car to patrol through the area and we saw how the people remained in their houses or at their doors with many children playing, all that after a brief visit to CSPD to see a patient who had been operated and had informed us he had fever; we verified he had a slight inflammation of the wound. He had been prescribed antibiotics, was now without fever and he returned home. We all had lunch together at Haydee’s house. Some of the group remained there singing in a kind of home Karaoke, and others went back to the hotel.
The next day we began our second week. We operated upon 14 patients. In the evening, while the last patients were being attended to, Teresa went with Sandra to Quinindé, city 30 minutes by car where they had two interviews in local radios and two in local TV stations, and they visit the public hospital, and its directors through Sandra accepted that the next Operation Hernia mission would be carried out in their two operation theatres which are very well furnished. On the next days we had many new patients as a result of the announcements. Stitches and staplers were removed for the patients operated upon the previous week, and we saw three patients with seroma, and one with hematoma, while the others were doing fine. Pepe Pascual taught two lady doctors how to remove staplers, one of the health centre in La Concordia and the other of the CSPD, who were to do the follow up of the patients to be operated on the second week. Every day we operated on more patients, 16 on Wednesday with 20 procedures, which is our record.
We finally reached out last day on CSPD. We operated upon 10 patients, folded down the operation theatre, and we placed all the remaining material in bags. The farewell meal took place with all the workers of the centre who had helped us all the time. We eat fish with peanuts and coco sauce, accompanied by white rice. We all were very happy. Jovita cried at the farewell. We had one day free before returning to Spain. Sandra and Kathia took us in two cars to Quito. We slept in Sandra’s apartment and the next day we went on a tourist visit to Otavalo, an indigenous village which is UNESCO Historical Heritage, with a high cultural level and a handicraft market which we liked very much. Now only our return flight was left. We had not imagined we would have to face the problem of the air traffic controllers’ strike in Spain which put our flight 24 hours later so that we reached Spain one day later than planned. We used that time to sum up our work: we had operated upon 106 patients, with 121 procedures in all. We had achieved our mission well beyond expectations.

Teresa Butron



Operation Hernia: Abidjan, Cote D’Ivoire November 13-19, 2010

On November 13, 2010, Operation Hernia embarked on its second mission in Abidjan, Cote D’Ivoire. Once a French colony, Ivory Coast is situated on the southern border of West Africa. Though the official capital is Yamoussoukro, Abidjan is the largest city with an estimated population of 3.5 million and the second largest francophone city in the world. Named after one of Ivory Coast’s most prosperous rulers, we arrived in Felix Houphouet Boigny airport at approximately nine on a sweltering evening.

Led by Professor Kingsnorth, the mission party consisted of two colorectal consultants from Wales, Brian Stephenson and Gethin Williams and myself, a fourth year general surgical resident from the US. Immediately after landing, we greeted by the warm embrace of Dr Desire Trazo, an old friend of Professor Kingsnorth from a previous mission in Takoradi. His Ivorian background and gracious hospitality facilitated our acclimation to Abidjan.

Similar to the first mission in 2/09, Operation Hernia reestablished its presence at at Chirurgicale Yopougon-Attie (UCYA) Hospital with the help of its director, Dr. Max Thalmus. Nicknamed a “gentle giant,” his intimidating physical demeanor contrasted his soft-spoken, yet effective manners. Critical to the mission’s success, Dr. Thalmus recruited not only patients, but also local surgeons who were eager to adopt the Lichenstein repair.

One main difference compared to last year’s mission was the exciting introduction of mosi-mesh, imported from India. At a price of $0.01 per piece, our goal was to pave the way for a cost effective repair for all future hernias. Indeed, our first day included the trial and error measurements of the correct dimensions of the mesh in the autoclaving process. Once the initial wrinkles were ironed out, the rest of the operation was smooth sailing, even making headlines with the local newspaper and television network.

Our day-to-day itinerary commenced with an air-conditioned van ride to the hospital, offering a 15-minute glimpse into the indigents’ customs and habits. Amidst the chaotic traffic and ubiquitous potholes were beautifully clad women donning remarkably heavy items on their strong, slender necks. Their opulence and dignity mirrored that of the towering skyscrapers in the business district, products of Ivory Coast ’s pre-civil war financial prosperity.

With the corroboration of local anesthetists and nurses, we operated on 51 patients, repairing 54 hernias. The majority of the patients were male, ranging from 6 months to 82 years old. More than half of the patients suffered from their hernias for more than 5 years and were either irreducible or had a significant scrotal component. Over 90% of the cases were performed under local anesthesia with only a few requiring spinal or general anesthesia, mainly incisional and longstanding scrotal hernias. The mission concluded with the unexpected rare opportunity of following up patients on postoperative day 3-4. The fruits of our labor yielded beaming smiles in our grateful patients and their relatively painless hernia free strides.

On our last night, we celebrated the success of the mission and also Professor Kingsnorth’s birthday with a lavish feast at a marvelous local restaurant. The highlights of the bittersweet festivities included speeches by both Dr. Thalmus (in French) and Prof. Kingsnorth. The highlight of the joyous occasion was receiving lovely African print clothing as tokens of their appreciation. From the bottom of our hearts, we thank everyone for their invaluable contribution to yet another successful Operation Hernia mission in Cote D’Ivoire. It was an unbelievable and unforgettable experience and we look forward to the third mission soon (hopefully with French speaking volunteers!).

Elaine Chan




UK Team, 7-12 November, Bole Northern Ghana

Operation Hernia broke new grounds in 2010 in Northern Ghana. Chris Oppong, Consultant Surgeon (and Director of Operation Hernia , Ghana) teamed up with Richard Dalton, a senior Surgical Registrar at Derriford Hospital, UK to work at Bole Hospital from November 7 to 12. Both of us had worked at the Operation Hernia centre at Carpenter the previous week. The other Operation Hernia Centre in Northern Ghana is at Nalerigu Baptist Hospital in the north west.
Bole is a town north east of Carpenter, about an hour’s drive on mostly good road with tarmac. It has a population of about 130,000 friendly people. The catchment population of the hospital is much higher.
Welcome: We received the traditional warm Ghanaian welcome at the hospital from the Medical Director Dr Joe Nyuz, the theatre and ward staff. They were all extremely respectful and hard working. They responded in a remarkable manner to our briefing and worked very efficiently. We were surprised when all the theatre staff agreed to support routine theatre work on a Sunday and a national holiday to help us operate on as many patients as we possibly could.
The Medical Director is a forward thinking administrator who has embarked on a project to renovate the run down hospital. The outpatients department has been transformed.
Accommodation: Accommodation was very good by local standards. We lodged in a government Guest House, in air conditioned en-suite rooms. Food was provided by caterers in the guest house. The whole Guest house and individual rooms are mosquito proofed. Laundry facilities were provided.
Theatre Facilities: The hospital has two air-conditioned theatres equipped with operating tables. The main theatre has a modern anaesthetic machine and a ceiling lamp which requires regular adjustment. The minor theatre has a standing theatre lamp but has no anaesthetic machine. Operation Hernia provided diathermy machines, 1 Little sister autoclave and 4 sets of hernia surgical instruments, in addition to the usual theatre consumables. Most of the hernias were, as usual repaired under local anaesthetic. All patients whose hernias were not amenable to LA repair had Spinal anaesthetic. We were immensely impressed with the skill of the experienced nurse anaesthetist. We cannot comment on his GA skills. All the patients were admitted post-op and discharged the ff day. This was due to poor access to transportation.
The hospital has reliable water supply. There is also a generator back up to electricity supply. On one occasion we had interruption of electricity supply. For a hospital in a developing country this is not unacceptable.
Operation Hernia Database: All operations were recorded on Operation Hernia Database. All hernias were graded according to Kingsnorth Grading. All patients were due to be followed up within a fortnight by the Medical director and post operative complications recorded on the database. In all we performed 83 surgical procedures in 67 patients.
Social: We were taken on a tour of a massive hydroelectric project in the Bole District. A planned visit to a game Park had to be postponed. An informal send off reception was organised for us.
Conclusion: Bole Hospital has great potential. We enjoyed our stay. The welcome was heartwarming. Staff very efficient. They are keen to host more than one Operation Hernia team per year. I will recommend Bole Hospital enthusiastically to all volunteers. We plan 2 visits in 2011- April and November.
Chris Oppong & Richard Dalton
Plymouth UK



UK Team, Takoradi,Ghana 1-5 November 2010

Team members

• Chris Oppong , Surgeon ( Lead) / Jayne Buckley, Theatre Nurse/ Christine Tinsley, Theatre Nurse / Lizzie Stone, Theatre Nurse / Andrea Warwick, Senior Registrar (Derriford, Plymouth)

• Terry Irwin, Surgeon (Lead NI) / Jenny Irwin, Theatre Nurse / Mary Kennedy Nolan, Theatre Nurse / Catriona Semple, Senior Registrar (Belfast, N Ireland)

• Shina Fawole, Surgeon(Dewsbury, West Yorkshire)

Our team consisted of 3 Consultant Surgeons, 2 Senior Registrars and 5 experienced Theatre Nurses. There were 4 first timers in the group (Catriona, Lizzie, Mary and I – Andrea) but the others were a wealth of experience and guided us through all we needed to know!

The week started with a day trip to Green Turtle Beach: gorgeous sunshine; white beach; volleyball (expert level ha!) and plenty of beer…was this the hard work I’d been hearing so much about?!

Reality hit the next day. The hernia centre is a fast paced machine. No sooner have you written your operation note than the next patient is on the table. The lists in the hernia centre were long and we generally worked until about 7pm, with an easier time in GPHA and Dixcove. Saying that Dixcove was so hot (air conditioner not really working) that even though the day was half as long, it was hard (and sweaty!) work!

At the end of the day on Wednesday Chris Oppong/ Shina Fawole operated on a young gentleman who had presented emergently with a huge strangulated hernia. He had become acutely unwell and they spent until late at night repairing his hernia. Thankfully the patient survived. He developed a minor wound infection.

Most hernias were operated on under Local Anaesthetic as in previous campaigns. There was no Consultant anaesthetist in the team this year. General and Spinal Anaesthetic was administered by the local nurse anaesthetists. There were a couple of anaesthetic near misses which were thankfully rectified without post op complication. One patient had a low saturation due to poor monitoring. The other was a large lady having a huge incisional hernia repair, converted from spinal to “GA” in less than controlled circumstances.

The recovery of children/ patients following GAs was also less than ideal. The hospitals need a dedicated recovery area. In 2011 we hope to recruit a Consultant Anaesthetist and a specialist recovery nurse to provide appropriate training to the local medical and nursing staff.

There was plenty of equipment when we were there, although we had of course taken plenty with us. On the last day Jayne and Christine went through all the cupboards making an inventory of the stock at the hernia centre. Hopefully this should help the subsequent teams to know what quantities of supplies to take.

So…our “stats” – we did 108 procedures on 100 patients. The vast majority were performed primarily by trainees under supervision (including 2 Ghanaian trainees who spent the week learning mesh repair with Chris Oppong). We operated on 10 children (9 inguinal hernia repairs, an umbilical hernia , and a 3 year old angel with an enormous lateral abdominal wall hernia). Most were primary inguinal hernia repairs but there were 8 recurrent hernias, and a handful of hydrocoeles/ epididymal cysts/ ventral hernias. Approximately half the patients had their procedures done under local anaesthetic , with 12 GAs and the rest under spinal anaesthesia (very quick and good results from the nurse anaesthetists).

We were extremely well looked after by the girls in the “villa” and by Bernard.
It was a very enjoyable and rewarding week for all involved and we are all looking forward to next year!

Andrea Warwick (Registrar)