Mission Report: Chittagong, Bangladesh (6-11th August 2017)
Group picture outside of Nurture General Hospital with local doctors and volunteers
Tucked away from the blaring horns of the main Chittagong roads, between paddy fields and an artillery camp lay Nurture General Hospital.
The 6-storey Nurture General Hospital
Nurture was founded as a charitable dispensary in 1995 by Mdm Nasreen Baqui. With the help of volunteers, well-wishers and organizations, it has since grown into a six-storied hospital for the disabled and a charitable school for destitute children.
After an overnight flight from Singapore to Chittagong with a layover in Dhaka, our team of 12 volunteers from Singapore returned for our second year of performing free hernia operations. In total, 50 operations were performed including 1 hydrocele repair and 49 inguinal hernia repairs. All operations were done under spinal anaesthesia unless contraindicated or deemed to be too high risk, in which case local anaesthesia was used. We arrived bright and early on the second day and started with screening patients and setting up of equipment. Our excellent anaesthesia team got to work immediately, administering spinal anaesthesia and pre-operative prophylactic antibiotics for the first round of patients.
Our anaesthesia team comprising of Dr Zheng Zhongxi, Dr Avinash and Dr Yeoh Chuen Jye (L to R)
Dr Avinash administering spinal anaesthesia
All inguinal hernia repairs were done using the Lichtenstein open mesh repair technique with pre-sterilised meshes kindly provided by Hernia International. We would run up to 5 operating tables at any one time and end the day with screening more patients for the next day. All patients were admitted overnight for monitoring and were reviewed the next day in a daily ward round and discharged to continue follow-up with their local doctors.
Dr Chok and Dr Ling at the daily ward round
“Our mission would like to give a loud shoutout of thanks to Sister Carol Reid from Omagh Hospital (UK) and Dr Aleksander Stanek for donating a diathermy machine for the mission’s use. This most definitely helped improve efficiency and operation performance!”
Dr Darren Chua (L) and Dr Lee Lip Seng (R) performing an open hernia repair
The assistance of Mdm Nasreen, her twin sons Yasmin and Yasir as well as their dedicated team of volunteers comprising of local doctors and medical students were invaluable in ensuring the success of this mission trip. The warmth and hospitality shown to us makes us look forward to returning again next year.
The team. From left to right. Front row: Dr Yvonne Ng, Dr Ling Xiao Shuang, Dr Teo Qi Tian, Dr James Ngu, Dr Goh Aik Wei, Dr Koh Ye Xin. 2nd row: Dr Lee Lip Seng, Dr Chok Aik Yong, Ms Wendy Lim, Dr Avinash, Dr Yeoh Chuen Jye. 3rd row: Dr Zheng Zhongxi, Dr Darren Chua
Takesure Mamvura. Operating Department Practitioner
THE HOST
Ganta City is a market town three hours’ drive (on a tarmacadam road recently built by a Chinese company) inland from the capital Monrovia, fairly close to the border with Guinea. The long-standing low level of health care provision in Liberia was made worse by the civil war 12 years ago, when many hospitals were taken over for military use, and then by the Ebola crisis of 2014, when many hospitals were closed. Both these events served to increase the sense of isolation experienced by Liberian doctors and rebuilding services following them has been slow.
Our host hospital, The E and J Medical Centre is an example of how some expansion of medical services is taking place. It was opened a year ago to provide mainly surgical and gynaecological services. Medical and surgical cover is provided by two doctors with support from a limited number of trainees. Anaesthetic cover is provided by two experienced anaesthetic nurse practioners, who work in both the E and J Hospital and a neighbouring hospital and a recently appointed anaesthetic practitioner working full time at The E and J.
OUR WORK
We had seven full days of work. We arrived in Ganta City late at night and spent our first day, attending a very impressive welcoming ceremony and then seeing patients in the Out Patient Department (OPD). There had been announcements of our mission on the local radio, informing that we were coming to provide hernia repairs free of charge. About two hundred and twenty people responded to the announcements, many more than could have been operated on during our limited stay. Each responder was given a number and then called in turn to be seen in the OPD. We spent all of the next two days in the Operating theatres and then had a further OPD session on our fourth morning. One more batch of patients were seen in the OPD by Dr George on the fifth morning.
We operated on 126 patients and repaired 135 herniae. 86 patients were adult men (18 years and over), 11 were adult women and 38 were children under 18 years. There were 73 adult inguinal herniae (25 were described as inguino-scrotal); 11 umbilical or other midline defects and 2 femoral herniae. The 38 children all of whom had inguinal hernia repairs (10 were bilateral) with an additional umbilical hernia repair performed in 4.
COMPLICATIONS
One man had a large scrotal haematoma the following morning which was drained through a scrotal incision. One man, who had a large femoral hernia repaired from below with some difficulty, due to dense scarring from previous surgery in the inguinal canal, had an obvious recurrence of the hernia by the next morning. A repeat repair was carried from above the inguinal ligament, with the pre-peritoneal space being entered through the posterior wall of the inguinal canal and the defect, along with the posterior wall, were then repaired with mesh. One man had a severe headache and neck stiffness on the morning after surgery. We were concerned about meningitis and recommended intravenous antibiotics. Two days later he had been sent home and it seems likely that this was a spinal headache. One infant developed laryngospasm shortly after returning to the ward. Respiratory support with a suitably-sized Ambu bag was required for a few minutes. This left the child with a very distended abdomen for the rest of the day, but his breathing gradually settled and he was back to normal the next day. One infant vomited during surgery and aspirated breastmilk. We learnt that he had breastfed an hour before his ketamine anaesthetic. He had a post-operative tachypnoea and some rib recession later that day but seemed back to normal by the following morning.
It is likely that more complications will develop during the days following surgery. Inevitably some of the patients with big scrotal herniae will develop scrotal oedema and haematomata, in spite of the seemingly very effective scrotal bandages which were applied by the anaesthetic practitioners. The later complication that worried us most was that of wound infection and chronic mesh infection. We had left the country before these problems would manifest themselves and, without a system of formal follow up, we will never know the actual incidence of septic complications. Dr George has said that he will keep us informed of any follow up information of which he becomes aware.
ASEPSIS AND ANTIBIOTICS
On leaving Liberia and reflecting on our six days of surgery, the aspect of our practice which concerned us most was the potential for surgical site sepsis. It was difficult to be confident that we were operating in an aseptic field during the course of any procedure. The skin was diligently prepared with antiseptic solution but there were many instances when asepsis could not be guaranteed. Our surgical gowns were thin, single use paper gowns as we might expect to wear in an isolation cubicle. They were clean, but not sterile. The drape isolating the surgical site was very often a single-use surgical gown in which a hole was cut to give access to the patient. This was sterile but not fixed in place. The scrub nurses clearly understood the theory of asepsis but sometimes the theory did not convert into practice. The sterilization of drapes and instruments was carried out in a pressure cooker type of container heated on a charcoal fire. When a live ant appeared from a drape as we unfolded it at the start of one case, one couldn’t help wondering how reliable this system was at achieving the required temperatures for sterilization.
We had not brought any antibiotics with us for routine use. Dr George had provided each adult patient with a three-day course of an antibiotic to take home. On reflection, we would have liked to be have been able to give all patients for mesh repair a single intravenous dose of broad spectrum antibiotic at the time of their spinal anaesthetic as a prophylactic against mesh infection. To do this a supply of the antibiotic would need to be brought by the mission team.
On considering the problem of asepsis, we were very fortunate to have an Operating Department Practitioner (ODP), Takesure Mamvura, as part of our team. Whereas the three surgeons were the workers of the mission, Takesure was the educator. He was able set an example on how to maintain asepsis during the procedures using simple suggestions such as covering the feet and lower legs with a drape and using small sterile towels, which seemed to be available in reasonable quantities, around the surgical site beneath the drape. He was also able to lead by example in other aspects of ODP technique, such as the benefits of maintaining a tidy and well-ordered instrument tray, instrument handling to prevent needle stick and scalpel blade injuries and the value of needle, swab and instrument counts.
PATIENT IDENTIFICATION AND MARKING
Another aspect of surgical practice that could be improved, following the experience of this visit, was that of patient identification and surgical site marking. All patients had a “chart”, which consisted of the two sheets of paper, one with the outpatient note and the other with the nursing note from the ward. Patients came to theatre with a chart usually, but not always, their own. Bringing the wrong chart seemed to occur more frequently with the young children. On one occasion the outpatient note stated “History of left scrotal swelling. No evidence of a hernia today in spite of crying ++. Not for surgery” and there on the table was an infant with a large right scrotal swelling. It would very helpful if every patient who was put on the list for surgery in the clinic was issued with a wrist band with identification details. Probably the name and proposed surgery would suffice. At the same time the surgical site could be marked. The wrist bands and surgical marking pens would need to be brought by the mission team.
ANAESTHETICS
One of the most remarkable aspects of our surgical experience in the E and J Hospital was the quality of the anaesthetic provision. Successful spinal anaesthetics were administered quickly and with great reliability so that additional anaesthesia, in the form of Ketamine or local infiltration, was only rarely required. The three anaesthetic practioners concerned, Abenego Yebakeh, Emmanuel Johson and Brenda Koly deserve great credit for this. In addition to giving the anaesthetic, they were also responsible for organising the operating lists and ensuring that the next patient was sitting waiting outside the theatre as the previous patient was wheeled out. The large number of cases that we operated on bears testimony to the way they worked. It enabled us to achieve a patient turnover rate which would be unthinkable in modern European practice.
One aspect of the anaesthetic practice with which we were not happy was the use of spinal anaesthetic in children. It seemed unrealistic to expect a young child to cooperate with the insertion of a spinal needle. It is true that some did manage, but others resisted and required Ketamine. We would have preferred to see Ketamine used as the first line anaesthetic for these children or at least a dose of Ketamine used prior to the insertion of the spinal needle.
EQUIPMENT
The mesh provided by Hernia International was perfectly satisfactory. We didn’t initially realise that some packets contained double sheets for bilateral hernia so there was some wastage. We also had with us some meshes donated by Braun Ltd which were very useful for large defects. We used the majority of the large number of sutures which we had taken with us. A good supply of surgical ties was very important, as most procedures were done without diathermy. We had brought some boxes of surgical gloves and extra were supplied by the hospital. Double gloving was regarded as the norm. Thomas Simon had been given several sets of surgical instruments by Braun Ltd. These proved very helpful and future missions would benefit from providing themselves with, if nothing else, suitable dissecting scissors. The hospital provided scalpel blades, but smaller ones for paediatric use would have been useful.
The operating lights provided good illumination but were sometimes difficult to manoeuvre. Also the electricity supply was erratic and a number of blackouts occurred. These were, thankfully, short-lived and hopefully will be less frequent when the planned solar / battery system is installed. Even so, we recommend that surgeons on future missions provide themselves with the reassurance of independent illumination from a good quality headlight.
One of our party sustained a significant needle stick injury during the course of a procedure. The spot test for HIV on the patient was negative. The surgeon concerned had brought a five day course of PEP (post exposure prophylaxis) with him and was reassured by being able to take it.
PAEDIATRIC SURGERY
A significant proportion of the surgery that we undertook was on children and we would strongly recommend that future missions include at least one surgeon who is familiar with groin surgery in children. We felt that the paediatric surgery that we did was potentially the most beneficial of all our work. If a simple herniotomy in childhood can prevent a large inguino-scrotal hernia, in which the vas is densely plastered to the sac (a very common scenario), in early adult life, then so much the better.
The infants who were bought for surgery all had bilateral, irreducible inguino-scrotal herniae. It seems likely that it was the recognition of the high risk of strangulation, with its very grave prognosis, which prompted the mothers to bring their babies for surgery. These were some of the most challenging cases that we were confronted with during our mission. The Ketamine provided no muscle relaxation and seemed (understandably) to be given fairly sparingly to the babies. A sudden flexion of the hip during the course of the dissection was not uncommon. Usually the inguinal canal had to be full opened before reduction could be achieved.
After we had spent our first day seeing patients in the clinic, we decided that we should put the children before the adults on the next days’ operating list and that, in line with our normal practice, we put the youngest children first. We realised, too late, that this meant that we had given ourselves the most challenging cases to do first in the unfamiliar operating theatre with unfamiliar staff. Subsequent missions may wish to pick some reasonably straight forward cases for their first morning.
The purpose of our mission was to provide the “free of charge” hernia repairs, which had been advertised on the radio, to as many patients as we could. This meant that we needed to do most of the operating ourselves, rather than spend time training the junior surgeons. Clearly, however, if we could train some of the local surgeons to do high quality hernia repairs, which in our case meant either a mesh repair or, in selected cases, a Shouldice repair, then we would leave behind a more sustainable surgical legacy. We had a particular incentive to do some training, as we knew that those patients who had presented following the radio announcement and whom we didn’t have time to operate on, were assured that they would have their hernia repaired as part of the “free of charge” deal by the local surgeons after we had gone. Two of the local surgeons, Dr Charles Manakpalah and Dr Charlie Kinpesa were very capable surgeons. They were taught to do both mesh and Shouldice repairs. We received a message subsequently from Dr Charles to say that they had successfully operated on the remaining patients.
Also assisting us were other surgical trainees of very variable experience. Some of them had not yet acquired basic surgical skills. They were advised to practise their knot-tying and suturing as much as possible before the next mission to the E and J Hospital in order to obtain maximum benefit as from the experience.
ACCOMMODATION AND SUBSISTENCE
We were provided with very comfortable accommodation at Jackie’s Guest House, where we had individual rooms with en-suite facilities, television and intermittent Wi-Fi. One of the pleasures of the week was sitting in the courtyard of the guesthouse in the evenings, drinking the local beer in the company of Peter George and his friends. The breakfasts and dinners provided by Jackie’s were much enjoyed. Food was not included in the $50 per night fee that had been negotiated for us by Dr George and future missions should be aware that subsistence expenses will contribute significantly to the cost of their mission.
There is no hospital restaurant in the E and J Hospital and special arrangements had to be made for lunch. We would advise future missions to discuss the provision of lunch with Dr George. During our week, Dr George usually arranged for food to be brought in from outside the hospital and we ate it in his office. (It is important not to forget to pay for this as otherwise Dr George would have to pay for it himself.). On two occasions we were taken into town in a hospital car and had lunch at Maggi’s Restaurant. This is something that we would recommend, both for the enjoyment of the lunch and for the welcome break it gives in the middle of a busy day. We also recommend that surgeons provide themselves with water to take to the operating theatres (or Coca-Cola if caffeine is required in addition to rehydration). We were aware that, in spite of the air conditioning in the theatres, we were often sweating freely during the long and sometimes demanding sessions.
CONCLUSION
We would like to pay tribute to the hard work undertaken by Dr George and his support team at The E and J Hospital in preparing for our visit. Missions such as ours require close co-operation between the host and the mission. The support we received at the E and J Hospital demonstrated that it was a very suitable host for such missions.
In the long term it is to be hoped that expansion of medical provision by the Liberian State will enable a service to develop which will begin to tackle the large number of people who would benefit from elective surgical care. For the time being, these people will have to rely upon charitable provision by external agencies. We hope that our mission has paved the way for successful missions in the future.
All four members of our team left Liberia with happy memories of the country, the town, the hospital, the people and the marvellous welcoming and farewell ceremonies that we found so moving. Our heartfelt thanks to all concerned for the hospitality that we received.
On July 29 2017 we eight volunteers started from Madrid, Brisbane, Cardiff and Mexico for Lima to carry out a Humanitarian Surgical Hernia Mission in the Ventanilla Hospital. This Campaign was undertaken by the Foundations “Cirujanos en Acción”, and Hernia International.
The Mission took place from July 31st to August 10th in the Hospital General of Ventanilla district. It is a Level II Hospital inaugurated in 2007 which has 100 beds and 5 operation theaters. It has 14 surgeons, 6 anaesthetists and 17 professional nurses. The Surgery Department carries out conventional surgery, abdominal wall laparoscopic surgery, biliar surgery and rectal surgery among others.
The Ventanilla District belongs to the El Callao Province and it is a densely populated community with about 375000 inhabitants, situated at two hours from Lima. The Ventanilla population is mainly poor, and part of the people live in settlements in the nearby hills with any number of huts and heavy environmental pollution owing perhaps to an excessive growing rhythm that has exceeded the capacity of the local resources. The “Ventanilla” name (small window) comes from innumerable caves and passages that looked like small windows from the sea and which pirates used to hide in them the treasures stolen from the forts and ships they attacked.
Voluntaries for the Ventanilla Mission 2017:
The Mission was made up by eight volunteers, four consulting surgeons, one consulting anaesthetist, one resident, one nurse and one in charge of Logistics, Communication and Documents.
Dr. Manuel Cires – General Surgeon – Navarra, Spain
Dr. Rafael Chaves – General Surgeon – Cardiff, England
Dr. Hugo Mc Gregor – General Surgeon – Brisbane, Australia
Lady Dr. Estefanía Villalobos – General Surgeon – Mexico City, Mexico
Lady Dr. María Remón Izquieta – Anaesthetist – Navarra, Spain
Lady Dr. Justine Etuláin – Resident 4, Anaesthetics – Madrid, Spain.
D.U.E. Lola García – Nurse – Madrid, Spain
María Orbe – Logistics, Communication and Documents – Navarra, Spain
The team was directed and coordinated by Dr Manuel Cires, with the co;;aboration of Dr Luis Bernaola, Chief of the surgery service of the Ventanilla Hospital.was directed and coordinated by Dr Manuel Cires, with the collaboration of Dr Luis Bernaola, chief of the surgery service of the Ventanilla Hospital.
We also had the valuable collaboration of all the enthusiastic staff at the hospital, including anaesthetists, general surgeons, nurses, helpers, cleaners, cooks, administrators and others.
Operating Theatres
The Hospital has five operation theaters in a single surgical area. Four of these were put at the disposal of the Campaign, leaving the other for urgencies in General Surgery and Obstetrics.
Of the four available operation theaters two are conventional and the other too are small, prefabricated and temporarily adjoined to the main building. They had the necessary resources for work, but the largest number of material, including surgical sutures, nets, electrical scalpels, antibiotics, analgesics, anaesthetic products among others were provided by the voluntaries themselves.
A system was established by which the majority of the patients were discharged in the afternoon and only a few with more complications were sent to the Short Stay Department.
The Patients
Patients were contacted before our arrival through announcements of our Campaign in the local media by surgeons there, as also through volunteers who visited poor areas in Ventanilla with our proposal for free interventions for all. Still, in some cases there was no discrimination made and people with greater resources were also treated.
The selected ones were previously evaluated by local surgeons and anaesthetists with a special study and reasoned consent, and they received due information on the whole procedure as well as instructions for their preparation including personal hygiene. As a result, all patients were properly prepared and at peace.
The way from our residence in the San Miguel area in Lima to the Hospital at about 40 km. distance took more than one hour on account of the heavy and irregular traffic of cars and lorries on the Panamerican road.
Our activity began at 7:45 hours with the introduction of the team of volunteers to the patients and their relatives in the hospital hall; then María Orbe, our expert in logistics and communication, gave them further information and answered their questions, thus informing the patients and their relatives and facilitating the team’s work.
The patients in the surgical area were first attended to by local doctors who collected the data for a proper control of the whole surgical activity; they were then questioned and reexamined by the surgeon and the anaesthesist in full detail.
The type of anaesthetic was in general local, although a good number of operations were performed under local anaesthetic and sedation, and a few under general anaesthetic.
In each operation theater the surgical team was made up by a Campaign surgeon assisted by resident doctor or surgeon, an anaesthetist, a nurse for the instruments, and a helping nurse.
We carried out the check list according to the OMS Manual for verification before and after each intervention, as this is the practice in the Ventanilla Hospital.
Distribution of inguinal hernias according to their classification as a help to fix the complexity of the operation.
– H1: (hernia inside the inguinal canal) n = 42
– H2: (hernia settled in the superficial ring) n = 27
– H3: (inguinoscrotal hernia) n = 10
Complications
7 cases:
1 Coming loose of suture in umbilical hernia when carrying out a new suture.
1 Slight inguinal pain of ingyuinal hernia treated with analgesics and antiinflamatories.
1 Seroma of incisional hernia treated with aspiration and ambulatory drainage.
2 Inguinal and inguinoscrotal hernia treated in a conservatory way.
2 Inguinal umbilical wound hernia and inguinal hernia treated with local cures and antibiotics.
Discussion of results
Of the 200 surgical procedures realized 7 complications were reported which did not need surgical intervention; the infection rate was 1%, a very low value, taking into account that the majority of the patients had not received any antibiotical profilaxis. The seroma was treated in ambulatory sessions with punction and drainage, and the hematoma was treated in a conservative way.
Observations
The personal at the hospital kept excellent asepsical measures during the whole campaign.
The nurses in charge of the instruments kept an excellent discipline and technique in the operation theatre.
– Washing of hands: with clorhexidina foam.
– Antiseptical preparation of the premises: they used clorhexidina soap to prepare the area.
Formation and Teaching:
An important teaching activity took place during the Campaign, so that the residents in surgery and anaesthesiology took an active part in diverse surgical and anaesthetical procedures under the supervision of voluntary surgeons and anaesthetists.
The last day of the Campaign we volunteers carried out an Academical Session with the following themes:
– Humanitarian Help: origin and actual state of the Hernia International and Surgeons in Action Foundations. Results of the 2917 Campaign in the Ventanilla Hospital, Dr. Manuel Cires.
– Surgery in the last century. Multidisciplinary handling of surgery in the last years. Dr. Rafael Chaves.
– Presurgery preparation in patients with giant ventral hernias: botulinica toxin, principles and technique; progressive and preoperative pneumoperitoneon. Dr. Estefanía Villalobos.
Surgical block. Standards and recommendations for the patient’s safety.
The Campaign ended on August 10th. Dr Wilber Espinoza, Director of the Hospital, addressed the voluntaries and gave thanks for the notable effort as well as for the high level of satisfaction of patients and relatives, and invited repetitions of new projects in the future. We were later given a diploma and were invited to a farewell supper in Lima.
ConclusionThe campaign has meant a great effort for all of us. It began several months before our trip to Lima with the creation of the voluntary group, unknown persons from different countries and cultures, who
The fifth mission of Hernia International to Brazil
The mission was carried out in collaboration with the Brazilian Hernia Society from July 23-29th, 2017. The regional focus of this mission was the state of Rio de Janeiro and was based out of the city of Rio de Janeiro as well. This included a one day conference on July 27th, bringing together faculty from the mission and healthcare providers from around the country. The team of 12 surgeons was lead by Dr Christiano Claus, along with local coordinators Heitor Santos, Luciana Guimaraes, and Marcio Cavaliere. The group also included myself and Arunkumar Baskara from the US. We repaired 125 hernias in over 100 patients at six different hospitals across the state, including: Laurenco Jorge Municipal Hospital, Iraja Hospital, Gaffre Guinle University Hospital, and Ipanema Hospital in Rio de Janeiro; Japuiba State Hospital in Angra dos Reis; and State Hospital Adao Periera Nunes in Saracuruna. The operations were aided by local volunteer surgical scrub techs and nurses, some of whom traveled with us from surrounding areas, as well as the residents from the local hospitals. Anesthesia coverage was provided by the hospitals. Traveling to the hospitals outside of the city provided a brief glimpse of the beauty of the state, as if the city doesn’t offer enough! Of course, there were plenty of social opportunities to get to know each other, including an awe-inspiring dinner at a famous Churrascaria in Rio de Janeiro.
MEMORY OF THE CAMPAIGN 16 June – 3 July IN THE HIPÓLITO UNANUE HOSPITAL, TACNA, PERÚ
After 4 months of preparation, the day came at last to start towards the Hipólito Unanue hospital in the Tacna region at the South of Perú. In the airport we all gathered with Teresa to prepare the bags with our equipment. This is always a great moment when the members of the team come to know each other in between chaos and nerves. We are 9 persons, 4 general surgeons, 1 paediatric surgeon, 2 anaesthetiologists and 2 nurses. For some of them this is their first mission, although most of us have had some previous experience
We land at Lima after a 112 hours flight, and there Dr. Herrera, who is coordinating all our Tacna mission, is expecting us. He takes us at once to the centre of Lima where we see the Main Square and the Cathedral.
We come back to the airport to catch our Tacna fight, where on arrival we are met by a great welcome committee headed by the Health Regional Director, Claudio Ramirez. They give us flowers and take us to our hotel.
We settle down in 10 minutes and proceed to the hospital with all our material. There are more than 70 patients waiting, and we begin, together with Dr. Chura, coordinator of the Tacna mission, and Dr. Carpio, to organize the program for the next days. Most of the patients have already gone through the proper preparation, and have been evaluated by cardiologists, anaesthetiologists and surgeons, what has meant quite an effort for the hospital staff.
The day after our arrival we start operations. With the help of the local surgeons we are able to operate upon 17 patients on that first day. We had 4 tables in 2 different rooms. Lady Dr. Pilar Murga, anaesthetiologist, together with nurse Almudena Ceballos in one room, and nurse Mercedes Contreras in the other. Paedriatic surgeon José Miguel Morán and general surgeons Lucía Catot, José Manuel Hernandez, Claudia Tinoco and myself went from one room to another according to need, always with the help of hospital surgeons, residents,students and nurses.
I want to underline the work of the nurses Almudena and Mercedes as well as Isaac, René and Delia who very efficiently organized the whole work.
In this way we began our daily work with Marathon timings with began at 7:30 h. with heavy work side by side with the hospital staff, so that by the end of the mission we had operated upon 170 patients with almost 200 procedures, with the greater part of patients being given leave on the same day. Those who had to be hospitalized were evaluated at the beginning of the next day. The operations were chiefly inguinal and umbilical hernias, some of them very large because of a long evolution, and incisional and epigastric hernias. Only a few children were operated upon, as there was little information and collaboration by locals.
In the midst of all this work there were always some moments to disconnect, particularly at the meals with the delicious traditionally Peruvian dishes prepared by Carmen and her daughter Vanesa, and also in our walks after work through the city of Tacna. One day Dr. Chura and Isaak took us to the seashore to admire the Pacific Ocean which many of us had never seen before.
Besides that daily work we also organized some teaching days where a workshop on operation theater work and experiences was carried out and three talks were given: “Inguinal hernia treatment through open hernioplastia mesh” (Lady Dr. Gay Fernandez); Inguinal hernia treatment by laparoscopic way. Tapp and TEP” (Dr Hernandez Gonzalez) and “Surgical calendar for children” (Dr. Morán Penco) with a large audience from hospital staff and students.
After 10 days of hard work came the farewell. They organized a function with the hospital director and the national health surgeon where they gave us a thanksgiving document from the Tacna community.
The mission in the Tacna Hipólito Unanue hospital, the first in the region, had been a success, and both the hospital staff and the patients are looking forward to new campaigns. All this has been possible thanks to good work relationships and to the outstanding persons of the team, together with the great persons who made up the team and the collaboration of the Hipólito Unanue hospital staff, chiefly Dr. Chura. Without of course forgetting Dr. Herrera and Martha Vasquez who helped us from Lima.
With the satisfaction of a work well done we started for Cuzco to see one of the marvels of the world before coming back to our usual routine.
In May 2017 Hernia International arranged for a team of surgeons and anaesthetists to be deployed to Korogwe Hospital in Tanzania. Mr Alex Stanek, a consultant surgeon from Northern Ireland led the team. With him were senior consultant surgeon Mr Biku Ghosh and consultant anaesthetist Dr Patrick Stuart. Trainees Mr Vernon Sivarajah (surgical registrar), Dr Christina Croitoru (surgical SHO) and Dr Jonny Guy (anaesthetic SHO) also joined the team.
The hospital was located in the small town of Korogwe some 300km (6-8 hours) northwest from Dar Es Salaam (the place of peace). Korogwe is primarily a transport junction and of relative anonymity despite sitting on the outskirts of the beautiful densely forested Usambara mountains.
Our journey took us from the UK to Dar Es Salaam were we stayed overnight before making the 8 hour mini-bus journey to Korogwe. On our arrival Sister Avelina Temba (Nun and chief surgeon) and her team were present to welcome us. During our introductions the importance of missions like ours couldn’t have been clearer. We were told that on average there were 10 deaths per years from complications related to hernias and that of the ones that were repaired there was a 60% recurrence rate. We would later witness the importance of the mission first hand when we performed an emergency femoral hernia repair on a young lady who was acutely unwell for days with a strangulated hernia and small bowel obstruction.
The hospital
The hospital itself was a blast from the past, a 1950s build consisting of approximately 100 beds divided into traditional nightingale wards.
Our journey took us from the UK to Dar Es Salaam were we stayed overnight before making the 8 hour mini-bus journey to Korogwe. On our arrival Sister Avelina Temba (Nun and chief surgeon) and her team were present to welcome us. During our introductions the importance of missions like ours couldn’t have been clearer. We were told that on average there were 10 deaths per years from complications related to hernias and that of the ones that were repaired there was a 60% recurrence rate. We would later witness the importance of the mission first hand when we performed an emergency femoral hernia repair on a young lady who was acutely unwell for days with a strangulated hernia and small bowel obstruction.
There were three operating theatres. Two were large, with one just about suitable for basic general anaesthesia and the other for spinal anaesthesia. Both rooms had state of the art, donated anaesthetic machines but they were lacking readily available key components necessary for safe anaesthesia (more on this later). Both rooms had descent theatre lights and semi-functional air conditioning. The third theatre was a tight squeeze and can only be described as a small bedroom with a theatre table and a standing theatre light. Non-the-less it worked well as a theatre for performing smaller hernia repairs under local anaesthesia.
The surgical sets often had an array of instruments, which were a little worn but were usually fine to use. To help with future missions we donated 200 instruments most of which were brand new. We were very fortunate to have three fully functioning diathermy machines.
Equally as important as the facilities and equipment was the full compliment of Korogwe staff who supported us and were essential to the smooth running of the mission.
Day to day
Our days would begin at 7.30am after a hearty breakfast with a short ride from our accommodation to the hospital. The pre-operative patients were assessed and listed for their operation by us at the end of the previous operating day.
The local doctors clerked, bled (viral screen), consented, marked and canulated them so that they were ready to go by the morning. Before we started operating we would review our post-operative patients from the previous day to ensure that they were well. We operated in all three theatres simultaneously and so had a continuous flow of patients, which was facilitated by the theatre staff. Lunch was provided by the hospital and was usually a mixture of ndizi-nyama (plantains with meat) or samaki (fish) with ugali (maize) and vegetables. The afternoon theatre lists would run until about 6pm after which we would see the pre-operative patients for the next day.
Operative record
Over 5 operative days we performed 64 procedures on 50 patients. The most common procedure were inguinal hernias repairs of which there were 32. Five of these hernias were the typical large inguino-scrotal hernias of the developing world and 2 were recurrent hernia repairs. Other procedures included 17 umbilical hernia repairs, 10 hydrocelectomies, 2 epigastric hernia, 1 cord spermatocele, 1 large incisional hernia repair and 1 emergency femoral hernia repair for a strangulated hernia. We also provided anaesthetic support for a category III C-section, which was undertaken by Sister Avelina.
With the expertise of our consultant surgeon Biku and consultant anaesthetist Patrick we were able to safely offer paediatric surgery to 14 children, the youngest of which was 18 months old. We utilised all three theatres and operated on 16 patients under general anaesthesia, 19 patients under spinal anaesthesia and 15 patients under local anaesthetic.
One of our most challenging cases was our very first. We performed a large incisional hernia repair in a 65-year-old gentleman under spinal anaesthesia, which later had to be converted to a general anaesthetic with ketamine. He made a slow but steady recovery and was discharged 5 days later. To avoid an inevitable seroma and because we didn’t have a redivac (negative pressure) drain, our surgical SHO Christina came up with a novel negative pressure drainage system using a 50ml and 10ml syringe and some tape.
The first two days were highly productive having undertaken 33 surgical procedures. Unfortunately heavy monsoon rains and floods made it difficult for patient to get to the hospital and as such our productively slowed. We did not get disheartened as this gave us more time provide training to the local surgeons in the technique of mesh repair for inguinal hernias.
Practical anaesthesia in a resource limited setting
Patrick and Jonny our anaesthetist performed valiantly with such limited resources. They had to adapt their normal practice and improvise when needed. To keep things simple and safe the kids received halothane to breathe and our surgeon Biku gave them local anaesthetic as he cut. The vaporiser can easily be used to provide halothane anaesthesia without too much fuss. Most of the adults received spinal anaesthesia using a single shot of bupivacaine. There were limited drugs, syringes, needles etc. Fortunately the anaesthetist brought 100 doses of bupivacaine and some emergency medications – worth their weight in gold.
The anaesthetic machines in theatre were only functional for monitoring and even then there was a lack of ECG adhesive pads. This was overcome by the application of some lubricating gel and tape to the bare lead electrode. The anaesthetic machines were missing key components. Crucially and somewhat frustratingly the plug from some of the machines did not fit the three-pin socket. All that we needed was a normal kettle lead fitted with a three-pin plug to fire up the world class monitoring system. In addition, CO2 absorbers were missing, which would have provided a readily usable ventilator and circle system.
One of the biggest problems was the limited provision of pressurised oxygen. Only a single large cylinder, which lasted about 10 hours was available. Replacing it wasn’t easy but Avelina’s team did well to source a small cylinder, which again is now unfortunately in the red zone. In addition there was only one regulator without which oxygen cannot be delivered. The lack of pressurised oxygen is probably the biggest issue to address as it is essential for keeping patients safe. It would be important before any future mission to request that Sr Avelina looks at finding a way to have one large cylinder being topped up, while at least two full ones are physically present in the hospital.
Shopping list for future missions
Visiting surgeons and anaesthetists need to consider how best to equip themselves prior to leaving. One important factor to mention is that patients who are planned for a hernia repair have to pay a small sum of money. This buys them a physical operation but not always the materials and drugs that come with it for example antibiotics, anaesthetic, syringes, needles, sutures etc. As a result we brought most of the materials ourselves.
With three theatres running at full capacity there is potential to undertake 90-100 procedures. We have provided a brief list of materials based on our recent mission.
Surgical materials needed:
· Gowns
o Korogwe do have their own re-usable gowns but we brought in excess of 200 disposable gowns ourselves. They should be able to accommodate for future missions without the need to extra gowns.
· Gloves
o Will need plenty for the team and korogwe staff
· Face masks and theatre caps
· Mesh
o Sterilised and of the mosquito brand
· Sutures
o Lots of 2/0 vicryl, 2/0 prolene, 3/0 monocryl
· Local anaesthetic
o They only had plain 1% lidocaine and adrenaline was available separately.
o Safer to take lidocaine and bupivacaine pre-mixed with adrenaline.
· Diathermy plates
o They have a metal plate which they re-use
o Recommend disposable plates, which we reused.
· Diathermy pencil tips
· Drugs – Antibiotics, analgesia
· Dressings, needles, syringes
Anaesthetics materials needed
· Oxygen regulators
o Only one available at present
· CO2 absorber and breathing circuits
· Laryngoscope
o I would suggest that one is not left there as they are very easy to misplace
· Intubation/airway equipment
· Paediatric masks, airways and LMAs
· IV cannulas
· Nitrile gloves, tape and cleaning solution
· Anaesthetic drugs
General
· Malaria prophylaxis and repellent is essential especially for a mission in May (very wet season).
· US dollars as well as Shillings, which can be bought from the airport or from banks close to the hospital.
· Tourist visa ($50 from the airport) – it’s a lot cheaper than a business visa.
Cost of the mission and accommodation
Our flights from various parts of the UK to Dar Es Salaam cost approximately £350 when we booked a couple of months in advance. Most of us landed late on the Saturday and spent the night at the Best Western Plus Colosseum Hotel in Dar Es Salaam (£100). Early on Sunday morning our mini-bus (£280 to total), which was arranged through Sr Avelina took us to the hospital and later to our accommodation – the White Parrot.
The White Parrot was basic but served all of our needs. Bed and breakfast was a modest £20/night. They had their own restaurant for dinner, which was also great place for a nice cold Tusker beer or Fanta after a long sweaty day at work.
Many people to thank
Above all, the biggest thank you is to Hernia International for opening doors for teams like ours to provide a service for the people of Korogwe.
Also, we are hugely thankful for the efforts of our team leader Alex, who behind the scenes been carefully masterminding every aspect of the mission. Our team, most of whom had not worked with each other before were excellent. We all appear to have just clicked, mucked in, and battered on through the work with great efficiency, warmth and good humor.
Finally, the team in Korogwe led by Sister Avelina has been marvelous. From the red carpet treatment meeting the officials on day one, to the generosity, hard work and willingness to accommodate shown by the staff. It was a pleasure to work with them through Hernia International and we look forward to future missions.
This is a small mission hospital in Dangbo that provides general medicine–adult and paediatric, maternity, an immunization and an HIV/AIDS service. It has a functioning pathology laboratory. There is a departmental hospital about half an hour away where the patients for emergency caesarian are sent. There is no full time surgical team in Dangbo, just charity missions from other countries–particularly one paediatric surgical team from Spain. This was the first mission from Hernia International.
We were 4 surgeons, 3 from Australia and 1 from the UK, 1 GP anaesthetist from Australia and 1 mission aide from Australia. Communication between us and the local staff was in French. Some patients spoke French but mostly the local staff translated for the patients between French and Fon.
During the week we had a visitor from Porto Novo, a training surgeon, Dr Juste. He had been a general practitioner at the hospital in Dangbo and often assisted visiting surgical teams. He had thus been inspired to enter surgical training. He recounted that surgical training was a very expensive exercise and that his parents had to support him financially. When he qualified he said that he would find it difficult to come back to Dangbo to operate because the patients would not be able to pay him. In the hospital in Porto Novo they did not do mesh repairs of inguinal herniae but performed a Shouldice repaire
Pre-arrival
Yellow fever vaccination and a visa are required to visit Benin. The 4 Australians needed to send their passports to London to obtain the visa. The process of returning the passports to Australia was somewhat precarious!
It is difficult for the hospital director Sister Opportune, to communicate by e-mail. She finds ‘WhatsApp’ to be more efficient when arrangements are being made for the missions.
Arrival
At Addis Ababa airport extensive questions were asked about the goods we were bringing in but the Hernia International introduction letter, the itemized list of contents plus the fact that we were only staying overnight meant we were allowed through. At Cotonou airport we were also questioned about the goods but the mission authority paperwork from the local health directorate in French was enough to allow us in the country with the donated medical supplies.
One of the nuns and a driver met us at the airport in the hospital ambulance/bus. The drive to the hospital lasted just under an hour over very potholed roads with dense traffic and the impression of many near misses!
Accommodation
We stayed about a 500m walk from the hospital down a dirt road in a paved compound of 2 large buildings, the use of which is donated by the owner who lived in Porto-Novo. This was luxury compared to the local population’s housing. Each of our 3 large rooms was air conditioned with an en-suite. Cold drinks, including beer, were supplied in an insulated box with ice added occasionally. Bottled water was provided. No bedding or towels were provided.
There was no access to internet other than by walking to the local hotel (about 1km away) to use their Wi-Fi. For the Australians, no phone coverage was possible. Our English surgeon Paul was able to get somewhat intermittent coverage.
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Food
Breakfast, lunch and dinner were provided by the nuns in their dining room at 5 minutes walk from the operating theatre. It was delicious, with either an African or a French focus. We ended up cutting back on lunch and snacking in the theatre store room so we could get our programmed work finished.
Patient Preparation
In preparation for the visiting teams, advertising is in the form of word-of-mouth, through the church network, radio commercials, through family and friends and even a man on a bike riding around with a megaphone informing the community at large. The patients write their name with their problem and contact details down in a book at the hospital pharmacy. The prospective patients are then vetted by the local doctors before being seen by the team.
Surgeon Richard flew in from Australia, arriving Friday night, and on the Saturday saw 100 patients who needed surgery. He programmed 10 patients each day for the Monday to Friday that we were to be operating. There were 45 inguinal herniae (2 bilateral), 1 large incisional hernia, 1 large neck keloid scar and 5 other minor procedures.
Each patient had routine bloods including HIV status pre-op. Only 1 of the 50 patients was HIV positive.
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Theatre
The theatre is a fairly small room (approx. 5 x 5m), with 2 operating tables, separated by a wooden screen. Thankfully it is air-conditioned! When we walked out of theatre during the day it felt like walking into an oven!
There is no pre-anaesthetic or recovery area; the patients return to a post-op ward which is in the adjacent building. For the week, this post-op ward was staffed by Gabin, a surgical nurse who came from Porto-Novo for this purpose and even slept in the ward for immediate access to the patients. He had some help from a nurse assistant.
Oxygen is provided by a large cylinder. Suction is a stand-alone ‘Medpap’ machine with foot pedal; for both surgical and anaesthetic use. There is a Drager ‘Fabiusplus’ machine which can provide ventilation (VC & Manual Spont. only) along with a monitor providing a screen with readout for SpO2. No airway gas monitoring is available. Both paediatric and adult circuits are present with spares. A ‘Laerdal’ bag is also present. Oxygen tubing, connections, ETT tubes, iGels & LMAs are also available, numbering in the 10s for each (inc. paediatric). At least 4 intubating stylets and 4 Cook’s-brand bougies were available. IV access was well supplied with cannulae ranging from 14 – 22g. There was a large number of various spinal needles (20 – 27g) along with 5 central line kits.
Presumably left-overs from previous teams, there was a surprisingly wide variety of drugs available, although many ampoules were out of date. IV drugs we found on arrival included :
In the store room was an eclectic array of equipment, ranging from a multitude of sterile gloves and dressings to a variety of instruments and even an old portable U/S machine. Suture material and small disposable drapes seemed reasonably plentiful.
Operating gowns were limited in number; for most operations yellow infection control gowns were used. We had brought only 30ml syringes. Small syringes were not abundant, making measurement of small volumes difficult (e.g. when mixing adrenaline in to LA). Another surprising deficit was in small stainless steel gallipots for mixing. The array of instruments is generally adequate, the most prevalent issue being the blunt dissecting scissors; bringing sharp scissors would have made a material difference to the operating.
Sterilisation is done on site with a turn-around time of approximately 45 min. It was unusual for us to have to wait for this.
Sister Ruffine was an able scout nurse in theatre. She managed the pace of the patient flow related to sterilized trays being available and laying out the next sterile set up for each patient.
Power was generally reliable, although it was not unusual to have brief outages (for 2-3 minutes) throughout the day. The main inconvenience was waiting for the diathermy to re-boot. Fortunately, this had no effect on the air-conditioning. Whilst we had brought head-torches as a fallback, these were rarely used.
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The operating lights are of reasonable quality and reliable; spare globes were available and we did use one.
Each day commenced at 8:30, although the first patient usually arrived at about 9. Operating was divided between the two beds; ‘1’ being next to the anaesthetic machine. Cases were planned with the potentially more complicated ones being for bed 1 although spinals were available for bed 2 if required.
Scrubbing is at a simple sink with Chlorhexidine and alcohol; the tap is a simple knob i.e. not able to operated once scrubbed.
Operations
Local protocol outlines every patient receives IV Ampicillin 1gm, Metronidazole 500mg, Gentamicin 80mg & Diclofenac 75mg. This is continued for 24 hours post op. A glass bottle of IV fluid also comes with each patient in their small cardboard box.
Each table was manned by 2 surgeons with 1 operating and 1 assisting. This was ideal given the very scarred cases that we found. Gabin the ward nurse was an enthusiastic surgical assistant on the occasion when we were down to 3 surgeons instead of 4. Half of the patients had large herniae but even the smaller reducible cases had a surprising amount of scarring at the external ring and of the sac to the cord.
We programmed 10 patients per day and didn’t finish until 8 or 9 at night.
Anaesthetics
Spinals were required for 50% of cases. These were generally reliable although 3 men had bony obstruction; 5 required supplemental sedation and on 2 occasions, the operations exceeded the duration of the spinal. Only one patient required Ephedrine for hypotension (asymptomatic; given out of caution, especially due to Phil’s concern about the accuracy of the sphygmomanometer, rather than physiological sequelae).
Our impression was that slightly larger volumes of ‘heavy’ Bupivacaine 0.5% were needed for the spinal anaesthesia for good effect. The usual dose would have been around 2.8ml; here, easily 3.2 – 3.4ml was needed.
Sedation was primarily with Ketamine but supplies of this were limited (over half of the stock found on arrival was out of date). Fortunately, the alternative of Midazolam and Fentanyl was available. Propofol was used twice, again, from found stock.
Due to lack of gas monitoring, no recovery ward or dedicated nursing staff, as well as intermittent unreliability of the oximeter, the decision was made to avoid GA with paralysis. Sevoflurane was the inhaled agent available, no NO2 or air mix was possible, so GAs were managed on 100% O2. Two GAs were given (in both cases secondary to failed spinal insertion), both on LMA without mishap. Recovery occurred in the theatre unit until both were clearly responsive to voice alone. Oxygen was used sparingly for events of demonstrated reduced saturations <94%. Post-op analgesia and management was done by Gabin, the surgical nurse in the post-op ward. It appeared that the range of analgesia extended to oral agents and IV Diclofenac. As such, all patients were given either local infiltration of 0.5% Bupivacaine or TAP blocks at the end of the operation (including patients with spinals).
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Post-Op
The expectation by local staff was that all patients would go home the following day. The ward is essentially a large room with closely spaced beds. It was notably hot and humid with the only medical facilities apparent being the IV flask holder and a sphygmomanometer.
Close assessment of post-op pain was not possible secondary to the language barrier but patients greeted us with smiles and waves, so the assumption was that the experience was within their expectations. The patients, in French or in Fon, when they got the chance thanked us and said “God bless you”.
Student Participation
15 year old Clancy accompanied her mother Cea-Cea on this trip as mission aide. Her participation was vital to the smooth running of the mission. She took primary responsibility for documentation of the team’s activity. She also proved adept in performing as a de-facto anaesthetic and scout nurse as well as in some English/French translating.
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Suggestions for next time
Surgical
* Program 8 patients per day
* Theatre nurse volunteer
* Good scissors
* Sterile gowns
* A new diathermy machine – one of the 2 didn’t seem to be working very well
* Diathermy handles and blades
* Scrotal supports
* Gallipots
* Self retaining retractors
* Large sterile drapes that cover the whole patient
* Local anaesthetic
* 2nd Mayo instrument trolley
Anaesthetic
* Oximeter, BP, capnography
* Small syringes for mixing
* Large non-sterile gloves for Phil
* Laryngoscope
* Portable U/S
Other
* Theatre snacks!
* Room shelving for storeroom
* Clear plastic organizing boxes
* No-touch tap to install for scrubbing (and plumber!)
Overall we had a wonderful time and I would recommend this mission to anyone with a sense of adventure and some heat tolerance. At least one French speaker per mission would be ideal. Cea-Cea loved the African “tissu wax” fabrics the locals wore. The staff arranged for a local woman to display some samples so she could buy some to take home at a very cheap price. We all left very quickly after the last operating day so unfortunately we could not do the sightseeing trip to the river that Sister Opportune had planned for us. Next time!
International Hebron Hospital – Phnom Penh, Cambodia, 9 to 13 Jan 2017
Team members:
Dr. med. Jürgen Meyer
Prof. Markus Heiss
Dr. med. Andreas Hohn
Dr. med. Simone Seefeld
Nicole Daams (nurse)
Our German team (3 surgeons, 1 anaesthesiologist, and 1 scrub nurse) arrived at Phnom Penh on Saturday 7 Jan 2017, and the next day we were warmly welcomed by the hospital’s vice director Dr Chul Lee and his team. He gave us a brief introduction to Cambodia’s history and the story of the Hebron missionary hospital which is funded and operated by Korean Christian missionaries.
The Hebron hospital has three well equipped operating rooms available, all with AC, full monitoring, and anaesthesia machines. As cardiac surgery and ENT surgery is regularily performed by different international teams, most common drugs and standard airway management equipment is available at the Hebron.
On Monday we started on one table, but temporarily, we were able to run two tables concurrently, depending on the personnel resources and the particular complexity. Our Team was supported by a local surgical resident, several scrub nurses, and two anaesthetic nurses. During this week, we managed to do 28 hernia repairs. Among these twelve children were between 2-12 years old with inguinal hernia to a varying degree. All children were operated by using the technique of Ferguson.
Most of the adult patients showed large inguinal hernia, three-times on both sides and in five patients chronic incarcerated hernia were met and operated under spinal anaesthesia. Only one patient with an altered coagulation due to liver cirrhosis and one woman with a large abdominal incisional hernia needed general anaesthesia. All children received general anaesthesia and an additional caudal block for postoperative pain control.
In adult patients, the Lichtenstein technique with polypropylene mesh implantation was used. The abdominal incisional hernias were operated with sublay mesh implantation.The patients were clinically investigated by our team. Sonography was available and used occasionally. All patients came with a preoperative checklist and were all well prepared by the local team. Patients had received perioperative antibiotic prophylaxis. Laboratory tests and chest x-ray were done according to the local standards and further lab tests as HIV, HBV, and HCV were available on the very same day.
Patients were visited by the Hernia International team twice a day and no major postoperative problems, especially no signs of infection were found. Only one young patient with a large incarcerated scrotal hernia had a prolonged hospital stay due to a postoperative bowel dysfunction and abdominal distensions The ward nurses did an excellent and dedicated job and took care for the patients. The ward nurses were supported by two local GP residents.At our last day, a great celebration in the hospital´s main hall was performed with a warm acknowledgement for the performance of our team.
As accommodation we choose the Dragon hotel in Phnom Penh, which is a little hotel nearby the hospital with friendly service and clean rooms. In dependence of traffic it takes 10- 15 minutes with the tuk-tuk to the hospital and 15-20 minutes to the city center. After our mission we traveled for two days to Ankor wat und Siam Reap. The tour was well organized by the people from the hospital, so we had the opportunity to visit the temples from Ankor wat.At last we had a great time in Cambodia, we met a lot of nice people, which helps us a lot and finally we could help some patient…..
Hernia International team, Canadian GRID team and Ghanaian organisers
Leighton (North West) Team: Magdi Hanafy, Sara Watson, Perry Board, Geraldine Burke, Ramona Maria Fetita, Emma Brown, Ambareen Kausar, Diane Dugdale, , Katherine O’Shea.
Northampton Team: Rob Hicks, Nichola Blunt,
Canadian Team: Tony Brown, Martin Stewart, Laurie Patry, Margie McGregor, Susan Simpson
German Team: Antje Hopt.
Spanich Team: Natacha Apentchenko
Ghanaian Team:George, Colin, Noah, Mathew, Daniel, Mumuni, Eric, and many others.
Our surgical team this year comprised of 18 volunteers from the UK, Canada, Spain and Germany. Many of us had previous experience and some were newcomers. We travelled differently this year. After arriving in Accra with our 52 pieces of luggage, we were transferred to a hotel to rest overnight. The next day, rather than travelling to Carpenter by coach (an 11 hour trip) we took the plane to Kumasi, followed by a four hour drive to Carpenter. We arrived by lunch time and had time to unpack. This difference made our trip much easier. Although that incurred a cost it was well spent.
On the first day while we were arranging our theatres we received a patient with a strangulated hernia. He has been in this condition for four hours. The anaesthetists were not ready yet but managed to prepare themselves very quickly to put him to sleep. The operation went very well without the need for bowel resection. For the first time our first operation was an emergency.
While we were operating, I was seeing patients in the clinic and listing them for the same and subsequent days to fill up three theatres with general and local anaesthetic cases. On that day, and subsequent days, I saw and listed sixty patients and refused to operate on lipomas, ganglia, skin lesions or anything else other than hernias.
One patient listed for an inguinal hernia operation in two days’ time was admitted on the second morning with the same hernia strangulated. He was operated upon successfully. In the evening after dinner another patient came with a small strangulated hernia. Two emergencies on the same day, three in 48hours, that was unbelievable. With the help of our anaesthetists’ sedation and pain control we managed to reduce the last hernia by gentle taxis. He was first on the next day’s list.
All children were screened for Malaria and 100% were positive. Each child required treatment for three days before the operation. The first children’s list was on Wednesday and the second was on Thursday of the second week.
This unpredictability of emergency admissions made me conscious not to overload the lists and tire our staff. Average 9-10 procedures a day per theatre, taking into account the complexity of the cases, was more than enough. The aim was to finish all cases, clean theatres and finish computer work before sunset (6:00 pm) every day. I successfully resisted my desire to get every hernia on the planet operated upon, and was content with that number per list per day.
By the end of our mission (nine days), we counted 268 hernias operated on (219 patients). We worked hard as well in a daily clinic on site to populate the lists and in the villages to populate the waiting list for 2017.
We were five surgeons (all consultant level) and one registrar paediatric surgeon. Seven experienced theatre nurses, two consultant anaesthetists (one full time and one part time), one experienced anaesthetic assistant nurse, and one ITU nurse for recovery and ward duties. Not to forget our Ghanaian helpers who organised admission, discharges, patient transfers, translation, consenting, meals, rooms, calling us if we were needed for a condition or a question. We were also supported by Collins, a community Ghanaian nurse who tested all patients for HIV and Malaria before their operation. He is the nurse who will take charge and care of our patients after we leave and he will communicate with us if there are any problems.
This year did not hide any surgical challenges more than the usual hernia operations. We had two wound infections, one deep and one superficial. Both treated by incision, drainage, antibiotics, pain killers and daily dressings in our facility followed by the community care with Collins. I had one of the most dreaded complications while doing a Stoppa repair for bilateral large inguinoscrotal hernias. I unintentionally entered the dome of the urinary bladder. I catheterised the patient and repaired the bladder with two layers of interrupted Vicryl. I conferred with my surgeon colleague and we decided to continue with the repair of the hernias. A tense five postoperative days with IV antibiotics, Iron tablets, plenty of water to drink and urine observation for amount and colour. Seven days afterwards the urine was clear and the patient was eating and drinking and sitting out with the catheter and asking for a football. Nurse Collins will remove the catheter 10 days after the operation.
We operated on a Lumbar hernia the size of a small melon for the first time. We had a patient with a large Spigelian hernia on one side (shown above) and a large inguinoscrotal hernia on the other. We had a hernia going into the femoral sheath under the inguinal ligament. We had the appendix inside the hernia sac (shown below), we had an aneurysm of the common femoral vein (Left alone). We had an epigastric hernia that turned out to be a large mobile mesenteric cyst or a tumour when examined with the patient lying down. She did not have an operation and was transferred for a scan. We had a lady with a huge abdominal mass occupying all the abdomen for the last three years. The mass was tense, dull, not tender. The patient was transferred to another hospital for a scan. ? Ovarian pathology. I saw a large inguino-scrotal hernia, which when reduced showed worms in the scrotal skin that kept dancing on touch, each the width of a pencil and about 3-5 cm in length. Without a diagnosis we started the patient on intense anti-helminthic medications for five days. I am looking forward to seeing him next year. We saw a patient with a “moderate” inguino scrotal hernia, who could not pass urine unless he squeezed his scrotal hernia. We concluded that the urinary bladder was atonic and relying on this manoeuvre to contract. Repairing this hernia would put the patient at a disadvantage.
Our Canadian colleagues kept helping us by supplying IV antibiotics and fluids, as well as antimalarial medications and test kits for HIV and Malaria. We took turns in joining them in the villages and short listed many more hernias for next year. We also helped with opening abscesses, diagnosing surgical conditions and recommending treatments. Our autoclaves this year were extremely hard working as we sterilised instruments for the dental team as well. Our Ghanaians helpers did, as usual, the most to care for the patients and kept us informed and helped us deliver the service at a high level. Collins screened every patient. Noah consented them and answered any questions. George translated for me in the clinic and made sure the wrist band belonged to the patient concerned. Mumuni brought patients from outside the compound into the wards and allocated rooms for them, and discharged those who had operations the day before, booked minibuses for them and advised them regarding their take home medication. Mathew was a man who would not sleep, informed us of any problems, stayed up all night with the engineers to make sure the Air Conditioners were in place and working. He was the one who knew where we were and would come and let us know if a patient came with an emergency and stayed with us for translation. Everybody liked his dedication and personality.
Our Anaesthetists had Eric who is a qualified nurse anaesthetist from Bamboi. He took time off from his work to come and learn and help at the same time. He is a very good man who is willing to learn and help and never got tired. He is a good seed for the dream hospital we are going to build in the future. Nicky our ODP was described as having a battery attached to her as she never stopped working.
The way the team, from different countries and with different experience, gelled together and worked like a “well-oiled machine” was impressive.
Sister Watson described the work as “seamless care, which is how it felt really, I am always amazed at how everyone pulls together and helps each other in the unique experience that is Carpenter. Alongside the Ghanaian support team we laughed, worked tirelessly and became more culturally informed and enriched through shared conversations”.
The team worked hard and enjoyed what they were doing. The satisfaction in the face of each member of the team at the end of each day and on the last day of the trip was noticeable. Other than every day work, the packing and inventory on the last two days were made to perfection.
I would like to mention companies who worked hard to provide us with instruments and consumables needed for the trip. Medline supplied us with gowns, drapes, gloves and swabs enough to cover our mission. Eschmann supplied us with more sterilisers and diathermy machines to compensate for those which were destroyed last year by the electric power surge. KLM was kind enough to wave reasonable extra weights and accept extra luggage. ERS medical for transporting our luggage to the airports. Our Local pharmacy in Knutsford supplied skin sterilisers without charging VAT. Many employees in Leighton and South Cheshire hospitals have made me aware of useful redundant instruments that I could take for the mission before they are disposed of.
Rob Hicks will take over the organisation of the missions from 2017 onwards. The mission is lucky to have him as a leader. He has a much calmer approach than me and he is liked by all the team. I shall still be a member and travel as a surgeon and help as much as I can in organisational matters.
See you all in Carpenter 2017.
Magdi Hanafy
Consultant Surgeon
Mid Cheshire Hospitals NHS foundation Trust
Volunteer in Hernia International group.
On behalf of Team Carpenter 2016 (UK-Ghana-Canada -Germany- Spain)
Mrs Margaret Cameron NHS retired physiotherapist and Mr Cameron’s wife.
On a hot and sunny afternoon in Tanzanian’s dry season we have arrived at the busy Dar Es Salaam International Airport, the meeting point of the team.
Despite heavy traffic, a member from the hospital staff and the hospital driver, managed to pick us up at the airport waiting area, with a slight delay.
Familiar faces made the foreign country more familiar to meet new people. We had a warm welcome to the country and began the journey, loading the car with all the boxes and baggage.
To avoid driving to Korogwe in the night, we spend the first night at the Bagamoyo, two hours (depends on traffic )drive from Dar Es Salaam a resort on the line of Indian Ocean. We had a very nice relaxing evening before our mission’s work and was a good time to get to know the team members. The hotel in Bagamovo was good value for money and the hotel staff was helpful.
On following day Sunday, Omari drove us to Korogwa. The drive took more than 4h for us to reach our destination.
Our first stop was at White Parrot Hotel where we were welcome by Avelina a local Surgeon and the organizer of those mission trips, to Ya Wilaya Hospital.
We continued our journey with Avelina to our next stop the Ya Wilaya Hospital where we were welcomed by all hospital staff. The hospital has experience working with Hernia International Organization and we were the 7th team who came to work with them .
Avelina took us to her office to brief on patients waiting list. At that moment over 100 patients were awaiting to be seen. The local staff had already made the screening for high risks cases. The ward was crowded with children and elderly placed together.
From start we did the usual practice, identifying patients who needed surgery and discharged home patience that didn’t required surgical intervention. Prior we did visit the operating rooms and meet closer the team to work with us in coming days. All our medical supplies were unloaded from car and we proudly notice our donations fulfill completely the storage space in the stocker site.
Our working week began as usual on Monday, but as tradition goes we had a meeting first with Chief Cancelor and the Mayor of Korogwa before commence our work.
Looking at the cases it was clear to us that some patients will need more than local anesthetics. We put all pediatric surgery under general anesthetic and we allocated all pediatric cases to be performed in most equipped operating room 1. Operating room 2 had an air-condition and basic equipment for Spinal and LA. The operating room 3 was allocated for LA, unfortunately the room didn’t had an air-conditioner.
Hospital staff provided us with full assistance in all aspects of our work. Local doctors took part in provided training and assist us in all ongoing operations. Avelina only managed to join us on our last day, Friday. Her main duty kept her outside of the hospital for the most part of the week.
It is worth to mention the hospital driver Omari who was a great help through out our stay.
We did enjoyed the local food prepared for us every lunch, daily by the hospital.
We stayed at the White Parrot hotel. The rooms were clean, the service was good breakfast was included, the dinner was paid extra also quite good. Sadly, we were the last customers they had to accommodate. After our departure the place was closed down for unpaid tax.
In regards to our mission, we had 91 patients on a waiting list including children. Nevertheless, we managed to perform 97 surgical procedures. Where 27 patients were children, most of them under 5 years old, and 64 were adults.
Pediatric cases of : congenital inguinal hernias, umbilical hernias, undescended testicle, two cases of hypospadias, and hydrocele. All done under general anaesthetic.
The adults operated were 64 patients, of whom the 16 were female. Most of the cases were done under local anaesthetic. We worked out the large scrotal hernias, non reducible inguinal hernias, incisional hernias, selected number for spinal anaesthetic.
We gave general anesthetic/Ketamin with the help of the experienced anesthetic local team in 3 cases with large hernias and one for incisional hernia. In one male case we had non response to any given analgesia and had to administrate general anesthetic with ketamine.
As per routine set, we performed usual postoperative assessment. Furthermore, the assessments were carried out with usual controls in place and we did final reviews for patients on discharge home.
We involve local doctors to participate in all stages of postoperative assessments and we have left necessary recommendations and instructions in place to follow on review assessments. Translated copy with postoperative care instructions was given to each patient on their discharge home.
In addition, we did daily ward rounds every morning reviewing each operated patient and run small daily clinic for new coming outpatients. It was noticeable that establishing good communication between our teams and hospital staff helped us to achieve good results in patients care.
It is important to mention that our medical supplies to the hospital prove yet again, to be an important part in our mission. Providentially, we have had an opportunity to organize our medical supply and it was vital in our work.
Our mission came to the end on Friday, some members of our team have organized a safari trip to finish their stay in Tanzania. I have decided to stay a little longer in the hospital and catch up with the staff, patients and local people. Working thorough the mission didn’t leave much time to do this and I am glad I’ve spent a bit more time with locals before returning back. Following morning I’ve travelled back to UK, after a short stop to Bagamoyo again. The split of the team made early good byes.
I would like to say our team has achieved very good results judging by responds we had from the hospital staff and the patients. Noticeable, the hospital had a rapid improvement with the changes we recommended and training we provide. We are happy to report hospital staff has in progress the implemented all given recommendations. For example: better ceiling in operational room 2, better air-conditioner in operational room 3 and an extra bottle of Oxygen supply, to keep always in stock.
Hospital surgical instruments stock contain large amount of unsuitable operational equipment. We advised hospital Metron to keep only instruments that are possible to use in surgeries, i.e. few selected hernia sets etc.
We understand hospital has a small affordable charge for the surgical procedures they performed; hopefully those funds will help hospital administration to improvements in place.
Considering constant demand for surgical intervention we hope the established improvements in the hospital will help other international teams to work in better settings.
I would like to mention Dr. Alexander Stanek, who helped to have donated new disthermy to hospital. The donation was made by Sister Carol Reid from Tyrone County Hospital and we all send a great Thank You*. Dr Stanek is planning his mission for May 2017.
Also, I would like to say, thank you, to each of you, on behalf of the hospital and myself to John and Ann Budd , Penny Howell, Alan and Margaret Cameron, who helped us to bring donated equipment all the way to the hospital and for the team work we have achieved.
Using this opportunity I also would like to say my gratitude to all my colleagues who helped me collect vital medical supplies for our mission. Especially, I would like to say “Thank You!” to: Dr. Nele Close who helped to cargo boxes of sutures; the staff at St Peter’s & Ashford and Crawley Hospitals NHS Trust for their support.
Medical suppliers, companies Ansell and Swan & Morton who kindly provide supplies of sterile gloves and disposable scalpels.
In addition to above I would like to thank all my Greek friends and families who never stop donating and helping people either here, in UK, or in Greece or far overseas. Your help was absolutely fantastic! Moreover, I would like to say “Thank You” to our Greek Orthodox Church Arche-Bishop in UK, Mr Gregorios who always is happy and ready to support a good cause.
