Swiss - Anglo Team, Okpoga, Nigeria, 3-12 January 2011

Irish-Australian team, St Vincents, Aliade, 3-12 January 2011 Team Estonia. January 2011 Farafenni, The Gambia

OPERATION HERNIA SOUTH EAST NIGERIA- A REPORT

Operation Hernia to Moldova, April 2011

Report of the Belgian - Italo team: Visit from March 12 - March 20 2011

BOLE HOSPITAL APRIL 2011

"OPERATION HERNIA" MISSION IN QUININDÉ, ECUADOR: 23-30 APRIL 2011

Elizabeth Central Hospital, Blantyre, Malawi: 24th June 2011 - 11th July 2011

Hope for Ghana, Report from a German/American Team in Takoradi and Dixcove: July 2011

UK Team Report. 2-16 September. Mandalgobi and Ulaan Baatar, Mongolia

Swiss - Anglo Team, Okpoga, Nigeria, 3-12 January 2011

On the occasion of a short visit to St. Mary?s Hospital in Okpoga, Nigeria in February 2010 it was decided to open a new site for future Operation Hernia activities in this place. After some months of preparing everything was set up and the team, predominantly members of the Swiss Surgical Team, was put together. At the same time a second Irish - Swiss - Australian team was getting ready to spend a week in St. Vincent?s Hospital, Aliade. After a night flight with British Airways we arrived in Abuja early in the morning. The airline had granted us a generous amount of free luggage which we used for bringing along surgical and anaesthesiological material and instruments. Despite the large number of boxes and suitcases we encountered only minor problems at Immigration and soon we could continue our journey. For six hours the two teams bumped in a very full minibus from the airport first to St. Vincent?s hospital where one team was to spend the next week. Two hours later after a dusty drive and a visit at the bishops place the three Swiss surgeons (Martin Walliser, Hanspeter Notter, Peter Nussbaumer), one English surgical trainee (James Barnes), one Swiss anaesthetist (Warner van Maren) and one Swiss scrub nurse (Claudia Baur) finally arrived at St. Mary?s hospital. A large crowd greeted us with dancing and singing. Posters around the town and announcements in the church had prepared them for our arrival. In order to make the most of the short spell of the mission we decided to set up the operating theatre on the same evening. Boxes of instruments, diathermy machines, gloves and sutures were hoisted onto porter?s heads and taken to the hospital for unpacking and sorting. Fortunately we had electricity 24 hours a day, thanks to a new generator donated by Operation Hernia. So the next morning we started. By dawn patients with hernias started to line up. Following confirmation of a hernia(s) they were put on the list for having surgery the same day or later in the week. The lucky ones put on their colourful nightgowns and sat in front of the theatre where they awaited their turn (photo 1). Nobody seemed to mind waiting for as long as it took ? neither the patients nor their families sitting under a plastic sunshade. For the next six days we continued operating from 8 a.m to 8 p.m, sometimes even longer. In between two procedures the two tables were vacant just long enough for cleaning. Eighty patients and ninety interventions later we reached full time and still the patients kept coming. Some had travelled for eight hours to reach the hospital and had to be turned down. How distressing to be the bearer of such bad news. Names were taken with the promise that the next hernia team would see to their hernia. Performing up to 18 procedures instead of the usual one operation per day was not only exhausting for the local scrub nurses, but also put the staff working in sterilisation to its limits. However having an experienced expat scrub nurse with the team improved the efficiency and quality of their work and increased the level of hygiene considerably. One of the aims of Operation Hernia is to teach contemporary surgical techniques to the local staff, but the three Nigerian doctors working in the 100 bed hospital were busy working in the different departments. Since none of them was trained in surgery our intention to teach and train was somewhat limited. In the end we achieved having one of the doctors performing the mesh-repair under supervision (photo 2). It goes without saying that our accommodation was excellent and the hospitality of the matron and her team generous. They went out of their way to make our stay relaxed and convenient. And Austin Ella, the local coordinator made a big effort both before and during the mission and has thus contributed substantially to the success of our work. Altogether the team spent a very satisfactory and unforgettable time at St. Mary?s, and we thank everybody involved for their help and support. Peter Nussbaumer

 

Irish-Australian team, St Vincents, Aliade, 3-12 January 2011

This Operation Hernia mission was part of a joint mission to St Vincent Hospital,Aliade and to St Marys Hospital. Peter Nussbaumer was lead for the overall mission, and headed up the St Mary?s team and Richard Stephens the St Vincent?s team. Travel The teams met up in Terminal 5 Heathrow Airport for the 03.01.2011 22:15 Departure : LHR London - Heathrow BA 002 Flight to Abjua.This flight is most suitable as it arrives early in the morning allowing day light travel to destination, which takes up to 6 hours allowing for stops and visits on the way .British airways staff are most helpful allowing extra weight for equipment, which included diathermy machines x2 for St Marys which was picked up and packed in terminal 5.Team members came from Switzerland, England and Ireland and Australia. Emigration at Abuja was very easy this time (everybody however finds getting the visa difficult and time consuming in the first place.)Our passage through the airport to the customs was OK, but there our host Dr Austin Ella had a deal of difficulty, as we were not registered with the Nigerian Medical council. This is becoming quite an issue at this point and may become a block in the future. Travel to Aliade was very cramped indeed and was the worst part of the trip for many team members. Teams must travel together and booking coordination is essential. The SSS took an interest in us at the Airport and visited us twice in the hospital. We were welcomed by young local dancers. The St Vincent?s Team Brian Lamont Anaesetist(Irish) Elvira, Claudia Theatre nurse(Swiss) Denis Mehigan(Irish),and Richard Stephens (Irish), John Garvey(Australian) and J?rg Wydler, (Swiss), Accommodation at St Vincent?s The accommodation at St Vincent?s is secure and very adequate indeed. Food is very good and we were well looked after and made most welcome. Temperature was reasonable, and this is a suitable time to visit the region, while March is to hot. Water for washing was from the shower some of the time, or from the ?big bucket?. Electricity was unreliable, but much more available that March 2010. Bottled water freely available. A bottle of beer was welcome in the evening. There were no mosquitoes at this time of year, but nets are available, for when they are plentiful.This is a Malaria area. The cost of accommodation and food at St Vincent?s was higher than at St Marys. I felt it was however most reasonable, but perhaps they should be the same. Goodbye party on the last evening was appreciated by all. Operating Theatre The team of nurses/theatre operatives are lead by Peter who is experienced at surgery himself as to varying degrees are other members of his team .Peters Team worked very hard while we were there and are most helpful.. The instruments especially the scissors are now becoming quite blunt, and we encouraged them to get these sharpened locally I doubt if this will happen and new instruments will need to be brought by future teams. Sterility is an issue and having a nurse with us brought these lapses more clearly to our attention. The drapes are too short and the holes to operate through to big, these could and should be remade locally. The theatres need to be cleaned daily and this is not done, dust is lying on all the surfaces and could easily be cleaned and a lot of unused junk remained lying around. I met with the Matron and brought these issues to her attention, Peter feels a cleaner should be allocated to the Theatre. These simple matters need to be attended to locally. We were unable to use the mosquito net for our repairs in either hospital as the gauges on the sterilisers did not work at all so we really did not know if the instruments were sterile either. Patient selection: very large numbers attended daily to be reviewed they were outside the theatre in large numbers and at times towards burst in! We saw patients in the theatre change room in between cases, and in sessions, by the one not operating, we estimate we saw well in excess of 400 patients and felt bad that we would not be operating on them. I am not clear if the patients were aware of this but they were very keen to be seen by us.. The local plan was that they would be operated on after we left by Peter et al. We said some particular problems must be operated on by the next Operation Hernia team. Antibiotics We engaged in discussions with Dr Austin in relation in relation to antibiotic administration, and he moved to pre op dose rather than post op.This was also more cost effective andfuture teams might bring antibiotics with them, we used ?left over?s? from the Spanish team. We all found the trip rewarding, enjoyable and interesting and any negative comments are intended to be constructive! Richard Stephens

Team Estonia. January 2011 Farafenni, The Gambia

After several months of planning, fund and equipment raising landed Team Estonia in Banjul, the capital of The Gambia. There were three of us - anesthesia would be covered by Dr Kristjan Kalling, a resident surgeon Dr Martin Adamson from Estonia, a resident surgeon Slawomir Koziel from Poland and myself as consultant surgeon. Instantly were we greeted by dry hot air of Africa, the Smell of Africa as we used to call it. It's just not the high temperature but the different scents in the air: smoke, rotten food, dirt and ocean - it all makes together an unique flavor one can only get in Africa. Jim Jallow, our man in The Gambia, greeted us in the airport. We had been talking over phone some times and exchanged a lot of emails and now indeed he was there to take us to Leybato Motel on the beach. Nothing fancy, no 5 star resort, but neat and tidy place a bit further away from the touristic attractions and noise. A place for travelers and expats as Lonely Planet puts it. And a place with a wonderful kitchen! So after some days of waiting and a meeting with Permanent Secretary of Ministry of Health where we had the opportunity to give a short presentation on Operation Hernia, we were free to go to Farafenni, our final and only destination in The Gambia. Travel there was an adventure in itself. Although Jim Jallow had promised to provide free transportation to the site, nothing of the kind happened. So finally we simply crossed the Banjul river with a ferry and rented a local taxi to take us the 150km along the north bank to Farafenni. Taxi-drivers shouting, fighting, grabbing our luggage, begging for some money - it all only put some colors onto our journey. Police checkpoints everywhere along the road, in some we had to produce also some id-s, well hidden so far in the underwear. But Farafenni hospital greeted us with warmth and sincerity that really took breathless, especially after adventures in Banjul. CEO Alhagi Saine, hospital manager Baboucarr Saine and our constant companion Sainey Dibba, the communication officer of Farafenni Hospital were the nicest people we have met in Africa so far and to be honest it seemed these guys really do need help in Farafenni. Although the hospital is state run and financed, the possibilities for patients in The Gambia are by far not the same we are used to in Europe. We were able to collect some medical equipment, surgical instruments, meshes and sutures which we donated to Farafenni hospital. We could also take along a cardiac monitor, that we left later in the OR, we hope it will find good usage. Medical personnel. Nurses are mostly local, Farafenni people, and to be honest very capable. Doctors on the other hand are mostly Cubans spending year or two in the hospital and afterwards being replaced by others. No surgeon had been around for a year. And patients were simply waiting. When the word spread that we were around, patients started to come from close and far, some came even from Senegal. Talking to them wasn't easy, Mandinka and Wolof was beyond us, but local nurses were very helpful. Specially capable of solving all possible problems was Mr Bondi, anesthesia nurse who was running the OR and usually also giving anesthesia. The hospital. A beautiful two storey building, built some 10 years ago with different pavilions for specialties all connected by hallways. Second floor of the hospital is used mostly as a huge storeroom, lack or inadequate electrical supply prevents them to use elevators. A Man with golden hands could get work there easily... Next team going to Farafenni could take an OR technician along, so many things needed to put in order and working state. But patients kept coming and we operated as many as possible. Electrical supply was from 9-16, afterwards some hours of generator supply, so head-torches were of good usage. Small children, older children, young people, old people, people with small hernias, people with huge hernias, people we could operate and people we had to put on hold for next teams to come. Living conditions. Motel AMCR: again a place for travelers, the best in town. Clean and mostly quiet. We were lucky to get every morning transportation by Mr. Dibba. And every evening after work a nice guided tour to some interesting spot: either a local village, border-town in Senegal or something else fascinating and beautiful. So in conclusion. Farafenni is definitely a place in need. In need for surgeons, anesthesiologists, technicians. To take supplies along would be nice, but there was a lot also around waiting for someone to put it into order and work. And most important: Farafenni needs us to show we care. It is definitely an Operation Hernia destination. J?ri Teras

OPERATION HERNIA SOUTH EAST NIGERIA- A REPORT by Oluyombo A Awojobi, Operation Hernia Project Coordinator in Nigeria

INTRODUCTION The seed of the third front of OPERATION HERNIA, OH, missions to Nigeria was sown in June 2009 when Dr J I Umunna, a rural surgeon of Jasman Hospital, Limited, Udo-Ezihinitte, Imo State, Nigeria, participated in the first Nigerian mission of OH at Awojobi Clinic Eruwa, Oyo State, South West, Nigeria. He made a request to Prof Andrew Kingsnorth, director of OH, for the extension of OH missions to the South East of Nigeria, his home geopolitical zone. Rather than have the mission conducted in his hospital, Dr Umunna co-opted other members of the Imo State branch of the Association of Rural Surgical Practitioners of Nigeria, ARSPON, of which he was the chairman, and they decided on hosting the mission at the government General Hospital, Abor-Mbaise, GHA. PREPARATION Although a site inspection was usually conducted by Andrew, this was not the case this time due to his tight schedule in Cote d?Ivoire. In fact, the mission slated for Eruwa was shifted to the South East. As project coordinator of OH in Nigeria, I visited the GHA on 16th/17th October 2010. This was preceded by exchange of emails that included several pictures of the hospital and its facilities. Thus, a prima facie case for the suitability of the hospital was made. My inspection confirmed this. The hospital was built by the Catholic mission several decades ago before it was taken over by the government. As with other Catholic mission hospitals, this hospital was well laid out on an expanse of land. I recommended that the theatre be upgraded by tiling the floor and providing efficient autoclave and air conditioning system. I was assured the government was enthusiastic about the mission and would carry out the refurbishment quickly. Further preparation for the mission was set in motion with the recruitment of volunteers by OH and getting patients with inguinal hernia. The latter was achieved through the mass media operated by Imo State government. It turned out that many patients had travelled from far and near even from the neighbouring states. By the time the mission started, over 400 patients had been booked. RECEPTION OF THE VOLUNTEERS The OH team included Drs Petr Bystricky (from the Czech Republic), Scott Leckman (from the USA), Denis Blazquez (from France) and the leader, Prof Andrew Kingsnorth (from the UK). I received Scott on Friday 25th February 2011 and we lodged at LaSal Hotel close to the Lagos Airport while Denis, Petr and Andrew arrived the following day. The team brought with it one portable Little Sister autoclave, four sets of surgical instruments for hernia repair, lots of gloves and suture materials. Earlier on Saturday morning, I took Scott on a brief tour of Lagos showing him the public park and avenue named after my elder brother, Prof Ayodele Awojobi, a mechanical engineering genius, mathematician and social reformer. We went to the department of mechanical engineering, University of Lagos, Unilag, where he taught and the alma mater of the Awojobis, CMS Grammar School, Lagos ending up at the international airport to await the arrival of the other three. At the Unilag, we observed the growing trend in Nigeria of replacing louvered windows that allowed 100 per cent ventilation with the sliding windows that looked more aesthetic but reduced ventilation by half. We felt this was unbecoming of a citadel of knowledge and relevance to the society in these days of global warming. THE MISSION The team flew into Owerri on Sunday 27th February into the warm reception of our colleagues led by Dr Jerome Afuka, national secretary of ARSPON and secretary of the Imo State branch. However, we were startled by the presence of five fully armed police men who would be our escort for the next six days. We quickly checked into the Mayfair Hotel on the outskirts of Owerri before proceeding on a 35-minute drive to the GHA where we were received by Dr Cosmas O Madu, the medical officer in charge of the hospital and scores of patients waiting for surgery. Andrew proceeded to examine the adult patients for surgery the following day and drew up a list of paediatric and adult patients which he handed over to Cosmas with the hope that work would start in earnest the next day. It was noted, at this point, that there were no proper case notes of the patients, just the list indicating sex, age and type of hernia. By 5.30pm when that first exercise was just being concluded, the security operatives were alerting us that it was time to depart for the hotel. And so, the team could not inspect the theatre facilities before returning to the hotel. FINANCIAL MATTERS During the preparatory period, it was decided that OH would be responsible for the internal flight tickets, the hotel accommodation and meals in Lagos and Owerri. Accommodation and meals in Owerri would cost N5000 per day per person. By the third day, Jerome informed the team of the huge expenses the association had incurred to get the mission going: N70 000.00 (?1 = N250.00) to obtain police protection, the hotel bill with one room reserved for the police who were fed, fuelling of the government bus allocated to the team and feeding the driver, allowances to the hospital staff, who were on industrial strike action, before agreeing to help with the mission. The hotel facilities were good enough but pretty expensive ? N11 000.00 per night with complementary breakfast. As a consequence of this expose, Andrew decided to double the commitment of the team while I waived the expenditure for the Lagos end of the trip amounting to N220 000.00. I advised Jerome to present any deficit incurred by the local branch to the national body for consideration since the Imo State branch had contributed more than any branch or individual to the sustenance of ARSPON. The doctors in the public service of Imo State were on strike before the mission started and a lot of pressure and persuasion was needed to get the striking doctors allow the mission to go on in the public GHA. THE ACTIONS Day 1, Monday 28th February Work started very late at about 10.00am. The team arrived GHA well before key members of the host team due to the fact that most of them resided in neighbouring towns about an hour and a half drive from the hospital. Jerome who lives a stone?s throw from GHA did not have the administrative power to influence the goings-on. By the time the mission was in full swing, Andrew realised many of the patients he had operated on were not on the list he prepared the previous day!! The hospital staff had hijacked the list before the arrival of Cosmas. The team left the hospital by 5.30pm having operated on 13 patients that included 6 children. At the hotel, Andrew handed to me the donations (?5 160.00) sent by Dr Ramon Vilallonga-Puy of Spain and Mr John Pickering of the UK in aid of the construction of a hernia centre and solar-powered lighting system respectively at Eruwa. Day 2 Tuesday 1st March. The day started for me at 12.05am with a text message from my teacher, mentor and benefactor, Prof O O Ajayi, CON and it read: ?At 60 years of age today, you have carved for yourself an indomitable reputation for hard work and indisputable integrity and transparency in public service with love, charity, care and compassion. You are frequently misunderstood, not out of ignorance or intellectual barrenness, but because you outmatch all by a vision many cannot understand. The solution is in your hands. Yombo, many happy returns as you build on a God-given talent for an enduring legacy on earth and for His eternal glory in Heaven. May God continue to keep you and bless your family as promised for those who serve Him. Amen. Happy birthday to a loyal, generous, affectionate brother. Many Happy Returns. Jide Ajayi.? At day break, I informed the team and my colleagues in ARSPON of that milestone and they all congratulated me and expressed their gratitude for the roles I had played in organizing the mission. Things worked out better on day 2 with some sanity restored to the list prepared by ARSPON members and the theatre system functioning well. The State Commissioner of Health, Dr F Ekwem, visited and was met by Drs Umunna, Madu and Andrew. The commissioner briefed the audience of the efforts of government in health care delivery in the state and thanked the OH team for coming despite the security situation. He promised a better reception the next time. Andrew, while reciprocating the complimentary remarks of the commissioner, observed that a three-year old maternity wing of the hospital built by the present administration with World Bank assistance was already depreciating due to disuse. I presented to the commissioner a set of books and booklets that included the third edition of Davey?s Companion to Surgery in Africa which I co-edited and published, the programme booklets of ARSPON 2008, 2009 and 2010, SURGEON IN THE BUSH by Dr Umunna and my other publications. I attached a copy of a paper I proposed to read if there was a formal reception. (Appendix 1) An hour later, I sent pictures I took on the occasion by email to his public relations officer. Day 3 Wednesday 2nd March Just as the mission was gathering momentum, it was observed that the only heavy duty generator (60kVA) was malfunctioning and autoclaving of instruments was unusually long. The technician informed us the generator was old and was recently repaired. The theatre staff was bypassing the autoclaving by soaking the instruments in antiseptic lotion. Together with Jerome and some of the patients, I organized that a mobile generator be rented for days 4 and 5 if things did not improve. The technician was brought into the picture. However, I observed that soon after our discussion, the performance of the generator improved such that work continued smoothly. Meanwhile, Andrew had opened up another makeshift theatre with two operating tables in the near-abandoned maternity wing so that he and Scott could deal with small hernias while Petr and Denis tackled the children and giant hernias in the first theatre. At about 5.00pm, I was informed that the nurse anaesthetist would not proceed with the children because there was no more intravenous infusion. I took over the situation, requesting Jerome to administer intramuscular ketamine while I performed herniotomy on four children assisted by a colleague. By now, several colleagues had assisted and been taught tension-free mesh repair of inguinal hernia by members of the team. Day 4 Thursday 3rd March The day started well. The generator (7.5kVA) had been brought by the owner and placed at the appropriate place near the theatre for use if the big generator malfunctioned. It was to power the portable autoclave exclusively and not for the theatre section of the hospital since it was not powerful to do that. I paid the owner a deposit of N5 000.00. At 11.30am, Andrew, Jerome and I set out to visit Dr Umunna at his base. But before leaving, I reminded the theatre technician in charge of the autoclave and the owner of the generator of my directive as to the use of the generator. ## Your picture: 'Dr Omunna's clinic.jpg' has been inserted here ## At Jasman Hospital, Udo-Ezinihitte, we were cordially received by Dr and Mrs Umunna and the members of staff. A mini ward round was conducted on patients who had had modified radical mastectomy for carcinoma because there was no facility for radiotherapy in the South East, prostatectomy, hysterectomy, suprapubic cystostomy for impassable urethral stricture etc. We saw the conference room used for ARSPON 2009 and the adjoining cafeteria. Andrew was presented with an autographed copy of Dr Umunna?s book, SURGEON IN THE BUSH. I promised I would send him pictures of a simple operative procedure to treat the patient with urethral stricture. This I did some days later when I operated on a man with stricture.When we returned about three hours later, the situation was chaotic due to malfunction of the big generator and failure to use the rented generator. I was told the government technician had insisted that the rented generator be connected to the theatre. I was so furious I carried the autoclave from the theatre to be placed under a tree with the generator near it. In 6 minutes, surgical materials were being autoclaved and the mission continued in full swing. I did not seek for the technician since he had, by his action, identified himself as a saboteur. One of the patients, an elderly man (shown in the picture above) who had worked in the hospital, assisted with operating the autoclave. He had his hernia repaired the following day. The team left the hospital at 6.30pm because our escort and we were getting more relaxed psychologically. I paid the owner of the generator the balance of N5 000.00. During one of the evenings at the hotel, we were told about the spate of kidnappings in the state that included the former commissioner of health and one of our colleagues. Heavy ransoms were paid to secure their release. This explained the heavy security presence around our foreign guests. On this basis, Petr, who was billed to stay an additional week, decided to come with me to Eruwa where security issues were not so serious. Discussions were laced with the political happenings in the state and the country. Day 5. Friday 4th March Scott was scheduled to return to the USA on this day and so, I accompanied him back to Lagos to await the arrival of Andrew, Denis and Petr the following day. Before setting out, my colleagues presented me with the traditional Igbo attire to mark my birthday and in gratitude for a mission accomplished. The generator was still available in the hospital for use. Jerome paid the rent for that day. Day 6 Saturday 5th March I met Andrew, Denis and Petr at the local wing of the airport and moved on to the international wing where I bid farewell to Andrew and Denis while Petr came with me to Eruwa. At the end of the mission, 120 patients were operated on leaving over 300 to be taken care of by the local team at affordable rates in their respective hospitals. The team left behind the autoclave, the four sets of instruments and the unused gloves and sutures. I had loaned the mission two diathermy machines and an autoclave meant for Eruwa centre. I hope to repossess them in time for the next mission in November 2011 during the joint conference of the International Federation of Rural Surgery and ARSPON. A 12-year old indigent boy had not had his hernia repaired since 2008 when the government launched a free-health programme. I handed him over to Jerome to fix his hernia on my bill. AT ERUWA Scores of patients had been waiting for me and throughout the next six days it was work from dawn to dusk starting with an obstructed inguinal hernia on Sunday 6th March. Petr and I performed 35 major surgeries in five days which included excision of giant tumors, torsion of ovarian cyst, drainage of 8 litres of pus from the peritoneal cavity, sequestrectomy of neglected chronic osteomyelitis, thyroidectomy, prostatectomy and some hernias which Petr fixed with the Indian mosquito mesh that was used exclusively at GHA. Petr left Eruwa for his home country on Friday 11th March on a three-hour trip to Lagos by a chartered taxi. He reported safe arrival at home like other members of the team. COMMENTS As noted in my proposed speech, I thought the Imo State Government was performing better than the others as far as health care delivery was concerned. But, this was not so as shown by the attitude and conduct of the hospital staff and the ongoing strike action in the health sector. Overall, the hospital staff did well but at great expense to ARSPON. The decision of my colleagues in ARSPON, Imo State branch, to choose the GHA was good. It was an opportunity to improve the image of the government and ARSPON thereby disabusing the minds of the populace who felt private doctors were exploiting them and so became targets for kidnapping. Although the patients were not charged any fee for the exercise, I was told by my colleagues that some still felt the doctors had collected large sums of money from our guests. I spoke to the patients on the rationale of the mission, the logistics and the expenses incurred by everybody involved in the exercises. I usually ended my talk with ?If you were in my shoes, what would you do??Their responses and comments indicated that out people would feel more at ease if they were carried along in the decision-making and execution processes. In a five-day mission, 120 inguinal hernias were repaired and over 300 patients were still waiting. There are about five teaching/tertiary hospitals in that region. This shows their low level of impact on health care delivery in the region. The absence of proper documentation of the patients will make future review of the cases impossible. This is not good for the science of surgery. Although, we knew of the security situation in the South East as in many parts of Nigeria, we (OH team and I) did not realize it was really that bad that a commissioner and a colleague had recently been kidnapped. However, we would recollect that Chief Bola Ige, the Attorney-General of Nigeria was assassinated in his room in Ibadan in the South West while being guarded by ten armed policemen some years ago and no one had been charged for it, then any crime could be committed with impunity in this country. So, it was understandable why our colleagues took such extraordinary precautions to ensure the safety of our guests. I must thank them most sincerely for still keeping faith with the Hippocratic Oath we swore to at induction into the profession despite the hostile situation they practice in. The administrative lapses observed were beyond their control and I quite appreciated the milieu in which Dr Madu was performing his onerous duty having been a public employee in the past. It was all praises for Andrew and his team for braving the odds in the spirit of Medicins sans frontier. However, it would take a long time before another mission is contemplated. I want to thank the members of staff of Awojobi Clinic Eruwa for holding fort and Dr S Ogunsina who came in from Ibadan to perform some emergency operations and his usual Saturday round of hernia repairs. This has been the third side of the countless sides of a coin that is OPERATION HERNIA in Nigeria.

Operation Hernia to Moldova, April 2011

Team Leaders: Andrew Kingsnorth & Etienne Steiner Where is Moldova? Why Moldova? During our preparations each time that I began to introduce the topic of our proposed mission, these two questions dominated the discussion. Imagine a small land-locked country, aligned to the East by a sliver of land which is claimed by its breakaway neighbour Transdniestra (which itself is infiltrated by Russian ?advisors?), to the West by its sister country Romania, and to the North, East and South by its big brother Ukraine ? then you will have some idea as to why Moldova has an identity problem. Stalin isolated the country further by redrawing boundaries to the South, cutting Moldova off from the Black Sea and even the Danube river except for 480 metres of access at the Giurgiulesti terminal which is suitable for only small vessels. At a Hernia Congress in Paris in the summer of 2010, I was delivering a lecture about Operation Hernia missions to serve the underprivileged in Africa and the use of ?mosquito net mesh? for hernia repair. After the talk Dr Steiner stood up boldly and asked me if I realised that levels of poverty seen in African also existed in Europe (at the time I was the President of the European Hernia Society[EHS]). He then invited Operation Hernia and the EHS to organise a mission to Soroca (the birth-place of his parents) in the north of Moldova under his guidance. I agreed ? and thus Moldova became the first European country to be taught to use Affordable Indian Hernia Mesh, at virtually no cost for the mesh material. Lichtenstein hernia repair or incisional hernia repair with mesh would otherwise not have been possible in a country with a populationof 3.5m, which has the lowest income per capita in Europe ($1800), and where in 2005 20% of people lived in absolute poverty (less than $2.15/day). In terms of human development Moldova is rated as ?medium?, being ranked as 111th out of 177 nations. Our team consisted of myself and Dr Etienne Steiner, his wife Brigid an ultrasonographer, his anaesthetist Dr Bernard Pelissier, Russian language expert and master hernia surgeon Professor Giorgi Giorgobiani from Georgia, President of the Georgian Hernia Society, Professor Tamaz Gvenitadze, and President of the Ukrainian Hernia Society Professor Yaroslav Feleshtynsky. Preparations had been somewhat erratic, with some uncertainty about our reception at Customs in Chisinau airport loaded with medical supplies on Saturday 9th April . We need not have worried, the bags were stranded at Vienna airport (and delivered the next day). After formal greetings with our hosts we headed north for 150km along practically deserted, liberally pot-holed roads to Soroca. Winter was lingering, the temperature was just hovering above freezing, making our journey feel even more of an adventure. The terrain was flat with some gentle hills stretching into the distance and the road was never far from the Dniestra river to the east. The soil was yet to burst into life at the beginning of Spring and thus large swathes were exposed and appeared dark and rich, in places covered with extensive vineyards and orchards. The rural communities through which we passed had a Slavic air, populated with small, rustic, single storey cottages with pitched roofs and gables painted in a variety of shades of distinctive greens and blues. Little livestock was visible; although rough horse-drawn farmcarts were a relatively common sight. That evening we were treated to a fabulous welcome Dinner by the Medical Director of the Soroca District hospital ? and each night thereafter another Dinner was hosted in a different venue, so that we became quite familiar with excellent Moldovan wines, vodka, customs and speeches . The next day, Sunday 10th April was a day for orientation, rest and relaxation. We wandered around the town square with its unreconstructed Soviet-style monuments (still with intact hammer-and-sickle) , sparsely stocked shops, and local folk shopping, waiting for busses or just socialising in the bitterly cold wind, sleet and hail. Thick padded felt caps for the men and head-scarves and shawls were the order of the day ? and were our first purchase. We were taken to the Rudi monastery, founded in 1770 and situated in an isolated sylvan setting. It is undergoing reconstruction after lying dormant for many years after destruction during the communist era. The visit was like stepping back into a medieval time of self-sufficiency, living off the soil and religious duty. The winter is survived by eating fruit and vegetables pickled in jars stored underground ? just like our great-grandmothers had been accustomed to survive. After a vegan lunch with the abbot we returned to Soroca via a woodcutters lodge where wild boars were raised for hunting and variety of other animals were stocked such as goats, beavers and bees in the summer hives. The working week lasted from Monday to Thursday and culminated in a meeting with the Deputy Minister of Health in Chisinau on the Friday. We were thanked warmly for our efforts and informed that the Operation Hernia mission was the first humanitarian mission to Moldova. Further visits were encouraged. Our pilot visit had accomplished operations on over 20 patients. A few were simple inguinal hernias which enabled us to teach the local surgeons the Lichtenstein method. The majority were large, incisional hernias which had probably not been offered surgery by the local surgeons because of the known high failure rate with sutured repair. Four of the patients were doctors working in the hospital. Mosquito net mesh was used in all cases. The working conditions were basic. Equipment would not have looked out of place in a medical museum. Instruments were clumsy, blunt and worn. Rags sufficed as drapes. A tour around the hospital revealed motivated and well-trained staff working with extremely limited resources to the best of their ability. Oxygen was delivered from cylinders, hot water was limited, the only CT scanner was to be found in Chisinau. I was invited to operate on a case of necrotising pancreatitis, and subsequently gave a lecture on management of acute pancreatitis. It had been a privilege to work with our colleagues in their difficult circumstances. We have a duty to help those in our own backyard. We will go back to Moldova. Join me! Andrew Kingsnorth The Moldovan surgeons that made our trip possible were: Angela Rusnac (Medical Director of the Soroca District Hospital), Valeriu Petrovici (Vice-Medical Director of the Soroca District Hospital), Veaceslav Costin (Head of Department of Surgery), Vasile Voloceai (Surgeon), Alexandru Samsonov (Surgeon), Serghei Manchevici (Urologist), Veaceslav Neamtu (Head of Department of Anaesthesia).

 

Report of the Belgian - Italo team: Visit from March 12 - March 20 2011

In March 2011 a team of three Belgian surgeons (Stefaan Poelmans, Marc Huyghe and Casper Sommeling) accompanied by an Italian registrar (Cecilia Ceribelli) visited Takoradi in Ghana. We again flew with Lufthansa/SN Airlines, which company we have to thank for giving us the opportunity to bring 15 kg of extra luggage each, so that we could take enough medical material with us. We brought meshes (kindly donated by BBraun Medical NV Belgium, Covidien Belgium, Bard Italy and Assut Europe), gloves (Cardinal Health), disposable drapes (M?lnlycke Belgium), suture material (Johnson & Johnson), local anesthetics (Astra Zeneca and BBraun), analgesics, syringes and needles. After a wearing drive from Accra to Takoradi through some heavy thunderstorms, we arrived very late Saturday night at ?the Villa? were we had a good night sleep. Sunday morning we took a cab to Green Turtle Beach Lodge, were we had a nice and relaxing day. Returning to Takoradi we made a stop in Dixcove were we observed and admired the return of a local fishing boat. In the evening we met Bernard Boateng, who again did the selection of the patients on forehand.The living circumstances in ?the Villa? are good. ?The girls? (Kate, Lilian and Benedicte) took good care of us. The food they prepared was fine and far better than the Western food served in the local restaurants. During the week the three surgeons rotated in the three different hospitals (Hernia Wing, GPHA and also for the first time Dixcove), accompanied by Cecilia. We operated on 74 patients, of which seven were children. Most of the adult patients, presented with groin hernias (61, in seven bilateral), in some accompanied by a hydrocele. In most of these patients a Lichtensteinrepair (with standard middle weight polypropylene) was performed. We did not use mosquitonets. Three other patients only had hydroceles. Most patients were operated under local anaesthesia, but loco-regional anaesthesia was used as a standard in all three locations in the more demanding scrotal hernias, contributing to a better comfort of the patients. The children ofcourse were operated under general anesthesia; in Dixcove the induction was done by the child relaxing on the back of the headnurse walking around.Again this year there were some challenging scrotal hernias, and also the age of the patients we operated on is increasing. The oldest patient was 90 years of age and in good condition!The presence of a registrar is useful; firstly, because she could assist us, but secondly and more important, we could assist her in performing operations, that will lead to more experience for her. She performed ten operations. The motivation of the local hospital teams is good and the level of care of the nurse-anesthetics in the three hospitals is high. The equipment in the hospitals (also in Dixcove) is of a reasonable level, but although we were convinced that we brought enough material, again at the end of the week there was a shortage of drapes, gloves and sutures. As can be understood by the total of operations performed we individually made long days, but it was rewarding. Even the last Friday we operated in the Hernia Wing until after eight o? clock in the evening.After a long week hard work we had dinner at the Planters Lodge Friday night.On Saturday we made a trip to Bushua beach, were we had a nice day at the beach. Sunday-morning we said goodbye to the girls and were brought to the Kakum National Park, were we made a quick trip to the forest and made the Canopy Walk. Entrance prices were threefold from last year and it starts to look like a ?tourist trap?. Much more pleasure we had from a visit to the ?Monkey Forest Resort? near the Kakum National Park. This resort was founded by a couple from the Netherlands. They try to save left-alone animals, that are brought to them by the locals. A visit is worthwhile (at the right side of the road when you drive to Kakum).After that we had (like last year) a nice meal at the Birawa Beach Restaurant. After a challenging drive to Accra (we were getting a little late) we arrived at Kotoka Airport just in time. Conclusion: a rewarding mission; due to the fact, that we were with three surgeons, we could operate in Dixcove Hospital, where there is a nice atmosphere and were patients are taking good care of. For this moment we think a mission to Takoradi should consist of three surgeons and one or two registrars. The participation of trainees should be encouraged. Also the presence of a nurse is valuable; a nurse can discuss and control some matters of sterility with the local staff. The presence of an anesthesist in the team seems not so important, because of the qualifications of the local nurse-anesthesists.

 

BOLE HOSPITAL APRIL 2011 REPORT FROM OPERATION HERNIA VISIT APRIL 18-22, 2011

Introduction This is the second visit to Bole Hospital in Northern Ghana. The first visit was in November 2010. The team comprised Mr Chris Oppong and My Aby Valliatu. The Medical Director, Dr Joe Nyuz and his theatre and ward teams should be congratulated for a well organised project. Adequate numbers of staff were mobilised. They were all well motivated. A whole ward was dedicated to the project. This allowed a smooth and efficient transfer of patients to and from theatre and contributed immensely to success of this campaign. Once again we had good accommodation and were well looked after. We paid a courtesy call on the Bole Chief. He later presented us with a goat and yams. Outcome: Aby and I performed 97 procedures in 79 patients. This is a rough average of 20 procedures a day.!! We worked over only 4.5days. The highlight was the repair of huge bilateral femoral hernias. Each of the hernias were associated with a huge varix of the femoral (NOT SAPHENOUS) popliteal junction. The varices were plicated to reduce their size without occluding the lumen of the femoral vein. I had a similar case at Carpenter in 2010 and was assisted by Mr Hanafy. I wonder whether there is an association! Training: One local surgeon, Dr Abraham Tsetsegah was trained in hernia mesh repair and given some mesh to use in his hospital. We hope to train more surgeons when we visit in November. Future Development: The Medical Director of BOLE Hospital would like more than 2 Operation Hernia visits a year for both service and training. I will organise some more teams to visit in 2012. Acknowledgements: We are again grateful to our sponsors ? Unisurge; Leonhard Lang; Ansell; MEMS, Derriford Hospital- for their tremendous support.

"OPERATION HERNIA" MISSION IN QUININDÉ, ECUADOR: 23-30 APRIL 2011

Dr Jos? Antonio Pascual Montero, 12 Octubre Universitary Hospital, Madrid, Surgeon. Dr Jes?s Salvador Torres Jim?nez, Infanta Sof?a Hospital, Madrid, Surgeon. Dr Jes?s ?ngel Garijo ?lvarez, Infanta Sof?a Hospital, Madrid, Surgeon. Dr Miguel L?pez Vizcayno, Sanitas La Moraleja Hospital, Madrid, Anaesthetist. We left Madrid on April 23rd at the appointed time without any difficulty in booking the medical material. The flight was normal for some of us and rather exceptional for others who witnessed the landing from the cockpit, courtesy of the pilot. On arrival at the ?Mariscal Sucre Airport?, Carlos Criado (airport commercial director) and Sandra Ocampo were waiting for us and speeded us through customs. The Health Centre staff took directly to La Concordia the parcels with surgical material. We put up at Sandra Ocampo?s house to be taken later to know Quito?s historical centre, particularly La Ronda, where we saw one of the typical processions of the city, after which we went for dinner to Casa Dami?n, a restaurant owned by one of Dr Pascual?s friends from Segovia. After a night rest at Sandra Ocampo?s house in Quito, we started for La Concordia, where we were received by Dr Kathia Tinizaray and Haydee Caicedo, the three of them essential persons in the organization of the mission. We collected the surgical material to take it to the Alberto Buffoni Hospital in Quinind? where the mission was going to take place and where we were received by the staff very cordially and warmly. We arranged all the material we had with us and left everything ready to begin surgery the next day. Then we came back to the Health Centre where we checked 70 patients in order to programme surgery for the following days. We programmed 50 out of those 70 patients, and we finished work at 18:30 hours. After some rest we had our supper, a typical barbecued grill from the place, prepared for us by our hosts at La Concordia, Sandra Ocampo and Dr Kathia Tinizaray. After supper we went to our lodgings in the Atos Hotel to gather strength for our mission the following day. On Monday 25th we got up at 6 a.m. and after taking breakfast we started for Quinind?, at about 40 kms from La Concordia, and we arrived at 7:30 at the Alberto Buffoni Hospital where the staff and the 14 patients in readiness were expecting us. We started operating in the operation theatre they had arranged, but as we were three surgeons and one anaesthetist, we asked for the collaboration of surgeons and nurses of the hospital in order to be able to use the other operation theatre, with the understanding that if an urgency would occur, we would vacate it and would offer our collaboration if necessary. On that first day we performed 15 interventions on 14 patients (2 eventrations, 6 inguinal hernias, 1 hydrocele, 1 scalp tumoration, 4 umbilical hernias, and 1 epigastrial hernia). One of the eventrations was very large and it required draining and hospitalisation for 48 hours. We want to stress that, besides the help from the hospital staff, two sisters, Carmen Alcibar and Rosa Alcibar, both helping nurses in the infirmary whom we had known in our previous Operation Hernia mission in CSDP in La Independencia, offered their selfless help which, in some moments, was of crucial importance. The work ended at 18:00 hours, and we made our way back to La Concordia in about 40 minutes thanks to the kindness of Sandra Ocampo who lent us her car for coming and going. After a short rest at the Atos Hotel we all had dinner together and got ready for the mission next day. Tuesday 26: We again arrived at Quinind? Hospital at about 7:30 and started interventions at 8:00 with the collaboration of Dr Zhunala and Dr Preciado, so that we could use both the operation theatres, and we showed them our technique in hernioplastia with mesh, as the use of meshes is not common with them due to the scanty resources at their disposal. On that day we performed 11 interventions (2 eventrations, 2 inguinal hernias, 2 epigastric hernias, 1 criptoquidia, 3 umbilical hernias and 1 abdominal sebaceous cist). One of the eventrations was a huge one and it required drainage and 24 hours hospitalisation. We then left for La Concordia as the previous day in the car Dr Tinazaray had lent us in the morning. Wednesday 27: Same time of leaving the hotel and arriving at the hospital, beginning our day at 8:00 with the help of the auxiliary staff of the operation theatres, with 12 interventions (2 eventrations, 5 inguinal hernias, 2 epigastric hernias, and 3 umbilical hernias). After finishing work at 16:00 hours we were invited for a meal by the two auxiliary sisters (Rosa and Carmen Alcibar) in their humble house in the outskirts of Quinind?, where we were introduced to their family and we duly appreciated her readiness, selflessness, and the great effort that going to work for the mission entailed. Back at La Concordia we, together with Dr Tinazaray and Haydee Caicedo, were invited for dinner by Sandra Ocampo. With them we planned future missions, and they indicated the possibility of extending such missions to villages in Esmeraldas and Santo Domingo de los Colorados. Thursday 29: We begin operating at the usual time with 12 interventions (5 inguinal hernias, 4 umbilical hernias, 2 epigastric hernias, and 1 abdominal lipoma). We end at about 15:00 hours and, as a sign of gratitude, we share an aperitif with the operation theatre staff that had collaborated with us. We had a meeting with the director of the Alberto Buffoni Hospital, Dr Saavedra, in which we signed an agreement between Operation Hernia (Dr Pascual signing in the name of professor Kingsnorth), the Hospital and the La Concordia Health Region (Dr Tinazaray) for a three year period. Dr Javier Saavedra thanked us for the work done and urged us to carry out new missions in the Alberto Buffoni Hospital. We collected all the left-over material and we gifted part of it to the same Alberto Buffoni Hospital, and part to the La Concordia Health Centre. We came back to La Concordia where we were received by the municipality mayor. In a simple act the statement of gratitude for our work was read out, and a copy of it was given to each one of us personally, and one to Operation Hernia. We then started for Santo Domingo de los Colorados, a city of about 200.000 inhabitants, where we were urged to open conversations for the possibility of future missions there. We want to emphasise that out of the 50 interventions carried out, 10 were on children between 2 and 10 years, and 2 on elders over 80. After a night in La Concordia, on Friday 30th we went back to Quito to come back to Madrid on May 1st. 1.Chris Oppong 2. Aby Valliatu

Elizabeth Central Hospital, Blantyre, Malawi: 24th June 2011 - 11th July 2011

Authors: Paul Thomas, Consultant General Surgeon, Epsom and St Helier Hospitals NHS Trust Caris Grimes, ST4 in General Surgery, Epsom and St Helier Hospitals NHS Trust Introduction This visit to Malawi was a site inspection as part of Operation Hernia, a UK-registered charity which teaches and trains local surgeons in hernia surgery in low income countries. Previous visits have been made to West Africa but also Mongolia and Ecuador. This visit was made to establish a link in Malawi. Malawi has a population of approximately 13 million and its health service is provided by 4 central hospitals and 21 district hospitals, plus a number of smaller mission hospitals which are outside government funding. Our primary attachment was to Thyolo District Hospital, but we also had the opportunity to visit the Queen Elizabeth Central Hospital, and its linked orthopaedic hospital, the Beit-Cure Hospital in Blantyre. These are recognised as teaching units within the College of Medicine. Thyolo District Hospital Thyolo hospital serves a population of approximately 600,000 in an area of approximately 721 square km. Within this, there are 32 health centres and one mission hospital (Malamulo), approximately 10 km from the government district hospital. The majority of patients attend hospital under their own means but there is an ambulance service to transfer patients from the local health centres and to the central hospital in Blantyre in cases of emergency. The hospital is run by the District Health Officer (DHO, Dr Andrew Likaka), District Medical Officer (DMO, Dr Michael Murowa), 20 Clinical Officers and nursing staff. There are no other Malawian doctors other than the District Health Officer and District Medical Officer. Whilst we were there, there were three doctors on intern programmes, and one qualified doctor as part of VSO from the Netherlands. The HIV services in the hospital are currently supported by Medecins Sans Frontiers (MSF), who assist with day to day running of the hospital, transport, equipment and supplies. They are due to withdraw in approximately 18 months time, which we foresee will cause considerable pressure on current service provision. The hospital has a pharmacy which is stocked with a basic number of drugs, an x-ray department, run by two radiographers who can do plain x-rays and abdominal ultrasound using a curved array transducer, and a casualty department. The hospital has 350 beds but caters for 4-500 patients, although this can exceed 700 patients, by placing extra mattresses on the floors. It has three operating theatres, only two of which are used, and these are staffed by two anaesthetic clinical officers and 4-5 clinical officers with basic surgical skills. Two of these are more involved in gynaecology and one in orthopaedics. The hospital deals with a large volume of emergency medical and surgical problems. It has a particularly active obstetric department with about 4000 births per year. We saw a lot of complicated obstetric problems and there were two maternal deaths during our time there. There are visits from specialists from Blantyre. We were told that there is an Obstetrician/Gynaecologist who visits in 2 weeks out of four to run clinics and to train Clinical Officers in the common Obs and Gynae conditions. There are also occasional visits from other specialists. Clinical Case Mix During our two weeks, we saw a large number of patients presenting with various medical and surgical problems. We saw cases of malaria, tuberculosis, HIV (prevalence 12% in this population), cholera, rabies, meningitis, transverse myelitis, pyomyositis, acute and chronic urinary retention due to prostatic hypertrophy (large volume of cases). On the maternity side, there are approximately 16000 live births within the district per year, some 4000 are born in the hospital. There are sometimes 10 deliveries a night, and 4-5 caesarean sections per night. The overall district caesarean rate is approximately 4%, and the hospital caesarean rate approximately 10%. There were cases of post-partum haemorrhage and uterine rupture. On average there are about 20 maternal deaths per year, of which about half are direct obstetric deaths (PPH, eclampsia, ruptured uterus etc.). The others are mostly HIV related. Our Experience Timetable There is a structured timetable in the hospital. The day starts at 7.30 am with a clinical meeting, to which all clinical officers, overseas doctors, DMO, DHO, pharmacy and nursing staff are supposed to attend. Reports are given from the previous days admissions by all departments (surgery, paediatrics, maternity, , internal medicine). After the reports are presented, more detailed case reports are given and difficult cases discussed. Advice is given by the DHO, DMO and visiting doctors as required. There are also separate case presentations given as part of the on-going academic programme. At the end of the meeting, the DMO usually gave a report on the current supplies, what was available in pharmacy and the petrol and transport situation which was difficult during our time there. After the morning meeting, surgical ward rounds take place on Mondays, Wednesday and Fridays, and would take approximately 1-2 hours when we would see 15-20 patients. Patients were examined and management plans instigated. If they needed to be transferred to tertiary care, the relevant specialist was telephoned at Blantyre, and transport was arranged. They have a good system here where patients keep their own medical records in a health ?passport? and communication is maintained through this, including prescriptions. On Tuesday and Thursdays, there is usually an all-day elective operating list, although emergency cases are done at any time and interrupt the elective lists. There is a surgical clinic on Wednesday afternoon, in which about 20-30 patients are seen. Our Experience We were attending the hospital as part of Operation Hernia, and therefore the focus of our activity was on hernia surgery. It had previously been arranged that the elective lists would be filled with patients who had complex inguino-scrotal hernias. We found this extremely interesting as we do not see this type of hernia very often in the UK. Technically, they proved to be quite demanding, especially as we did them all under local anaesthetic. We also inserted chest drains for pyothorax and haemothorax following trauma, saw cases of pyomyositis, severe third degree burns and advanced skin malignancy. We saw many cases of prostatic outflow obstruction, which are usually dealt with at Thyolo by the Clinical Officer within surgery who is able to perform transvesical prostatectomies. His logbook shows that he is doing more than 100 per year. One theatre is almost in constant use with caesarean sections, hysterectomies, and D&C?s. Other activity We had the opportunity to visit the local mission hospital at Malamulo. This is a privately funded institution and charges patients a small fee for the service. Unfortunately this is beyond the vast majority of the local population, and despite having slightly better facilities than Thyolo District Hospital, is relatively quiet ? there were more medical staff than patients on the day we visited. The senior medical staff are on secondment from organisations in the United States. They do provide good training for the local nurses and clinical officers who then transfer to the government hospitals. They can also provide obstetric and paediatric care under a Service Agreement with the Ministry of Health of Malawi who then refund the costs. We visited Professor Eric Borgstein, Professor of Surgery and Professor Nyengo Mkandawire, Head of Orthopaedic Surgery, at Queen Elizabeth Central Hospital. This hospital was built 50 years ago to serve a population which has now increased fourfold. Our initial impression was that the fabric of the hospital was not as good as Thyolo, but that staffing levels and support facilities are much better with MRI scanning, CT scanning (currently out of service) and access to specialists such as oncology and neurology. The casualty department there sees approximately 700,000 adult patients a year, and 350,000 children. We attended the launch conference of the COST Africa project for two days whilst we were there. COST Africa is a large multicentre randomised controlled trial, funded by the European Union, to look at training Clinical Officers to provide surgical cover in district hospitals in Malawi and Zambia. There were attendees from both countries, as well as the Royal College of Surgeons of Ireland (RCSI). The Principal Investigator is Professor Ruairi Brugha, from the RCSI. This conference gave us great insight in the problems of providing surgical cover in low income countries. We also gained insight into the differences of provision of surgery in tertiary and secondary hospitals within Malawi and Zambia. Towards the end of our stay, we convened a meeting between Professor Borgstein, Professor Mkandawire and the Dean of the College of Medicine in Blantyre, with a view to developing clinical and educational links between surgical trainees within the UK and the College of Medicine, Blantyre. We feel that the experience gained overseas would be very beneficial to trainees within the UK in a number of specialities, particularly general surgery, obstetrics, urology, paediatric surgery and orthopaedics. It is our plan to move this forwards as we received favourable interest at the Malawi end. We also feel that there is potential for exchanges in other staff, such as nursing and physiotherapy. We have drawn up a Letter of Agreement between Thyolo District Hospital and Operation Hernia to provide annual visits over the next three years initially to build on the skills of Clinical Officers in hernia surgery. This could potentially be expanded to involve other district hospitals in due course.

Hope for Ghana, Report from a German/American Team in Takoradi and Dixcove: July 2011

A German/American mission visited three regional hospitals in the area of Takoradi and Dixcove in southwestern Ghana from 14th to 25th July. The first team from Berlin consisted of Dr. Petra W?lkering (anestetist), Zhanna Bourtseva (OP-assistant and scrub-nurse), Manuale Menke (anestetist-nurse) and Dr. Ralph Lorenz (surgeon), who was leading the whole team. The second team consisted of MD Timothy Napier (surgeon) from Mauston/Wisconsin, Dr. Karl Spitzer (surgeon) from Munich/Germany and Mario Frey (OP-assistant and OP-attendant) from Hamburg/Germany. The suspected problems with the excess baggage (ca. 250 kg) on the check in desk where fortunately absent as well as the expected problems with the customs in Ghana. In Takoradi we were kindly accomodated in the Villa, the guesthouse of the Health-Department, where Kate, Lilly and Barbara expected us and supplied us lovingly with all we needed the whole mission through. A big heartfelt thanks to all! The first two days were taken for acclimatisation and team-building and lead us to the sightseeing-points of the area. On Saturday already we visited on the way to a dreamlike beach of the Gold-Coast also the hospital in Dixcove, a small city westward of Takoradi. In that moment we were not aware that our humanitarian mission was also scheduled for this hospital. During our survey we were struck by the fact that no doctor was around ? he was attending an advanced training course in Accra for two weeks, we later heard. During our survey in the hospital one patient touched us especially: a six year old boy was accommodated on the same day after a gas-explosion had caused third-degree burns in his face, both arms and both legs ? the nurses did the wound treating meanwhile. This case would accompany us throughout the following week. We felt empathy and hoped passionately together with the nurses and attendants to save his life. On Monday 18th July, we began with our work with two teams in Ports and Harbour Hospital (Takoradi) and in Takoradi Hospital. We performed surgery from 8 am to 8 pm treating as many patients we could. There were many patients on the waiting list. At this point we would like to say a deep-felt thank you to the regional persons in charge as well as to nurses and attendants in the three hospitals under the supervision of Dr. Bernhard Boateng-Duah for their perfect preparation and coordination! The statistics added up to 77 operations on 67 patients within six days: All together 61 inguinal hernias were operated, including 32 inguinoscrotal hernias. 15 patients had a hernia with a 20 cm hernia sac (Kingsnorth classification H3/4-20 and 4 patients were treated with a large-size Hernia with a 30 cm hernia sac (Kingsnorth Classification H3/4-30). Futhermore 9 ventral hernias (6 primary -epigastric and umbilical and 3 incisional hernias) as well as 7 hydroceles were operated. All of the three hospitals were attended by our teams within those six days. Nearly all patients apart of the younger patients were supplied with a mesh. Thanks to the generosity of companies donations in all cases original meshes could be used instead of mosquito-nets. All currently possible open operation-techniques like SHOULDICE; LICHTENSTEIN; Plug and Patch and TIPP were applied. The diagnostic findings however cannot be compared to European standards. Nearly all hernias were indirect, mostly with a small defect but with a large hernia sac. In certain cases there was additionally a hydrocele. Anesthetic methods included local as well as general anaesthesia, in certain cases spinal anaesthesia was the preferred method. Besides a postoperative hematoma in one case, all operations were successful without complications. The majority of the patients were outpatients. In addition, we assisted in one emergency-laparotomy and we supervise patients with chronic wounds, accident injuries and a thoracic drain. Mrs. Dr. W?lkerling however managed to give a lot of advices and tricks to the anesthetic nurses in charge. Our wish to instruct other local surgeons could unfortunately not be satisfied, since no Ghanaian surgeon could be present at that time. The sustainability if our mission resulted mainly in giving away a lot of medicine materials the surgeons are now able to use. Without the generous support of numerous private and company donations as well as from the German Hernia Society this mission would have been unthinkable. We have gained a lot of positive insights through this humanitarian mission. Emotionally most touching was the deep thankfulness of the patients, and last but not least of the nurses and hospital workers. The great success of that mission was mainly possible because of the distinguished capacity for teamwork of every participant. All team-members expressed their wish to participate on the next humanitarian mission. Furthermore, a lot of colleagues in Germany have a lot of interest for that project, and also uttered to participate themselves the next time. The small boy with the severe burns was at the same time attended by our team, especially through giving him urgently needed wound dressings and medicine. After initial fever, he was at the end of our mission ?out of the woods?, free of fever and the large wounds were healing. New hope for a new life! We are deeply thankful! Ralph Lorenz f?r das Team Germany /U.S.

 

UK Team Report. 2-16 September. Mandalgobi and Ulaan Baatar, Mongolia

 

This was the second visit of the charity to one of the most remote countries in the world. The team was Andrew Kingsnorth, John ”Schumacher” Shaw (so-called by our hosts as he was the fastest scalpel in history), Alan Cameron, and Frank MacDermott . We had the unique privilege of having Tsetsegdemberel Bat-Ulzii Davidson (Tsetske) as our translator – unique because although Mongolian, she is undergoing surgical training in the UK. As on the previous mission, we had the smooth, efficient and capable organizational skill of Mrs Enkhtuvishin of the Swanson Charitable Foundation.

Andrew Kingsnorth wrote about the first Mongolian visit in last year’s report so I am doing this account as a novice to both Operation Hernia and to Mongolia. Before going further I must say that this mission was one of the most enthralling, worthwhile and fun things I have ever done. I was hugely impressed by the dedication of the Mongolian doctors and nurses; here in the UK we seem to have interminable delays in theatres, but in Mongolia the organization was superb (which did also mean we were kept busy in theatres all day!). And the anaesthetists’ skill with spinals was amazing. The Mongolian people were friendly and charming, and the scenery was stunning.

 

We arrived at Chinggis Khan airport -everything in Mongolia is named after their marauding hero – and were loaded into 4x4s to travel down to Mandalgobi, our base for the first week. First surprise was the absence of any road for nine-tenths of the 260km journey; just tracks through the steppe. Seemingly relying on celestial navigation we arrived long after dark!

Mandalgobi is a one-horse settlement of 11,000 people on the edge of the Gobi. The hospital had been through some bad times after the fall of communism, but seemed to be improving rapidly under the able direction of Dr Dolzodmaa, who was herself a surgeon. We spent a very happy week operating on a mixture of adults and children. The equipment was fine and the theatre environment very satisfactory (although I was amazed to find that one of the couches had been manufactured in my home town of Ipswich). We had the usual somewhat stilted dinner with the deputy provincial governor, but Andrew’s explanation of the purpose of the visit was well-received.

 

At the end of the week the whole team decamped (literally; the nurses came with us and brought the food and drink) for a bit of sightseeing so we were taken hundreds of miles into the Gobi to look at spectacular rock formations. We had two nights in ger camps out in the vast stillness of the desert before getting to the chaos of urban Ulaanbator.

The capital is a sprawling mass of pollution and congestion with some of the worst traffic in the world, but fortunately the 2^ndhospital was within walking distance of the hotel. (John Shaw went to the paediatric hospital during this week). So we were on duty early for a post-operative ward round, followed by seeing the new cases, and then operating all day. There were attentive medical students, and lectures after the lists. We had again a mixture of incisional and inguinal cases. The operating lists were tightly-organized, with Andrew in one theatre and me in the other. So we were able to do cases ourselves or assist the Mongolians surgeons as appropriate (Andrew had met and taught many of them in 2010 and they were keen to show off newfound skills). We had a couple of evening social events, but there was actually no time for sightseeing in UB – I don’t think we missed much because the steppes had been wonderful and were a hard act to follow.

The success of this mission was due to the enthusiasm of our two professors, AK in the UK, and Tsagaan Narmandakh in Mongolia. There was a great feeling of teamwork at all levels and in the two weeks I felt we had achieved a great deal. In simple terms the team did 124 cases (58 children) cases, but more importantly we supervised the local surgeons who can hopefully build on this teaching. Mongolia is the ideal place for this kind of mission because the infrastructure exists to carry on the work after the visiting surgeons have left. Before I signed up Andrew told me this would be the most worthwhile holiday ever; he was wrong about the “holiday” bit, but it was certainly worthwhile in every other sense.

 

Alan Cameron