Mission Report: Chittagong, Bangladesh from 23 to 28 November 2016
(Exterior of Nurture General Hospital)
Buried in the hustle and bustle of a sprawling seaport city, amongst paddy fields and a maze of roads filled with street peddlers and crazy tricycle ‘CNG’ taxis whizzing past, was the small 6 storey building that housed Mdm Nasreen Baqui’s Nurture General Hospital. Away from the chaos of the Chittaggonian roads, where no traffic lights or road rules hold true, our team from Singapore (comprising of 10 surgeons and 2 anesthetists) found our response in the operating theatres where we performed 70 operations in 69 patients -69 inguinal hernias and 1 hydrocele over a period of 3.5 days.
(Our team members: Top row – Rajesh, James, Darren, Zhongxi, Yexin. Bottom row – Sing Ying, Chok, Shuhui, Norman, Yvonne, Jacklyn, Siok Yen)
We arrived on the evening of the first day, after an internal flight from Dhaka to Chittagong, and immediately started screening patients and planning out the workflow and logistics. All of the hernias were done under local anaesthesia or spinal anaesthesia for the larger ones, using the open Lichtenstein repair. Each day began with a ward round to review all the patients that were operated upon the day before, and discharge those who were well. Following which we would spend the day in theatre where we had 5 operating tables going on simultaneously, and then end in the evening by reviewing our post-ops and screening more patients for the following day.
(Nisha, a local medical student, assisting our team in a surgery)
(Our anesthesia team – Zhongxi and Jacklyn, ensured that our operations were carried out smoothly)
(Postop ward)
Nasreen, her twin sons Yasir and Yamin, as well as her local support team were quintessential to the execution of this mission. They provided us with the most wonderful hospitality by accomodating us in a pleasant hotel, ensuring we had delicious warm meals and always going the extra mile to ensure all our needs and requests were met. We will never forget the smiles of gratitude on the faces of the patients, nor the enthusiasm of the local volunteers who were ever ready to help with translations. Everyone thoroughly enjoyed themselves on the mission and are looking forward to our trip back!
1ST SLOVENIAN “HERNIA INTERNATIONAL” EXPEDITION – GAMBIA 2016
(22nd – 29th October 2016)
India was our first choice of destination for an expedition in 2016. We put a lot of effort into it, however, due to poor communication from the Indian contacts we started looking for alternatives. We turned to Prof.Andrew Kingsnorth, who suggested Farafenni, The Gambia. It was a complete unknown, this tiny West African country, but with trust that our boss Andrew will not let us down, we started preparations with enthusiasm. First, we needed a team. There are quite a few Slovenian surgeons and other doctors, who are active in charity work in the third world. However, there has not been an entirely Slovenian “HERNIA INTERNATIONAL (HI)” mission up to now. Before taking the challenge to organize this expedition, I took part on missions in Mongolia, India, Ghana, Tanzania and elsewhere and gained a lot of experience and knowledge, which helped me bring together a national team. I brought together experienced doctors on one hand and enthusiastic youth on the other. The team members were Tomaž Benedik (consultant surgeon), his daughter Selena Benedik (medical student), Eva Pogacar (consultant anaesthesiologist), Urška Bricelj (resident of anaesthesiology), Luka Kovac (resident of obstetrics and gynaecology) and Jurij Gorjanc (consultant surgeon and team leader). Additionally, Alex Lupke (resident of anaesthesiology) from Grimma in Germany joined our team. He attended an expedition in Farafenni the previous year and helped us a lot with his previous experience. His practical skills in anaesthesiology and his information about the country, hospital and important details about the surgical team from Gambia were of great help.
Team members – smiling with the lost luggage
The communication through e-mail-exchange, before the mission with the director of the AFPRC hospital (Armed Forces Provisional Ruling Council) Dr. Mamady Cham, PhD was excellent. He gave us the feeling that the team in his hospital was well organized, cooperative and appreciative of our help. The impression was strongly confirmed during and after the mission.
There were many possible ways to fly to Farafenni. We decided for a one-stop combination (Venice-Barcelona-Banjul), all other flights were two or more stop flights. A mistake! It was a low cost flight. Luggage was strictly weighed and any additional luggage had to be paid for. We tried to reserve extra luggage beforehand, but to no avail. Even worse, our extra luggage was lost and arrived at the hospital in Farafenni in the evening of our third operating day.
On our arrival to Banjul, we were highly honoured. We were welcomed to the country by Dr. Cham, the hospital director and the Gambian minister of health, the honourable Dr. Omar Sey. The embarrassment about the missing luggage at landing was reduced after Dr. Cham, again showed just how good a host he was. He gave provided materials from the hospital and medicine from the hospital pharmacy for our disposal. Without the help from the hospital, we would be limited just to a few surgeries until the fourth operating day.
Meeting honorable Omar Sey, Gambian Minister of Health
After spending one night in Banjul, we headed east on the south bank of the River Gambia and crossed it with the ferry just south of Farafenni. The journey in the hospital Taxi-van was pleasant as our Public Relations Officer Mr. Sainey Dibba explained many details about the country. Sainey was of great support during our whole mission.
Our accommodation was Eddy’s hotel, about a kilometre away from the hospital. After checking the operation theatres and the hospital gear, there was a lot of positive energy to start working the next morning. The AFPRC hospital is cleverly designed and strongly built entity. It is a renowned regional hospital with trained personnel. Essential persons for us were surgeon Dr. Lamin Jammeh (a very well educated and practically skilled young consultant), Dr. Francisco from Cuba (a perfectly trained and skilled anaesthesiologist) and Christiana, a skilled Anaesthesiology Nurse and great organizer in the operating theatre. Dr. Jammeh and Dr. Lupke did almost all the triaging and pre-operation preparations. This allowed the rest of the team to concentrate fully on surgery. We tried not to disappoint over a hundred carefully recruited Gambians with many diseases, because we wanted to stay focused on patients with hernias and hydrocoeles. Every day from Monday to Friday, we operated from 8.30 am to 8 pm, sometimes even longer. At the beginning the fast pace was not easy for the hospital staff but we all got used to it quickly (Friday was an exception, we finished early).
Postoperative transport of the small patients to the ward – personally by Eva and Urška
We performed operations on two tables, separated by screens. There was air-conditioning, so we only felt the 40oC during lunch.
In 5 working days, we performed 63 procedures on 57 patients. There were no perioperative complications. 45 patients (80%) were male, 12 patients (20%) female. 19 patients (33%) were children. 36 patients (63%) had different inguinal hernias. Other hernias/diagnoses were 12 umbilical hernias (21%), 10 hydrocoeles (18%), 5 incisional and/or epigastric hernias (9%). One patient had a cystic scrotal tumour (orchiectomy) and two patients had symptomatic haemorrhoids (Milligan Morgan). Due to the excellent anaesthesiology team, almost 44% of all operations were performed in general anaesthesia, 46% in spinal and 10% in local anaesthesia. According to the statistics from the hospital administration, 82% of the patients were Gambians.
I was proud to lead a professional team: Tomaž, a very experienced consultant mastered even the most difficult hernia cases. His daughter Selena, a medical student, was assisting as a “real doctor” to her father up to 12 hours daily. Luka performed his first hernia repairs and showed talent for operations. Eva took a great deal of responsibility on her shoulders as the leading anaesthesiology consultant of the team, performing anaesthesias even in 1 year old babies. Her cooperation with Urška, who will make her consultant exam in 2017, was of great value for our success. So was Alex from Germany, as mentioned above.
We also provided education to the local surgeons and operating theatre staff on new techniques. Dr. Jammeh is now more skilled in Lichtenstein repair and Rives-Stoppa sublay procedure. However, there was also a lot that we learned from the Gambian team. Many details of the surgical procedures can be simplified without a risk to the patient and are less challenging for the operating team. Medicine in our home countries is definitely very sophisticated, which is good and necessary, but perhaps it is also too complicated in some ways?
Education in the Op. theatre-dr. Jammeh performing Lichtenstein and Rives-Stoppa sublay repair
All the good work in Farafenni could not been done without good cooperation between the Hernia International team and local professionals at the AFPRC hospital. Therefore, on the last day of the mission in Farafenni, we did not have the impression that we just came there to operate on patients for one week, but that we cooperated with the local professionals in order to do something for the Gambian people. The centre of our interest was the well-being of the patients.
In the Bible, there is a saying: “If someone works well, he should also eat well.” (2 Thes., 3, 10). Theexcellent cook JenabaSecka was taking care of our meals throughout the week. She provided us with local delicacies from grilled chicken to fresh fish from the River Gambia, not to mention the local fruit and vegetables. Without her food, we would not be able to stay in the hospital for 12 or more hours daily.
Who could forget our experience? Not just the good medicine of that week, but also new friendships, friendly Gambian people, social evenings in Eddy`s hotel garden with cicada songs and falling coconuts? What remains in the long term is our gratitude towards our Gambian hosts and our plans for future expeditions.
The 2016 campaign of “Cirujanos en acción” and “Hernia International Foundation” has been successfully carried out from 2 to 12 October 2016 at the Ecuador Public Health Ministry Hospital of the San Agustín de Calceta province. The initial plan was to have carried out the mission in the amazon region of Ecuador in the San Francisco de Orellana Hospital between 2 and 14 October 2016. Owing to bureaucracy problems alien to our NGOs, that initial plan was postponed when we had already bought and organized all the flights and personal logistics, so that we had to work hard together in order to plan out our mission all over again. Since October 14th was the day for the team to come back, and the 13th is a local feast day in the city of Calceta the surgical mission was limited to 8 days. As a complement we were offered the possibility of working in the Mobile Surgical Unity of the Santo Domingo de los Tsáchilas Hospital, and so we worked there on 7th and 8th October 2016 with full success and satisfaction.
The working team members have been in order of age: Dr. Leopold Mitterger (Austrian retired general surgeon), Dr. Alejandro Unda (retired paediatric surgeon from Ecuador residing in Spain), Dr. Paul Wilkins (British anaesthetist residing in Australia), Dr. Francisco Gomez (infirmarian from Spain), Dr. Cesar Ramirez (General and digestive surgeon from Spain ), Dr. Ana Sepúlveda (anaesthetist from Spain), Dr. José Luis Guerrero (General and digestive surgery, from Ecuador residing in Spain), Dr. Olga Morató (Genera and digestive surgery, from Spain). The coordinator and responsible person for the organization of the mission was Dr. Cesar Ramirez.
The Calceta Hospital is a public hospital belonging to the Public Health Ministry of Ecuador which has two operation theaters and a room for childbirth, plus about 90 beds with an average use of 90%. The city was affected by the earthquake of April 2016 and it has a high unemployment rate, so that offerings of health and social work are always welcome. This was the first time they hosted a mission from Cirujanos en Acción and Hernia International Foundation, and the organization on behalf of the medical hospital direction and the local health authorities has been excellent. They set up two marquees for the reception and classification by two local doctors of Primary Attention sent by the District Office. Once the patients were seen to need surgery they were examined by our team in another marquee. Facilities for the analytic and preoperative study (which took place in 15% cases) have been high, as well as the organization of subaltern staff for shifting the patients. We’ve had a full operation theatre at our disposal every day, in which we worked simultaneously on two tables from 8 to 18 hours; the time was limited because of the need to coordinate with the timings of surgery staff of the hospital, since at least 3 nurses were always at our disposal. We had carried with us more than 100 Kg of medical and surgical material, including all the meshes and suture that have been used up, as well as syringes, needles, catheters, local anaestheticals, gauzes, compresses, surgical sterile operative fields, anesthetic medication, antibiotics and anaelgesicals, and finally three sets of surgical material entirely new for hernia surgery, two for adults and one for children. As the initial calculation was for 200 patients we gifted the remaining material fo the Calceta Hospital.
The collaboration from the part of all has been excellent, particularly from the District Director Dr. Julio Mejía, the Medical Director of the Hospital Dr. Don Christian García, and the Medical Directress of the Santo Domingo Hospital Dr. Kathia Tinizaray. I also would like to single out the great help of lady doctor Jennifer Zambrana, the queen of Calceta and all her family who have helped us in our getting places in the University Residence of Calceta and in our moves through the city at any time. Local media, radio and TV, have daily reported on our work, which has spread the news of our presence there so that we have been able to help a larger amount of patients.
On the whole 125 interventions have taken place in 8 working days, and our satisfaction to have achieved our aim is great. The collaboration of all the members has been very high, with a great team-work spirit, and I can say that the dynamics of personal relationship have been very good so that we have enjoyed ourselves and we have greatly enriched ourselves. The weekend on 8 and 9 October we visited the so called “World’s Half” and the city of Baños de Agua Santa with its spectacular geography: Río Bamba city, Pailón del Diablo and Chimborazo volcano.
I has been a great work and a good team, and we have worked in a place where there is real need and a great possibility for help. The great collaboration we have all received from all quarters and personal of the Hospital (so that a real feeling has gone beyond the purely professional activity) lead me to propose this hospital and its city for future missions of Cirujanos en Acción and Hernia International Foundation.
Hernia International Mission 2016: September 10-17
Luwero, Uganda
After the great success of last years ‘Hernia Camp’ a new team of enthusiastic volunteers embarked on another trip to Luwero, Uganda, once again led by Andy Pilcher along with consultant surgeons Tim Brown and Scott Caplin (Morriston Hospital, Swansea). The second collaboration between Hernia International and Care For Uganda saw the addition of consultant anaesthetist Dave Hepburn, trainees Edward Brown and Charlotte Brown and photographer/videographer/general enthusiast Dan Evans.
We arrived safely at the Care For Uganda Headquarters in Bbowa bright and early on Sunday morning. After a brief rest we made the journey to Bishop Caesar Asiili Hospital where we caught our first glimpse of where we would be working for the next week. We spent time exploring the theatre complex and making introductions with the local staff. It soon became apparent that much like last years trip, the main challenge would surely be the anaesthetic equipment (or rather lack of it)! Still, in Dave’s capable hands, and after the identification of some clean tubing for the anaesthetic machine we were raring to go. We unpacked the supplies we had brought and departed the hospital, eager to return the following morning. On Sunday afternoon we were offered the chance to see some of the other projects co-ordinated by Care For Uganda and meet some of the local children, a truly unforgettable experience.
Monday morning we began the work we came to Uganda for. On our arrival at the hospital there were already plenty of eager faces waiting patiently for us in the courtyard. We devised a makeshift theatre list and began seeing the patients in turn. On identification of a hernia suitable for repair we marked the patient and they were sent immediately to the ward for assessment. All patients had their HIV status checked prior to theatre and signed a consent form. We finished assessing all of the patients before getting started in theatre; a somewhat lengthy process at the Ugandan pace of life! It was a day filled with new experiences, from operating by torchlight to repairing large recurrent hernias venturing up the abdominal sidewall. We repaired 14 hernias on our first day of work, with plenty of inspiration for how to streamline the process in the days to come.
The days that followed just got better and better. We found ways to optimise our time at the hospital, for example being proactive with the autoclave to prevent long delays between cases, and dividing manpower between the clinic and theatre. We enjoyed the daily challenges that faced us and devising means of overcoming them. We took great pleasure in reviewing our post-operative cases and experiencing first-hand the difference we were helping to achieve. We also saw the darker side of such an effort; the swellings that weren’t hernias but most likely malignancy, and even an elderly patient with groin pain that transpired to be a fractured neck of femur. Turning away patients was undoubtedly the hardest part of the trip, especially at the end of the week when we physically couldn’t make theatre space for all those in need of our support.
By the end of 4.5 days of operating we had repaired 72 hernias on 65 patients. In addition we had strengthened relationships with staff at the Bishop Caesar Asiili Hospital and had the chance to take our operating skills back to basics as we performed surgeries using the most basic of equipment. Outside of the hospital the team shared a wonderful week in Uganda, cared for by the fantastic staff employed by Care For Uganda.
For me personally I was delighted to be offered the opportunity to join the Hernia International/Care For Uganda trip to Uganda last September. The skills I developed and experience I gained were invaluable and have already provided great benefit to me as I progress through my surgical training.
Mongolia is amazing country bordered by China and Russia with a population of just over 3 million people. The local surgeons where graceful in having the combined Australian/UK team back in 2016 following an amazing mission in 2015 that further enhanced the collegial relationship that is longstanding between Hernia International and Mongolia.
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The team travelled the first week of the mission from the capital of Ulan Bator and made the journey to Dalanzadgad, the capital of the Omnogovi Aimag. Dalanzadgad was where the team examined and operated on over 40 patients with the case mix ranging from paediatric herniotomies through to complex incisional hernia repairs. The team enjoyed the local hospitality in the evenings and were treated to various displays of the stunning local culture and food.
Team Members: Trent Cross (Team leader), Shambhu Yadav, Rob Bohmer, John Copp, Vesselin Petrov, Prafull Bohra, Usha Bohra
The second week at the Second general hospital in Ulan Bator was a return to our familiar surrounds and to old friends. The local surgeons are a well trained and enthusiastic team and this year a wide variety of case mix allowed building on the hernia techniques training of previous missions. This year some 20 large complex cases where undertaken demonstrating component separation, advanced laparoscopic repairs of TEPP and Hiatal hernia repair.
The whole mission was coordinated by Enkhee, who not only organised all logistics support but also went above and beyond to take care of the whole team. Once again thank- you Enkhee.
Hernia International is looking forward to 2017 and the continued relationship with Mongolia.
The 4th hernia mission in Brazil, conducted in partnership between International Hernia ONG and Brazilian Hernia Society, occurred in the state of Mato Grosso between 22 and 28 August. Surgeries were performed in 3 hospitals in the city of Campo Grande beyond the city of Bonito.
There were involved 8 Brazilian surgeons and 5 surgeons from different parts of the world. In total, 78 surgeries were performed. Different from what happened in previous years when a larger number of patients were operated (less complex cases), this year the surgeries were mostly complex cases. During the mission, a regional meeting was also organized where the main advances in the treatment of abdominal wall hernias could be discussed. “The feeling is that we could benefit even more patients” says Artur Seabra, brazilian surgeon “It was a unique, indescribable experience. Make new friends, share experiences, help people. This was one of the best professional weeks of my life.” says Marcio Eduardo, local team leader.
Africa Amini Alama – AAA (www.africaaminialama.com) is a charitable hospital, located on the tableland between Mt. Meru and Mt. Kilimanjaro in Northern Tanzania. The name AAA means “place of trust in the future of Africa” or also “Africa, we believe in you”.
The organization was founded by Christina Wallner und Cornelia Wallner-Frisee just 11 years ago. After Austrian radiologists, like dr. Celedin, made contacts to the organization and donated some devices, we were encouraged to start the cooperation between Hernia International (HI) and AAA. This first “inspective” mission consisted of experienced HI specialists in order to treat as many patients as possible, but also to check the possibility for further cooperation.
Our team consisted of 8 members: surgical consultants Christoph Sträuli and Jurij Gorjanc , surgical resident Lara Maniglio, anesthetist Katharina Wentkowski, gastroenterologist/endoscopist Klemen Mojškerc, anesthetic/theatre nurse Petra Koch, medical device expert Michael Wentkowski, medical device expert assistant Alex Koch.
Good communication between our team and Mag. Dr. Cornelia Wallner-Frisee started almost 1 year ago and the mission was well prepared. All our patients were treated free of charge exclusively on humanitarian basis. The hospital is compared to African standards surprisingly well equipped. They even started to perform basic laparoscopic operations and we also performed 1 laparoscopic appendectomy with very elementary equipment that we intend to improve.
Experienced anaesthesiologist Katharina performed general and spinal anaesthesia to both operating tables while teaching the two local anesthetic nurses. Alan and Fanuel are very experienced in spinal anesthesia already. Training concentrated on safe general anesthesia in children, low flow technique to reduce the use of anesthetic gas and regional plexus techniques. Nurse Petra was of great help in anesthesiology and surgery. In addition she trained the local theatre nurses in hygiene standards. Christoph and me enjoyed performing surgery as well as educating talented Lara and local surgeons Dr. Kombo and Dr. Sebastian. Dr. Kombo is already very independent in various procedures as a young consultant and Dr. Sebastian has indeed a fine feeling for surgery. The majority of patients had hernias and hydrocaeles. Michael and Alex repaired the sterilizer, diathermy machine, CO2 regulator, endoscopy and laparoscopy monitor and many more. In addition they organized a 4-days hands-on workshop to train local engineers in maintenance and repair of medical devices. Excellent endoscopist Klemen brought the endoscopy in the hospital to a higher level, also performing some polypectomies.
Our team did not meet before but as Dr. Wallner-Frisee stated, we worked together as if we have known each other for a long time. We started surgery at 8.30 in the morning, had a lunch break in the hospital restaurant and then proceeded with surgery and recruiting new patients on the ward till sunset.
Good work in the hospital was also possible because we were accommodated very well in the Lodges Nature Homes and Hillside Retreat. There is basic accommodation available on the hospital campus as well, but it was already occupied by other volunteers. Thursday afternoon we visited a Massai boma in the evening. On Saturday (after finishing work) the whole team walked and drove through the nearby Arusha National Park.
Other diagnoses (appendicitis, foreign body)………2 Pts (6%)
In children the inguinal hernias were repaired with Mitchell Banks technique, with or without fascia closure, according to age, respectivelly. Suture repair was used in children with umbilical hernias. In teenagers, Shouldice technique was instructed and local surgeons loved to learn this approved meshless technique. In incisionals, epigastric and umbilical hernias in adults, sublay repairs were performed with LDPE and PP-mesh. Surgery was performed in spinal anaesthesia (20 Pts) and general anaesthesia (12 Pts).
Additional work:
Gastroscopies…………………………………….……..10 Pts
Colonoscopies…………………………………………….3 Pts
OPD…………………………………………..daily up to 30 Pts
Repaired machines and devices:
Autoclave for theatre…………………………………………1
Diathermy machine……………………………………………2
Laundry machine………………………………………………1
Refractometer/Optimetry……………………………………..1
CO2 monitor……………………………………………………..1
Anaesthesia gas monitor……………………………………..1
Endosopic camera color adjustment……………………….1
Perfusomat………………………………………………………1
Electromyography and stimulator device………………….1
Invasive plexus stimulator…………………………………….1
Colorimetric blood analyzer…………………………………..1
General training for local engineers (electricians, car mechanics, carpenters)
Topics: Types and composition of medical devices (diagnostic, surgical, therapeutic, invasive versus non-invasive). Electrical and biohazard safety measures, electrical characteristics, general main power concept and safety checks, typical maintainance tasks, systematic disassembly and assembly devices, testing procedures and strategies to detect typical failures.
Our team:
Christoph Sträuli – consultant surgeon, Switzerland
Jurij Gorjanc – consultant surgeon, Austria (team leader)
Our Senegal adventure begins on January 22nd, 2016 at 19:30 hours. We, the members of the team who are going to carry out the Sédhiou mission, have gathered in the Barajas airport. We almost all know one another. Teresa Butrón, surgeon and president, Pepe Pascual, surgeon and patron of the Foundation, María Fanjul, paediatric surgeon, Carmen Santiago, urologist, Beatriz Revuelta, anaesthetist, and Elisardo Bilbao, surgeon. Faustino accompanies us to help us with our bags and to encourage us. He also takes regular photos to preserve the images of our trip.
Boarding card in hand, and after sealing and checking our bags, we pass controls and get ready to begin a journey we all had been looking forward to. We first fly to Dakar, where Mariama Badji is waiting, and from there to Zinguichor. Then to Sédhiou, 143 km by road in about two and a half hours.
Mariama is a Senegalese reporter who had worked a long time in the Guinea embassy in Madrid. Back home she has been a great help to us, both in personal matters and in the development of the mission. His relationships within the country, the organization of official events, her help in the daily routine of administration, provisions and translations, reservations of places, her company, her advice…
We arrived on time but tired at our destination after a long journey on 23/01/16 in the afternoon. Our first visit was to the Sédhiou Hospital where, for five and a half days, we carried out our mission. After being received by the officials of the centre, we download our cargo from the two vans from Zinguichor. We place each object in its proper place. Teresa does it with the help of the rest of the team. The operation theatre has sufficient place for our sutures, meshes, electric scalpel terminals, etc. We also place the two generators we have brought from Madrid (one of them donated by the Bilbao Red Cross) which, together with the one they have, will allow us to operate three patients at the same time. For that we place another table in the largest room and a partition to separate them from one another The ceiling light is quite satisfactory. The small room is also ready for surgery with full guaranty.
With everything in order and with the collaboration of Dr. Camara and all the rest, we give order to clean up the whole zone as we intent beginning work the next Sunday, 24/01/16.
Tired and with things still pending we decide to retire to our quarters. None of us knew where we were going to spend the night, but Mariana, once again, took care of it. La Palmarie is a hotel reserved for hunters and situated by the river Casamance, with great confort, food and good rooms. None of us had seen such luxury before. We had always have had good lodgings, but the arrangements in Sédhiou were the best we had ever seen. We were grateful for it, as it is important for us to go to work each day in good condition.
Watching before breakfast the sunrise over the river gave us sufficient energy for the whole journey. The light in Africa is different.
January 24, though a Sunday, became a working day for us. We began our work with the hospital in full swing. Three tables were ready. We distributed the work among us together with the local surgeons. This time we had three anaestesists: Beatriz, Ousman Sarr the chief, and Ousman Thiam. We checked the reports and the patients. We operated upon our first three patients and got used to the instruments there. The first day went by easily with a rest at midday with the sandwich Mariana had ready for us. Meat with onion, potatoes and eggs. That will be our menu all those days.
Monday 25 full work. We attend the first interventions of the Dakar gynecologist who has come with Mariama. Dr. Moustapha shows a great ability, knowledge and good criterion. He is anxious to learn, and prys attention to everything he is told. He is like one more in the team.
Special mention deserves the work of our urologist, Doctor Carmen Santiago, who added to her fine character her scientific training in dealing with hidroceles, and worked with the gynecologists in the correction of vesico-vaginal fistulae we found it would be worth thinking of organizing specific missions for this type of pathology that in Senegal, and particularly in poorer zones in the country, is a social problem.
Child surgery is one of the most delicate aspects of these missions. The collaboration in this occasion of Doctor María Fanjul, of great energy and solvency, solved this problem for us. A good companion, she enjoyed more than any the relaxing baths in the swimming pool at the end of each day.
That this mission has been important and should be repeated regularly is established by the interest shown by the official institutions in the Sédhiou department. On January 26 we attended a reception prepared for us by the civil and religious authorities of the region presided by the governor himself. He, together with the mayor of the city and the director of the hospital and of health stressed the importance of such collaboration, not only for the direct action on the largest number of patients, but also for the possibility of informing local doctors and nurses in techniques for hernias, which are very frequent, and often turn out to be mortal, in the area. The president of the Foundation answered with a few words of thanks and her offering international cooperation right from now. The effect of our expedition was enhanced by the interview that the RTS1 (public TV in Senegal), made to one of the members of our team, Elisardo Bilbao, and which was relayed at state level 5 times on successive days.
The 27th began as usual. Part of the team visited those operated upon on the previous day and exploring new patients, and the rest began operations. We worked simultaneously on three tables, and this was possible thanks to the coordination by Doctor Beatriz Revuelta, helped by Doctors Saar and Thiam. Her serenity, her permanent smile, and her camera always ready enlivened our work and will help us to keep good memories of it. The anaesthetist is in such situations indispensable in every way. One day we were able to see film seven vultures “analising” samples of pathological anatomy…
One of the most touching acts of our stay took place in the afternoon. After work and showers we were taken to the “Casa de la Cultura” in the city. Together with the governor and the local authorities, we enjoyed local music by a small group. We came to know the instruments, songs, and verses. They even showed us their dances. It was unforgettable. Each of us was given a diploma by the Health and Public Affairs Ministry. The ladies were dressed in their best with full elegance, while us…
Work is intense and occasionally with unforeseen complications. South of Senegal there is a serious problem with vesico-vaginal fistulas. Some women become mothers when they are still girls, and they suffer for life many anatomical hurts, with the consequence for family and society life and exclusion from them. That is why the arrival of a team with gynecologists and urologists encourages such patients to come. Unfortunately we we could only solve some cases as others would need a greater specialization. It would be interesting to organize special missions for such problem exclusively.
What with one thing and another part of our team returned to the hotel on the 28th after 23.30 hours. We were worried about the impossibility of communication. We called the hospital director who came from his home to the center and told us he had left the operation theatre late and would be arriving shortly. Senegal is a safe country, but there are accidents, chiefly on the road.
January 29th was in theory our last working day there. We had to finish early as our translator, Mr. Sankoun Gassama, had invited us to his home in the Boraya island, where we enjoyed a crab dinner prepared by his family. The crossing of the Casamance River was done on a boat full of people (more than sixty crowded together) with their goods, hens, cattle etc. They risk their lives desperately seeking a hypothetical paradise, and this is very sad. We were very well received and we visited the village chief who expressed us his thanks. We sat down in a semicircle to share in their prayers. Back home and surrounded by children we took again our boat in darkness thanks to the expert pilot who took us to the landing place where we were not seeing anything.
The last day of our stay we saw again all the patients we had operated upon and we gave their leave to those whose wounds had healed. We operated on one more patient, and Dr. Camara on another one. All together 74 patients (13 of them children) with 89 procedures in six days. The predominant pathology was inguinal hernia, followed by epigastric hernia, a good number of hidroceles, most of them giant ones, and vesico-vaginal fistules, some anus wounds, skin tumours, etc. We were happy we were a multi-discipline team and could share experiences with learning on both sides, which made our mission a very successful one.
But all comes to an end, and we have to look forward to new missions. We have found an extraordinary human team, ready to work and eager to learn. Farewells are always mixed feelings, chiefly when one has shared so much and so intensely.
We had our last meeting in the director’s office with all the hospital team and the local Health Chief where we examined our work and looked forward to future missions taking into account the present needs, particularly the treatment of fistulae.
Then the family photo and the trip by car to Zinguichor in a hurry as the drivers had to go back before the road would be closed for curfew as that zone at that moment was occupied by independent rebels who, though controlled at that moment, they still could threaten our way. Our trip of about two hours was uneventful. Mariama had reserved for us the Aubert Hotel where we enjoyed full comfort and commented on all our experiences.
On the 31st at 7.30 am we were at the airport to fly to Dakar at 9, arriving an hour late. After leaving all our luggage in the house of Mariama’s brother and resting for a time, we went to the harbour to take a ferry fo the Goree Island, from where slaves started for America for centuries.
The bilingual guide we engaged took us round the island and to a restaurant where we had our meal. In the afternoon the most interesting thing was our visit to the slaves house. It was a painful experience. The way the overfed them so that they would weigh more than 60 kg, the punishments to those who protested with flogging and even death, the abuse of women, chiefly of virgins, the contrast with the quarters of the bosses on top of the jail itself overwhelmed us. Whatever you read about this will never approach the reality of the awful vision.
Buck to our boat we were taken to a painter’s workshop where they showed us how to draw a picture with only resin and sand with spectacular results.
We disembarked and went to a market near the harbour where we bargained, bought, got tired and finished up our adventure.
After collecting our luggage from Badji’s house we went to the airport to come back to Madrid with the satisfaction of having carried out our mission and the sorrow to have to leave back such marvelous persons, with the intention to come back as soon as we have another occasion.
It was deep night when we arrived in Addis Ababa. Almost 2 hours in the passport control and we found ourselves in the warm dark night. Of course there was no hotel shuttle waiting and as a must in Africa, the hotel was also overbooked. So whoever follows us to Ethiopia- be aware that Addis has the most expensive and most certainly most unreliable hotel service I have seen in Africa.
But Fish, a surgeon in Sodo Otona hospital and our host for two weeks in Ethiopia, managed to find us the next morning somewhere in Addis and without further delay off we drove towards Sodo.
Wolaita, (the region with Sodo as the centre), is (according to wiki): Wolayta is one of the 13 Zonal Administrations of the Southern Region In Ethiopia, Located 300 kilometers south of Addis Ababa.
The vegetation and very comfortable climate of the large part of the region are conditioned by an overall elevation of between 1,500 and 1,800 meters above the sea level. There are, however, five mountains higher than 2,000 meters, with Mount Damota – at 3,000 meters – at the centre.
Through mildly undulating hills, one can travel through the whole area without difficulty, there are no Large forests except in the Soddo Zuriya, and Omo river basin, which is well below 1500 meters and a malaria zone.
The climate is stable, with temperature variation between 24 and 30 °C during the day and 16 to 20 °C at night, all year round. The dry, temperate heat makes the climate simply “delicious”.
The year is divided into two seasons: the wet season (balguwa) from June to October, and the dry season (boniya) from October to June, broken in February by a short period of so-called “little rains” (baddessa). The average rainfall for the entire region is 1350 millimeters per year.
We visited the region in January, so climate was quite cool and dry, one could say that nights were even chilly. And the mosquitoes were not that aggressive, we took our malaria medication very obediently though.
Sodo Otona hospital is part of Wolaita Sodo University that has a Medial faculty. The hospital, built in 1975 by Christian missionaries, has not seen any reconstruction or maintenance during past decades and is in quite worn-out state. Two operating theatres facing the main entrance of the hospital are spacy and could accommodate also third table if needed would be, we didn´t have that need though during our 2 week mission.
It was a scouting mission to Sodo, there hadn´t been a mission to the Otona hospital before, and therefore we didn´t know what to expect, neither knew the local staff what to fear. 7 operating days and 55 operations was our limit this time, hernias, inguinal, scrotal, umbilical, epigastric, mostly done under local, mesh repair using mosquito mesh. We prepared our meshes at home, sterilized them and took along, left some 80 pieces in the hospital after completing the work, together with our sterile gloves and sutures. As usual in Africa, patients have to buy everything beforehand for the operation – gloves, sutures and other materials, drugs and even saline. So, whenever we needed another infusion-bag a prescription was written and some relative ran off to hospital pharmacy. God knows if our donations will also end up there or not. Surgical instruments were divided into major and minor sets, both more or less usable, only scissors being from the not-cutting type. I hope our advice to sharpen them will be taken seriously, we did find such a device in Sodo Christian Hospital.
Postop care is non-existent, at least for our European standards. No possibilities to monitor or ventilate the patients, so actually complex abdominal wall reconstructions had to be turned down. Most of our cases left next morning though, after being watched overnight by their relatives as it is usual also in other parts of Africa.
There is a CT scan in the hospital, but still packed somewhere in a storeroom and waiting for something now almost for a year, but USG an X-ray were there and functioning.
And two functioning ventilators in OR, one coagulator with one reusable cord, so if possible take a cord or two along.
There are 3 surgeons, Fish being one of them, working in the public hospitals in Wolaita, a region of some 3 MM inhabitants. On our first operating day we had the privilege of having them all in our operating theatre, but later they disappeared. No luck of having them operated and us teach, we did offer that though. 2 surgical residents were around, we had some luck in coaching them through basics of hygiene and sterility but surgical residency is a new thing for Otona and I hope they will get some proper training later. Scrub nurses on contrary where most efficient and well trained, but needed constant reminding of need of their presence in the OR and using daylight efficiently.
Actually, the only one being always punctual was our driver, waiting every morning exactly at 8am in the hotel. Anyway, we got the work done and waiting after OR or anaesthesia people is familiar for us also in Europe.
We were lucky to have anaesthetist with us, so spinal or general for 3 kids (all round 1 yoa) was no problem. Ketamine and halothane were the only drugs available, but this is typical for Africa. We managed well though. Local, lidocaine at least, was available and we used it generously, taught also locals to do local anaesthesia.
Although in Sodo there is another hospital, the private Sodo Christian Hospital, collaboration between these two institutions has been so far almost non-existent, but some warming of relations happened during our stay. We had even a joint dinner together with surgeons from the two hospitals organized by the University management in our hotel, of course when checking out some days later the bill was added to our account. To be honest, we refused that.
There are some possibilities for accommodation in Sodo, we had the best and newest, Abebe Zeleke Hotel, quite fashionable and cosy, worth recommending to others.
So in conclusion:
-Going for a mission to Sodo, Ethiopia is feasible.
-Take everything with you, try to “sneak” through the customs with your i/v cannulas (you´ll need a lot), sutures, gloves and meshes. Don´t believe any promises of help, you are alone facing the officials.
-Prepare you mission well ahead, convince Sodo hospital to start advertising early for the campaign.
-Wolaita is beautiful, but try to visit also Arba Minch, we stayed at Paradise Lodge and loved every minute of it. Avoid Addis, it is expensive and definitely not the prettiest of African city, but visiting Lucy in National Museum is worth the effort.
Trainee Report by Michael Wong and Benjaporn Nuntasunti
This would be my first trip with Hernia International to Thailand in November this year. It was an absolutely pleasure to be involved in such a meaningful mission.Thailand, also known as the ‘Land of Smile’, is a beautiful country; home to some of the world’s most beautiful tropical islands and famous for its glittering Buddha temple, fascinating culture and amazing food.
The two-week mission, led by Prof. Chinswangwatanakul, was very well organized. During the first week of the mission, there were few surgical conferences held at Bangkok. These were held annually by the Thai Hernia Society and it was well attended by the surgical communities locally.
At the end of week one, residents and clinical fellows had successfully organized a Hernia Workshop at Siriraj Hospital. We had three operating theatres and repaired twelve open inguinal hernias. They were performed under different anesthetic approaches (local, regional, and general anesthesia). The department was well supported by anesthetists and theatre staffs. Since all of those patients were public, they were selected from the general pool of waiting list.
From second week onwards, the team was then joined by volunteer surgeons from United States (Dr Scott Leckman), Czech Republic (Dr Petr Bystricky and Dr Stepan Matoska), France (Dr Denis Blazquez) , and Poland (anaesthetist, Dr Paulina Mysliwy) , led by Prof. Andrew Kingsnorth and Dr Scott Leckman, continued their mission at Chiang Rai and Khanchanaburi province. We went to four rural district hospitals. We were able to perform about 20 cases in each by thed open Lichtenstein’ technique (LA, RA, GA) and laparoscopic hernioplasty [Totally extraperitoneal (TEP), Transabdominal preperitoneal (TAPP), Intraperitoneal onlay mesh (IPOM) repair] with mesh. All the surgical equipment was kindly sponsored by pharmaceutical companies.
We experienced different operating theatre settings, exchanged knowledge and learning experiences on surgical techniques from each other, and enjoyed local food and sight-seeing. We were very well taking care of by the local hospital staffs. It was indeed a fun and friendly trip.
I would like to take this opportunity to thank Prof. Chinswangwatanakul and his colleagues for facilitating logistic arrangements locally. I am looking forward to joining similar mission again in Thailand.
Michael Wong, Surgical Registrar, Blackpool Victoria hospital, UK
