This is the third mission by Hernia International to Brazil. Recent economical downturn in one of the world’s largest economy has led to reduced funding in an already challenged healthcare system. The distribution and quality of health care provision is known to be patchy, particularly in rural areas; whilst funding varies vastly amongst different states and municipalities. Elective surgeries, such as inguinal hernia repair, have an extremely long waiting list in the public sector due to the lack of funding.
The mission visited four hospitals in the state of Rio Grande do Sul, the southernmost region of Brazil that borders Argentina and Uruguay, in three phases. 103 hernia repairs in 80 patients were conducted between 30 August to 9 Sept 2015. The service was delivered in collaboration with Brazilian and international surgeons. Our Brazilian team consisted of: Artur Pacheco Seabra (mission leader), Alberto Meyer, Miguel Nácul, Cristiano Mourão, Marcos Tannhauser (anaesthetist) and Mauricio Seabra. The international team: Todd Heniford (USA), Martin Kurzer (UK), Hugh McGregor (Australia), Keith Towsey (Australia), Bentos Domingos Vieira (Italy) and Henrietta Poon (UK). We mustered at Porto Alegre, the capital of Rio Grande do Sul, before heading out to our first destination.
Phase 1: Sananduva
Sananduva is a small agricultural municipality with an estimated population of 16000 inhabitants, with an economy primarily driven by soya bean, corn, wheat and meat production. It is approximately 230 miles and 5 hours drive through narrow windy roads from Porto Alegre. Hospital Beneficente Sao Joao (a state funded hospital) is the only hospital in Sananduva, the nearest alternative health facilities are located in Passo Fundo which is 60 miles away.
Anaesthetic support, patient consent and selection was facilitated locally by the only general surgeon and anaesthetist in Sananduva: Drs Márcio L. de Abreu e da Dra and Etaine Roxo. We had three operating theatres with wonderful theatre staff, who worked extremely hard to understand our mispronunciation of surgical instruments in Portuguese and made the quick turnover of patients possible.
Over the two days we treated 30 patients; we repaired 35 hernias (26 inguinal, 1 femoral, 5 umbilical, 3 epigastric/ventral) and performed 1 appendicetomy. Sanadunva had laparoscopic facilities and we were able to perform two TEPs. The patients were kept in contact via telephone with the local team for any problems that might arise.
We were hosted wonderfully throughout our time in Sananduva, and stayed at the Sao Jose Palace Hotel for 2 nights. The highlights were the gift hampers of the local produce and a fantastic evening of delicious churrasco and gaucho music with the Grupo Tradicionalista Os Aporreados.
We returned to Porto Alegre for the next phase of the mission, which began with the International Hernia Symposium held at Hospital Moinhos de Ventos. It was an educational day covering variety of topics in hernia surgery by excellent speakers. Surgeries were conducted in two hospitals: Hospital Moinhos de Ventos (private hospital) and Hospital Porto Alegre AFM (funded by association of the municipal employees for its members). The cost of theatre facilities and inpatient stay were kindly donated by the hospital, patients were selected from waiting list in the public healthcare system and otherwise could not afford the surgery privately.
Over the two days, we treated 18 patients and performed 27 hernia repairs (17 inguinal, 2 femoral, 5 umbilical, 3 epigastric/ventral). We were able to perform 6 laparoscopic inguinal hernia repairs (5 TAP, 1 TEP).
We stayed at Hotel Ibis Porto Alegre Moinhos de Vento and the après surgery program was excellent. We were hosted by Prof Cavazzola at his place for delicious homemade churrasco and had the opportunity to try the local German and Italian cuisines.
Phase 3: Lagoa Vermelha
Lagoa Vermelha is a municipality with a population of 28000 inhabitants with an agricultural and furniture production industry, located 750m above sea level. It is approximately 160 miles and 4 hours drive from Porto Alegre. Hospital Sao Paulo (a charity hospital funded by Fundação Araucária) is the only hospital at Lagoa Vermelha, with the nearest alternative healthcare facilities at Passo Fundo 60 miles away.
Over two days, we operated on 34 patients (25 male, 9 female) including 3 children and 1 pregnant woman. 41 hernias were repaired (28 inguinal, 5 umbilical, 6 epigastic, 2 incisional), of which 8 were laparoscopic repairs. Some of the patients had been waiting for surgery for some time, one as long as eight years. The theatre staff and anaesthetic team worked extremely hard to allow the early morning start and quick turnover of patients.
During our time at Lagoa Vermelha we stayed at Lagoa Parque Hotel, and were treated to a sumptuous churrasco at the town hall. Representatives from the local government also visited the hospital during the mission.
We concluded the mission on the 9 September when we left Lagoa Vermelha for Porto Alegre and said goodbyes to the new friends made across the globe.
Acknowledgments
The mission is grateful to Sociedade Brasileira de Hernia e Parede abdominal (SBH) for logistical sponsorship; B Braun, Covidien, J&J and Bard for the donation of the surgical materials.
A new cooperation campaign took place last August in the city of Pucallpa (Perú). Pucallpa is situated by the Ucayali river in the region of the same name. It is a city of constant population growth, which actually has 250.000 inhabitants. Its main economic activity is fishing, agriculture and timber. Since 1994 the Nacional Pucallpa Police manages and promotes (through its Health Department “Sanidad de la PNP” and Dr. David Tarazona, surgeon and chief of that body) a surgical campaign for persons without economic means and with difficulties in acceding Public Health. This risk population, chiefly made up by working age men, is a serious problem for society and family, since such hernia patients cannot carry out in a normal way any work or family activity given the problems this entails at a financial and social level. Since 1994 the yearly number of patients operated upon in that campaign has been between 40 and 60; still this year, with the help of Dr. Ameth Álvarez (general surgeon and captain of the PNP) the ambitious project was proposed of operating about 200 patients during the August 2015 campaign, given the great problem that hernia pathology was in Pucallpa society. In order to achieve that objective a perfect coordination was achieved between Dr. Álvarez, Dr. Tarazona, Dr. Juan Jaime Herrera (Head of Surgery in the Police Hospital in Lima) and the “Hernia International ONG” with the collaboration of “Cirujanos en Acción”. Thanks to the excellent disposition of all these and to the collaboration of professional doctors /anaesthesists and surgeons) of both ONGs it has been possible to carry out and bring to a successful end that hernioplastics campaign which ended on last August 12th after having operated upon more than 170 patients (many of them through more than one surgical intervention, which raises the figure to more than 200), Since 1994 when this selfless and ambitious surgical campaign began, more than 1300 patients without economic means have been operated upon for hernia pathologies.
MATERIAL AND METHODS Objective: Operating upon 170 patients without economic resources and with a hernia pathology in the Pucallpa region, thus achieving the recommended level (less than 2%) and making use of the surgical techniques used in higher economic milieus (hernioplatics with placement of prothesis) so as to bring down the number of repeated cases in such a pathology. Place: The surgical campaign has always taken place in the SANATORIO DE LA POLICÍA NACIONAL in Pucallpa where we had at our disposal the following facilities: – Surgical room with two beds – Room for minor operations with two beds – Room for sterilization – Room for examination of patients – Several rooms for recovery with beds where 16 patients could be accommodated at a time who usually could leave the same day of the operation if there were no further complications.
Staff: The health staff has been the FUNDAMENTAL element in this campaign so that it would not have been possible without it. The commitment of nurses and helpers has been excellent. The people who have worked in the campaign have been the following: – Nurses from the Police Health Centre – Clarks, helpers, cleaners and and the rest of persons in the said centre. – Surgeons: Dr. Tarazona, Dr. Álvarez, Dr. Jaime Herrera, Dr. Sambu, Dr. Verdes, Dr. Abellán. – Anaesthetists: Dra. Renata, Dr. Paul Wilkins – Students from the “Universidad de Medicina” in Pucallpa.
Anaesthetic and surgical material: The necessary material for the surgical campaign has been chiefly provided in a selfless way by the anaesthetists and surgeons who have taken part in the campaign as it is given in detail lower down. The Police Health Centre, thanks to some local institutions, has also contributed with some material (serum, nylon and polyester sutures, sterile gloves, surgical gowns, surgical llinen…) Material provided by medical staff: Dr. Shambu: Mosquito net prosthesis supplied by Hernia International for surgical operations. The given material has been sufficient for all the operations. Dr. Abellán/Dr. Verdes: Endotraqueal tubes (6), epidural syringes (3), spinal needles (8), subcutaneal, intramuscular and “de carga”. Local anaesthetic (mepivacaina) (25 un). Gentamicina (10 un). Polipropileno meshes (30), boxes with gloves of various sizes (4), box with caps (100), 2 boxes of masks (100), 2 boxes of exploration gloves (200). Sutures: polipropileno 2/0 (2 boxes: 72 un), polipropileno 3/0 (2 boxes: 72 un),silk 3/0 (100 un), Vicryl 2/0 (2 boxes: 72 un), lazo Maxon 0 (21 un), polisorb 3/0 (8 un), polisorb 2/0 (7 un). Silk ligature (50 un). Surgical washing gel, hidrogel, clorhexidina, tegaderm gel (9 un), Acuacell silver (8 un), Surgicel hemostatic (4 un), Espongostan (1 un.), Mepitel (2 un), Steri-trip (25 un), Iruxol. Furacin, Silvederma… Drainages: 7 drainages of the aspirating type with their pouch, Foley catheter (8 un), endotraqueal catheter (15 un), Penrose type capillarity catheters (5). Electric scalpel (8 un). Long scalpel terminals (4 un), cold scalpel blades (100). Sterile gauzes and compresses More than 200 un. Surgical staples and staple removers (10 un) Elastic bandage, crepés and other material Dra. Renata/Dr. Paul Wilkins: 2 ambús (adult and child), 4 philters, 2 endotraqueal guides, 15 endotraqueal tubes, 8 Guedel cannulas, 15 adult and pediatric larynx masks (3 un), 75 vein cannulas with peripheral access. – 2 pediatric circuits for the respirator, endotraqueal pediatric tubes (4 un), lubricating for tube, anesthetic pediatric mask Oxygen therapy systems. Intubation wings (laryngoscopies). (3 un.) Metamizol ampoules (100 un) Dexametasona 4 mg ampoules (100 un) Buscapina (100 ampoules) Ropivacaina for local anaesthetics (150 ampoules) Cefazolina 1 gram (100 un) Epidural syringes (100 units), epidura charging needles, subcutaneous and intramuscular needles and diverse sizes syringes (more than 200 units). Sterile gloves (100 un) Surgical dresses (10 trousers and 10 shirts) Sundry material (gauzes, antiseptic, sterile pads—) NOTE: 1. All the remaining material from the medical team remained in the health centre at the disposal of the health staff in Pucallpa. 2. It was necessary to buy some anaesthetic material locally (Spinal needles and anaesthetic medicines for sedation) whose cost in its entirety was supplied by the team of anaesthetists.
Criteria for refusal of patients: Those patients with VIH and those with multiple basic pathology (advanced cardiopathy, breathing problems, alteration in coagulation…). ULTS
RESULTS:
1. Teaching
Part of the medical team (Dr. Israel Abellán / Dr. Jorge Verdes) gave a talk with the title “Surgical handling of the complex eventration” in the Casa de la Cultura of Pucalpa addressed to medical students of the region and to the whole medical staff interested in the topic. At the end of the session there was an interesting time of questions and debate. 5
Daily during the surgical activity there were activities for the formation of medical students of all courses. Given the high number of patients and the need to work simultaneously on 4 surgical tables the usual team for each intervention was formed by a surgeon and a medical student. The satisfaction on the part of the students was total as this was a very practical and very unusual practice during formation.
2. Clinical results
During the health campaign 170 patients of hernia pathology were operated upon, some of which needed several interventions for bilateral hernias. The type of hernia/eventration treated was not similar to the one within us, as they were usually hernias of a great size of many years standing, which required a more complex surgical prodcedure. The type of intervention carried out was similar to the usual one with us, placing the polipropileno prosthesis or the mosquito net mesh according to availability. The interventions were carried out in equal number by all the members of the medical team, with 1 anaesthetist and 2 surgeons. All patients beyond 60 years with some complication or with large size hernias were given ATB prophylactic treatment. Number of patients treated: 170 Number of procedures: 220 Number of adults: 162 Number of children treated: 8 Number of daily procedures: 14-17 procedures. BY PATHOLOGIES Inguinal region hernia: 142 Umbilical hernia: 30 Epigastrical hernia: 20 Middle type eventration: 20 Spiegel hernia: 2 Lipomae/soft parts hurts: 3 Other: 3 Total: 220 procedures Type of anaesthesis used: SPINAL 105 PATIENTS / LOCAL AND SEDATION 60 PATIENTS / GENERAL: 5 patients. COMPLICATIONS Heavy: there was no acute complication during the first 24 hours after the operation. Recurring: Up till today that we are in touch with Dr. Ameth to follow the evolution of our patients we have had the following complications: Surgical seroma wound: 2 patients Surgical hematoma wound: 1 patient. He has not needed surgery and improves with conservative treatement. Surgical wound infection: 4 patients.
CONCLUSIONS
The conclusions after finishing our Hernia International campaign 2015 cannot be more positive. When we arrived at Pucallpa we found that Dr. Ameth Álvarez had done great work in the study and selection of patients (all of them had gone through pre-operation preparation with serology and hemogram and pathological exploration, and had been uniformly distributed by days according to the complexity of each procedure). The cooperation on the part of the healthstaff at Pucallpa was excellent, from workers, nurses, cleaners to medical students… All of them were at our disposal and worked intensely in order to achieve the daily objectives. At a personal level, dealing with the patients and the people of Pucallpa has been an intense and unforgettable experience, and this is doubtless what has given its real justification to the whole work on those days. On the last day of our work (August 12th) we had a thrilling closing function where ALL the patients and relatives how had taken part in the surgical campaign were invited, together with the Pucallpa health staff and the medical team. Thanks to Dr. Ameth, to the health staff and to the patients and the people of Pucallpa this health campaign has been a success with respect with the intended objectives. There is no doubt that the organization, the selfless work and the sharing of such staff will be assured in future campaigns.
ISRAEL ABELLAN
Addendum (Paul Wilkins)
Educational Activities Besides on the go teaching of the medical students, Dr Israel Abellàn and Dr Jorge Verdes also gave a talk at La Casa de Cultura de Pucallpa on the subject of the ‘Surgical Management of Large and Complex Incisional Hernias’. This was well received by the medical students and other interested health personnel present.
Social and Cultural Aspects The working day began at 8 a.m and usually finished about 2.30 p.m. This left time free to explore the local markets and the nearby Lake Yarinacocha, where the opportunity was also taken to visit a village of the indigenous people. We also had one day off and took an excursion by minibus to a nearby waterfall where we enjoyed a pleaseant swim with the locals. Our after work activities were advised and often accompanied by Dr Àlvarez and his lovely wife who took great pains to ensure our stay was as enjoyable and interesting as possible. All members of the team got on very well socially and professionally and we hope to meet and perhaps work together again one day.
Conclusions All in all, I can say that this was a successful mission in every way. 220 procedures were successfully completed with minimal complications on 170 patients many of whom showed their gratitude by attending the moving closing ceremony on the last day of the campaign. The medical students whose help we were very grateful for were very appreciative of the teaching and patience shown to them by the surgeons and in particular Drs Verdes and Abellàn. We were moved to receive some small gifts from them to show their gratitude. The preparation of patients, staff and facilities was excellent and the hard work of Dr Àlvarez must be noted again in this regard. If anything could be improved, it would be that there should be direct communication by email beforehand with the person co-ordinating the campaign locally, in this case Dr Àlvarez with regard to case mix and materièl available locally. This, together with communication between surgeons and anaesthetists as to the most suitable type of anaesthetic, would ensure that all the necessary and the minimum of unnecessary supplies could be brought by the team. It was remarkable to me how well and enthusiastically everybody, whether nurses, students, ancillary staff or doctors, worked together towards a common goal. Conditions and demands were different and challenging for all in their individual ways and yet everybody worked harmoniously to achieve a successful mission. The stoicism, patience and gratitude of the patients was salutary and I feel humbled and privileged to have been able to help these people. Finally, I must thank my fellow team members for the sacrifice of their time and resources, their patience and skills, which made all this possible. I could not have wished for better colleagues.
Hernia International mission trip to Lima, Peru June 2015
Team members: Dr Arun Baskara, Dr Laurence Turner, Dr Leo Mitteregger, Dr Paul Edwards, Dr Kathryn Rock.
This is my second trip to Lima Peru for “Hernia International”. The experience from my last trip was spotless and that made me to request Professor Kingsnorth to include me in the mission for June 2015. I am very thankful to him for allowing me to participate in the trip. I wouldn’t mind going again and again on this trip for the humbling experience a Surgeon can ask for is immense. .
I reached Lima on June 14 2015 and was received for a lunch by Dr Jaime Herrra, his wife and his two daughters. During my last visit, I was moved by their hospitality and there was nothing short of their usual love and affection during this visit as well.
We were a team of four surgeons and one medical school graduate. We all were from different countries with different cultural background and to work as a team was phenomenal. Our accommodation was excellent and food was great.
We received warm welcome at the Puente Piedra Hospital by the president and the Chief of Surgery on June 15 2015. Our day started with 20 patients on the to do list. It was an accustomed atmosphere for me and it was nostalgic when I started. The day went by quick and we had immense sense of satisfaction when we accomplished the goal for the day. Evenings, we all had our own agenda and spent time in nice restaurants or long walk or staying at the room.
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We worked as a team and were able to do close to 148 hernia repairs in 10 days time. Some were complex hernia repairs and challenging. The anesthesia and OR staff were very supportive and again their love and affection was commendable. The trainee surgeons were helpful in writing post op notes and orders. The chief of the hospital Dr Miguel was very helpful in achieving our mission. Our mission ended on June 26 2015. It was quite a journey and there is no doubt I will do it forever.
Unlike previous Hernia International missions, our hosts were not interested in volume of operations undertaken, but more in training & teaching. It was therefore agreed that we would teach their young surgeons the standard Lichtenstein inguinal hernia mesh (using mosquito net) repair each morning in the Operating Rooms & run Basic Surgical & Anaesthetic Skills in the afternoons. The latter was made possible by the generous loan of equipment by Mr. Martyn Coomer, Head of Research at the Royal College of Surgeons of England.
We were met at the airport by the hospital administrator, Stephen Kim, who aided us without any problems through customs with surgical instruments, which we donated to the hospital, as well as the teaching equipment, sutures & other aids. The team stayed at three different hotels in the city. One of the biggest problems in Phnom Penh is travelling around the city as the traffic is thick with thousands of scooters & tuk-tuks weaving their way through the cars. The traffic problems stem from little public transport. The Hebron hospital is situated near to the airport but some way from the centre of the city with all its sights & restaurants.
BACKGROUND to CAMBODIA
History: Peoplehave been living in what is now present dayCambodia at least since the 5th century BCE. The ancient kingdom of Funan occupied a wider area & the culture became heavily influenced by Hinduism. This was followed by the Chenla Empire (6th century – 802 ACE) & then the Khymer Empire which had its golden age between the 9th & 13th centuries during which time Angkor Wat was built.
As in many countries there followed the Dark Ages from 1431 – 1863 & was under the suzerainty of Vietnam. It then became a protectorate of France being ruled as part of Indo-China. The monarchy remained in place & they as well as many of the leaders were educated in France. The French ruled until the Japanese occupation during the 2nd world war, during which time thousands of Cambodians died. The French ruled again after the defeat of the Japanese until 1953 when King Norodum Sihanouk declared independence back by the Geneva talks. In 1970 Lon Nol ruled the country & the King fled to France. Lon Nol was replaced by Pol Pot & the Khymer Rouge in 1975 when they entered Phnom Penh. They ruled for 4 horrendous years during which >2 million people were slaughtered or died in captivity from starvation- the “killing fields”. They were overthrown by the Vietnamese who occupied the country until 1993 during which time it was called the Peoples Republic of Kamputhia. Meetings were held between 1991 & 1993 in Paris to agree on an independent Cambodia with the King as a titular head. However, civil unrest continued until 1997 when the present day Cambodia took shape. It covers an area of 180,000 Sq. Kms, has >14,000 villages & a population of 14+ million people of whom 20% are urban. The GDP/Capita is given as $1,000 with a growth rate of 6.5%.
BACKGROUND to HEBRON HOSPITAL
It was founded by Protestant missionaries (<2%of the population is Christian) from Korea & opened in 2007 with 3 medical doctors & 1 dentist. At that time it was purely an outpatient based unit though clinics were also held in the provinces. In 2010 the hospital was extended with in patient wards, operating rooms, heart services, an eye centre, a cancer centre & regular staff training in Korea. Clinics were also held in Laos & Myanmar.
The present facility comprises- 3 well equipped operating rooms, a recovery room, an Intensive Care Unit, 70 inpatient beds (only 40 were being utilized during our visit), an endoscopy suite, a radiology unit, department of pathology, dental & eye clinics, a library, auditorium, board/teaching room. Chapel & nursing college. The medical staff includes 5 general practitioners, 1 ophthalmologist, an internist(Korean), an orthopaedic surgeon(Korean), 2 pathologists(Korean) & 3 part-time clinicians, a surgeon, an anaethetist & a physician (all Korean). There are 11 trainees. The dental unit has 2 dentists & an hygienist. There are 2 pharmacists (Korean) & 12 Korean volunteers. The nursing staff include a Head Nurse (Korean) & 16 nurses. Support services include 7 people in the laboratory, 2 opticians, 2 medical engineers, & 2 physicists. Administration (as seems universal) was well staffed with 13 people.
The hospital would be classified as a Day Hospital in the UK being an elective unit though emergencies are accepted during the day being seen in the clinic or admitted directly to a ward. The Hospital opens at 0500 hours by which time there are usually >200 patients waiting in an outside seated covered area. The clinics commence until 0730 when there is a half hour meditation time followed by another half an hour entitled preaching time. Ward & operating work commences at 0830 until noon when all work ceases for an intersessionary prayer time & lunch. Apart from a skeleton staff on the wards the hospital is closed until 1400. The day ends at 1700 hours by which time >300 outpatients have been seen 94% of whom are Cambodian.
The case load has increased dramatically from 2007 to 2014. In 2007 5,000 patients were seen, 1,000 investigated in the laboratory & 4,000 prescriptions given. 7 years later these figures reached-53,000 patients seen, 28,000 investigated & 40,000 prescriptions written. The surgery covered most specialties comprising 34% orthopaedic, 28% plastic, 16% ophthalmology,21% general, with 1% gynaecology & ENT surgery.
Cambodian fertility rate are 2.5/female; household size 4.7; infant mortality rate 40/1,000 number of doctors 2.3/10,000 & number of nurses 7.9/10,000 population. We were informed the cost of medical services was broken down as health care 31.25% public, 26% private & 12.7% non-medical with transport costs accounting for 6%.
The Hebron Hospital sums up its role as a) providing medical care, b) educating future medical Christian leaders, c) caring for missionaries & d) supporting the local churches. To this end they are extending the hospital by a further 100 beds.
PROGRAMME at HEBRON HOSPITAL
Day 1, Friday 24th April.This was an orientation day. We had a tour of the hospital which is a 60 bedded hospital with 40 beds in use. The foundations were being built for enlargement by an extra 100 beds. We visited the wards, theatres (3 well equipped operating rooms), endoscopy unit, out-patient clinic, auditorium & lecture/ board room. We were introduced to the Senior Anaethetist, Dr. Kim Jae Seon, who spoke good English, the Senior Surgeon, & the Pathologist (one of two consultants in Phnom Penh) who had trained in New Zealand. The staff were a mixture of Cambodian & Korean Doctors. Jacqueline Platt met with the Senior Nurse & theatre nurses.
After a midday service in the entrance hall, we had lunch with the staff, enjoying typical Korean fare (photo 1). We learnt that there was an enforced siesta every day from 1200 to 1400 hours. We then had two lectures, the first on the hospital by Stephen Kim & the second on Cambodia by Dr. Seon. Following this we were informed that the hospital did not perform elective work at the week-ends so we would start work on the Monday. However, they had arranged for the patients on whom we were to operate to come to be examined by us in the wards. With an unexpected free week-end, Ramesh, an avid golfer, discovered Stephen played golf. We thus arranged for Ramesh, Mike, Stephen & myself to play very early on the Saturday & to visit the “Killing Fields” on the Sunday. I managed to visit the exquisite Royal Palace as well on the Sunday afternoon.
Day 2, 27th April.We arrived at the hospital early to discover that nothing really started before 0900 hours. We did another ward round & then briefed the theatre staff about our intended operations, Mr. Payne & Mrs. Platt introducing them to the WHO guidelines on “time out” prior to commencing any operation.
Three operations were performed, all inguinal hernia repairs. One was repaired under local anaesthetic, a large irreducible hernia under GA & the third case started under LA, but found to be a sliding hernia, so was converted to a GA. After lunch, Dr Platt helped in a pain clinic. Mr. Payne, Dr. Ramesh instructed 12 trainees on the basic surgical skills of knot tying & instrument handling. Lectures were delivered on “The Past, Present & Future of Surgery” by Prof. Rosin” & on “The WHO Guidelines” by Mr. Payne. A post-operative ward round was carried out & patients for the following day reviewed.
Day 3, 28th April.
Due to heavy rains during the night we were collected an hour late & our journey to the hospital took a further hour so we did not arrive until 0900. We carried out a post-operative ward round as we found the patients from the previous day were still on the wards (the staff were reluctant to discharge patients) as well as seeing patients for the morning lists & marking the appropriate sides as necessary.
Once again only 3 operations were arranged-2 inguinal hernias & an umbilical hernia all children & all operated on under general anaesthesia. During the morning a young woman was admitted with peritonitis. I discovered they had a unused laparoscopic stack so agreed to laparoscope her after lunch.
Dr. Ramesh & Jacqueline Platt were released to see the Royal Palace. During the afternoon Mr. Payne taught the trainees on further basic surgical skills whilst Dr. Platt & myself operated on the lady with peritonitis. She had a purlent perforated appendicitis so I was able to perform a laparoscopic appendicectomy with extensive peritoneal lavage. Dr. Platt then helped in the pain clinic whilst I joined Mr. Payne teaching. Instrument handling & interrupted suturing was taught & practiced. I gave a lecture on “The different approaches to Inguinal Hernia Repair with videos on Laparoscopic TAPP & TEP repairs”. Prior to departure our usual post-operative ward round was carried out.
Day 4, 29th AprilWe arrived early to find 4 children with hydocoeles, 1 young boy with a phimosis & 2 inguinal hernias were scheduled. Also Dr. Platt had agreed to deal with 8 pain patients for blocks under C arm control. The post-operative patients were seen & the patients for the day’s operating were also seen & the relevant sides marked. The 5 children were all operated on under GA & the 2 adults with inguinal hernias under LA. During the afternoon Dr. Ramesh performed a mastectomy for an advanced breast cancer whilst Dr. Platt dealt with his pain patients & Mr. Payne & myself took the afternoon teaching session which was devoted to all types of suturing followed by lectures from Mr. Payne on “The Management of Haemorrhoids” & a further one on “Anal fissures & Fistulas”. At our post-operative ward round I was delighted to find that the lady who had undergone the laparoscopic appendicectomy for peritonitis had bowel sounds present.
Prior to our departure Stephen had found out that it was my birthday & presented me with a cake & candles & collected all the staff to sing Happy Birthday to me. Unfortunately Drs. Ramesh & Platt had not been informed about this & were drinking coffee in the operating suite talking to the staff.
Day 5, 30th April
Only 2 patients were scheduled for surgery. A young man with an irreducible inguinal hernia & a bilateral inguinal hernia on whom I had agreed(providing he was a suitable candidate) to perform the surgery laparoscopically. However he did not show up for the operation so only one operation was performed after our ward round. We started the teaching session early with lectures on “Soft Tissue Injuries” & “A Clinical Quizz” from Dr. Ramesh & on “Different Types of Anaesthesia” & “Pain Management” from Dr. Platt.
Discussion with the trainees & feed back was carried out by Drs. Ramesh, Platt & myself. The trainees informed us that they had never been taught any surgical skills previously & they thoroughly enjoyed the sessions, asking us to stay on to carry out more. We were gratified to hear that 8 of the 11 first year trainees now wanted to become surgeons.
The day ended with the presentation of a tribute to the team from the staff at Hebron by Stephen Kim. A speech was given by Dr. Seon & a reply on behalf of the team by Professor Rosin.
David Rosin
Report of Anaesthesia and Pain Management performed by Dr Michael Platt in Phnom Pen
April 27 – May 1st 2015
My wife Jacqueline (a seasoned senior nursing sister currently working with Health Education England) and I (a seasoned anaesthetist and Pain Medicine specialist), arrived in Phnom Pen on April 22nd and checked into the Dara Airport Hotel in the centre of the city. The Dara Airport is a modern hotel with large rooms and excellent dining and spa facilities, and superb air conditioning (very necessary in 43 degree Celsius heat!).
After spending a few days familiarising ourselves with the city, meeting up with the surgeons, David Rosin, Ramesh J, John Payne and their wives, we spent Friday at the Hebron Hospital where we were due to work, as part of a Hernia International programme. Here we were introduced to the hospital: a small but very modern hospital with two floors, the operating theatres and wards being on the 1st floor, clinics downstairs on the ground floor. The hospital is funded by a South Korean Christian organisation called ‘Jesus Cambodia’. It was reasonably well supplied and had the latest anaesthetic machines, sterile surgical gloves and most of the equipment needed for straightforward surgery and anaesthesia (including sevoflurane anaesthetic vapour.
I performed general anaesthesia for the more difficult patients, and one elderly gentlemen who was not coping with local anaesthesia.
The age range was 11 months to advanced elderly. All were remarkably fit and posed no anaesthetic problems. All the patients received local regional analgesia, giving excellent post-operative analgesia. All the patients received intravenous cannulae in the pr-operative ward prior to surgery, with Normal Saline solution running as they came to theatre. All the patients were anaesthetised using propofol intravenously, maintained on oxygen and air with sevoflurane via facemask or LMA.
It was on the second day of operating that our hosts discovered that I was also a pain medicine specialist and asked me to see some difficult patients for them. The first patient was actually the wife of one of the surgeons who had recently had a knee replacement operation but was getting much pain in the lateral aspect of the knee at the Fibular/Tibial joint. I injected this with some steroid and local anaesthetic under x-ray guidance. The pain immediately abated and she was able to mobilise much more easily. Of the seven further patients I saw, they included knee pain in soccer player (reassurance and encouraged to exercise); cervical disc prolapse with C8 radiculopathy (x-ray guided nerve root injection plus cervical epidural with steroid and local anaesthetic), Two patients presented with lumbar L5/S1 radiculopathy (x-ray guided nerve root injection and epidural); An elderly lady presented with symptoms and signs of lumbar spinal stenosis (but no MRI available, so she was treated with epidural, requiring admission for weak legs, but fully recovered by next morning with no pain. Two patients had hand issues with evidence of some arthritis, relived by injection and prescribed exercises. It seems there is no formal physiotherapy available in Phnom Pen currently.
My wife worked with both myself and the nurses, encouraging them and demonstrating some modern nursing techniques and help with some of the more difficult patients to nurse. We also introduced to them the WHO surgical checklist, encouraging them to use it routinely and to increase their safety processes. I was very impressed by the standard of care, the standard of anaesthetic assistants, many of whom had been trained overseas including in Australia. It was a very fulfilling week working with a keen workforce and teaching some very keen young doctors who are all anxious to help patients in the best way they can. In addition to the work, we spent every afternoon teaching, involving both lecture/tutorials and practical teaching. I attach several photographs illustrating the anaesthetic equipment and monitoring, clearly to a surprisingly high and modern standard.
I would highly recommend the experience, and I would be happy to return.
All praise to the organisers of this trip that everything went brilliantly smooth. Being on my first mission with Hernia International, I landed in Bewal with great apprehension. Hosts (Atiqur Rehman & family) were great in looking after us, from accommodating us in their luxury mansion, providing us with delicious feasts to giving us pick-n-drop everyday. Bewal is a small but rich town with great traditions, people like to wear silwar kameez. Most people have a relative working in Uk. They like to sit and talk about anything to everything. I loved potohari accent, although Leo seemed to miss on that.
Bewal International Hospital is built to a great standard. The staff worked efficiently and tirelessly helping with the mission. Our daily routine included home cooked breakfast, followed by quick ride to hospital. Patients were lined up to be seen and categorised. We performed a range of procedures, in 2 to 82 year old patients, under GA/spinal/local anaesthetic. This included a laparotomy for incisional hernia. Post graduate trainees from Rawalpindi attended daily to assist and learn. Towards the end of everyday, patients were reviewed, and this is when I found the priceless satisfaction, gratitude and thankfulness on the faces of patients & their relatives. Every day ended with tasty multi-dish dinner.
A ceremony was held on the last day of the week, where community leaders also joined in, celebrating the end of a very successful Hernia mission, hoping to have more every year!
Asad Parvaiz
Some of my extremely positive impressions of “Mission Hernia 2015 in Pakistan“:
Atiq himself picked me up from the airport and I was offered luxurious accomodation in his uncle`s house in Bewal. The following days we didn`t have to walk the distance to the hospital but were taken there by car. In hospital we did our morning ward round and checked the patients, and operated all day. In totall we operated on 64 patients doing nearly 90 interventions because there were sometimes both sides ( inguinal) to operate. My medical presents were highly welcome (sutures, swabs, local anaesthesia, tablets against pain,…) and therefore at the evening ward round we were able to give some “pain killers” to the operated patients.
The food we got was local (spicy) and excellent and I enjoyed it a lot. The following “sightseeing week” was also great as I had a very competent guide (rented car with driver) who showed me interesting and marvellous places, among others the UNESCO world heritage “Taxila”. We also made a trip twice to the Margalla hills as well as to the highest village in the region ( 2300m) called “Murree”. On our last day we visited “Centaurus”, the biggest shopping center in Islamabad. As i have allready mentioned this was a very impressive stay for me full of experience. The Pakistani people were very friendly and pleased to meet a European and they offered their help whereever they could.
Hernia International visits Trinidad in the West Indies
Whilst at an Intercollegiate Specialty Board Examination in the UK I was asked about groin hernia repairs using mosquito net mesh. The thoughtful surgeon (Prof Vijay Naraynsingh) later asked me to demonstrate its ‘value’ in the West Indies. I was honored and found the invitation hard to turn down! I gathered another volunteer (not too difficult!) but eventually traveled to this friendly region as a single surgeon team.
Trinidad, which lies outside of the Caribbean hurricane belt, is known for its Carnival and is the birthplace of steelpan, limbo, the music styles of calypso and rum (which I was engaged to try on numerous occasions). It is recognized as a high-income economy in the Americas by virtue of its petrochemicals industry. Indeed, I had not realized that many countries around the globe, irrespective of their ‘GDP spending on health’ still had difficulty in persuading patients that groin hernia repairs under local anaesthesia are safe and cost-effective. This was later to prove to be the ‘goal’ of this mission.
After some obligatory paperwork (registration with the Medical Board) I travelled with my wife to be welcomed with open arms but set to work within 36 hours of arrival. At 7am daily I was transported to three different hospitals (Port of Spain General, Mount Hope and San Fernando) on the island, introduced to the patients and asked to choose the most appropriate cases. All the theatres were modern and had temporary AV connections installed so that I could teach the Islands’ audience of medical students, residents and interested surgeons (state employed and in private practice). There was still concern with regards to using EO sterilised mosquito mesh and, as was the case in the first mission of Operation Hernia (2005), I used commercially available mesh. I took my time and explained the steps required of a safe and comfortable repair under a local. None of the hernias were as large as those we see when neglect/delay has taken its toll.
Every night my wife and I were whisked off to various venues to give dinner lectures to an audience of surgical residents and surgeons numbering 40 or so. I spoke about the ethos of Hernia International, Preventing parastomal herniation, Emergency repairs of groin hernias and other topics (7 lectures in total). On the last night I was quizzed by the junior staff on various difficult colorectal problems and realized they too had as many unanswered questions as we do here. After four long days I relaxed on the nearby island of Tobago with my patient wife where we hiked through tropical rain forests.
The Trinidadian medical fraternity proved to be exceptionally welcoming and inquisitive and their patients most grateful (so I have since heard). I hope that I have managed to persuade all concerned as to the value of groin hernia repair under local anaesthesia.
Brian M Stephenson
Inguinal Hernia Workshops
23rd – 25th February 2015
This workshop was initiated by Professor Vijay Naraynsingh who met Mr Stephenson at the Royal College of Surgeons examination in September 2014. It was held over three (3) days which comprised of interactive live surgery sessions and a dinner lecture per day.
Mr Brian Stephenson is a Consultant Colorectal Surgeon with special interest in inguinal hernia repair. He is a founding member of the British Hernia Society and has done a considerable amount of work through this affiliation. This includes travel to developing countries where he teaches and proctors the science and art of inguinal hernia repair. The majority of these are done under local anaesthesia.
General Hospital Port of Spain
The University of the West Indies in collaboration with the North West Regional Health Authority (NWRHA) conducted a Workshop in Open Hernia Repair under Local Anaesthesia on February 23. 2015.
Dr Andy Bhagwandass, Chairman of the NWRHA Board, opened the workshop and applauded the efforts of the local organizing team. Dr Bhagwandass affirmed the NWHRA’s support for these educational initiatives. He noted that Trinidad and Tobago was taking a ;ead role to advance surgical practice across the Caribbean.
Professor Vijay Naraynsingh, Head of Surgery at the University, reiterated his intention to strengthen the existing partnership with the NWRHA to ultimately benefit the people of Trinidad and Tobago. The University has undertaken to host two surgical workshops each year at the General Hospital Port of Spain.
Local workshop director, Shamir Cawich, was pleased at the success of the workshop reporting that over fifty (50) surgeons and residents from across the Caribbean participated, including representatives from Grenada and Bahamas.
Mr Brian Stephenson did repair of inguinal hernia under local anaesthesia. Patients were able to return home the same afternoon. The dinner lecture, on hernia repair, was done by Dr Brain Stephenson. It was held at the Tanmak Thai restaurant it was well attended by about fifty (50) doctors.
Eric Williams Medical Sciences Complex: Open Herniorrhaphy Workshop.
This was of great value for us as limited operating time with high trauma and oncological volume has led to a substantial waiting list for inguinal hernias. This workshop, as part of a wider workshop with San Fernando General and Port of Spain General, allowed surgeons in training the opportunity to learn about inguinal hernia repair under local anaesthesia; as a same day/outpatient procedure.
This workshop, coordinated by Dr Ravi Maharaj, Lecturer in Surgery, took place on Tuesday 24th February and commenced with opening remarks from Dr Andy Bhagwandass, Medical Chief of Staff, Mr Kumar Boodram, Chief Executive Officer of the North Central Regional Health Authority and Prof Vijay Naraynsingh, Head of the Department of Clinical Surgical Sciences. Three hernia repairs were performed by UK Visiting Surgeon. All hernias were safely performed under local anaesthesia, the first two (2) with onlay mesh and the third with the plug and patch technique. Case presentations and literature review by the residents during the turn over time as well as thought provoking moderation by fellow consultants made this event a success.
The workshop culminated with a Dinner Lecture at the Radisson’s Hotel, Port of Spain under the sponsorship of the Ministry of Health and patronized by the Honourable Minister Dr Fuad Khan. The feature speaker Mr Stephenson edified the audience on parastomal hernias. Minister Khan brought greeting from the Ministry of Health and encouraged our surgeons to perform these hernias under local anaesthesia.
General Hospital, San Fernando
The third day was hosted by the General Hospital, San Fernando. The live surgeries were well attended by the residents in training and also visiting residents from the Bahamas. The residents had the opportunity to clarify any doubts regarding the relevant anatomy and steps of the procedure. A mesh plug was demonstrated and most significantly the procedures were done under local anaesthesia. The patients did well and were allowed home the same day in minimal pain.
The workshop culminated in a dinner lecture at the Priveé Restaurant. This was well attended by residents and Senior Surgeons from the four main hospitals in Trinidad. The residents presented three challenging cases of colorectal cancer. Each case generated important discussions and allowed Mr. Stephenson to impart more of his knowledge and experience on the subject. The evening was chaired by Mr Patrick Harnarayan FRCS. Professor Naraynsingh presented the University tie and pin to Mr Stephenson as a token of appreciation for his work.
Hernia International Mission, Santo Domingo, Ecuador; January 2015
Team from UK: Mr John Chester (Consultant Surgeon), Mr Nicholas Markham (Consultant Surgeon), Mr Paul Houghton (Consultant Surgeon), Dr Jasmin Lucas (Consultant Anaesthetist), Miss Hina Bhutta (ST4 General Surgery).
Our journey began on the road from Quito to the Province of Santo Domingo de las Tsachilas- a 3 hour drive along the ‘Avenue of Volcanoes’ and a tortuous descent from the dizzying altitude of the Capital to the country’s 3rd largest city. The spiraling road can be combined with dense fog and all manner of vehicles hurtling past at breakneck speed making this a road best travelled with an empty stomach and in the cold light of day!
On arriving in Santo Domingo we were taken straight to the Santo Domingo public hospital where we were acquainted with our tiny (14 x 8 foot) but entirely functional operating theatre in a ‘Unidad mobil Cirugica’ i.e. mobile operating unit, and introduced to the handful of lovely staff with whom we would have the pleasure of working during our short time there.
The next day, business began at 8am promptly. Ecuadorians had traveled from up to 200km away after hearing about the free service through a public campaign by the Ministry of Health and were triaged by the resident Cuban anaesthetist recently recruited to the hospital. Each morning we were shown a rapid-fire sequence of potential patients selected by our Cuban colleague (who spoke Spanish as machine gun fast as he presented patients!) and would select as many as we thought we could manage in a 12 hour shift.
There were challenges throughout our mission. Few Ecuadorians spoke English making communication/ informed consent etc. the first issue. We had arrived anticipating 2 operating tables for our British team of 4 surgeons (3 Consultants, 1 trainee) and 1 anaesthetist (Consultant) but unfortunately were met with only one, limiting the number of procedures we were able to complete. Technical issues also slowed us down such as intermittent loss of water in the mobile unit preventing scrubbing up and breakdown of the autoclave which could be detected by the slightly alarming whiff of singeing filling the little unit! Perhaps one of the most irksome technical challenges was not having a self-retaining retractor, proving to be the bane of one Consultant’s existence (you know who you are JC!).
On a more compassionate level, we all felt sadness and frustration when we had to ask patients to return another day, regardless of how far they had traveled, as we simply could not operate on them all in one day, and for example when patients were presented as having a hernia but clearly has some other diagnosis- including one gentleman with weight loss and a large hard testicular mass, and another gentleman with a 1 year history of flank pain. Turning these patients away without being able to assist further with investigations or appropriate re-referral was a sobering aspect of the mission.
During our time our British team, with the invaluable assistance of Noel the resident anaesthetist and Marlene our adorable Ecuadorian nurse, completed 35 procedures in 29 patients. Broken down, these procedures consisted of 19 inguinal hernias, 2 recurrent inguinal hernias, 10 paraumbilical hernias, 2 epigastric hernias, 1 recurrent incisional hernia and 1 sebaceous cyst. 23 procedures were carried out by the trainee under supervision. All operations were undertaken under spinal anaesthesia. 1 patient with an inguinal hernia repair returned to theatre with minor bleeding.
Despite challenges, the mission was rewarded by virtue of the immense gratitude we received from all of our patients. Without this service, many would continue living with their hernias or have to endure a long wait to receive surgery. Private hernia surgery at a cost of up to $3000 is simply not an option for most of these patients who earn on average only slightly more than this per annum. It was also humbling to be assisted by Marlene and Noel who were not paid overtime for all the extra hours in which they tirelessly aided us and who never stopped smiling. As a trainee, this was an incomparable experience on many levels. I was privileged to have 3 wonderful and patient Consultant surgeons supervising me, and the chance to finally understand the anatomy of hernias (!) and increase my confidence as the operating surgeon.
Thank you to Professor Kingsnorth for this invaluable opportunity and to Kathia Tinizaray Mera, Sandra Ocampo and Teresa Butron for making this mission possible.
Team members: Andrew Kingsnorth, Antonella De Rosa, John Hack, David Earle, Angleo Sorge, Alberto Meyer, Artur Seabra, Elaine Marinho, Luiz Alfredo, Sidney Chalub, Flavio Malcher.
Brazil is the fifth largest economy in the world, and is the world’s fifth most populous country, with an estimated population of 202,768,562 in 2014. The Brazilian health system consists of public and private components. The public subsector (the Unified Health System; Sistema Único de Saúde, SUS) was established in 1988 based on the principles of ‘health as a citizen’s right and the state’s duty.’ Since the creation of SUS access to health care has substantially improved, however regional disparities in healthcare still exist and are unacceptably large; the remote and poor regions of the north and northeast have reduced life expectancy compared to the south region, where life expectancy approaches that of rich countries.
The 2014 mission to Brazil was to the Amazonas state, in the northwest region. Most of the state is tropical rainforest with cities clustered along major waterways, accessible only by boat or plane. Manaus is the capital and the largest city, home to 45% of the states population.
The following three government hospitals were visited:
Hospital Geral de Manacapuru. The city of Manacapuru is located 80km west of Manaus with an estimated population of 92,996 in 2014. The hospital has three operating theatres but only performs emergency surgery. There are no elective surgical lists because of the lack of surgical expertise.
Hospital Universitário Getúlio Vargas, Universidade Federal do Amazonas. This is the University Teaching Hospital in Manaus, which is a busy, public hospital with five operating theaters. The hospital has the facilities and equiptment to perform laparoscopic surgery including laparoscopic hernia repair.
Hospital Regional Dr. Hamilton Cidade, Manicoré. Manicoré is a small town located in the south-east of the Amazonas state with a population of 52,200 in 2014. The hospital is well equipped with three operating theatres however no emergency or elective surgery is performed because of a lack of surgical expertise. At the time of our visit there were no doctors working in the hospital, which was run solely by nursing staff.
Eighty-nine hernias were repaired in 74 patients (female = 22, male = 52) with a median age of 44 years (range 2 – 83 years). Nine patients underwent more than one type of hernia repair, and there were 9 laparoscopic inguinal and ventral incisional hernia repairs. Local doctors were trained in hernia repair techniques, and an International Hernia Symposium was held at the University of the State of Amazonas, Manaus.
The humanitarian mission provided hernia surgery to the underserved population of Brazil and training to local doctors, building local sustainability. Practicing hernia surgeons from the host nation and the international surgeons were able to share ideas and learn from each other, a rewarding and invaluable experience for all team members.
Cambodia is an amazing country that has suffered enormous tragedy during the reign of the Khmer Rouge in the mid to late 70’s. Genocide of over 3 million of its 15 million population and countless other atrocities have resulted in unimaginable suffering for the surviving population. The country has been in a state of rebuilding since 1980, with still a long way to go with over 20% still living below the poverty line. Few hospitals exist and those that do are largely private in nature expecting significant payment from the very poor population.
Hebron Medical Centre was the base for our team of 6, which included 4 surgeons, an anaesthetist and a theatre nurse. Hebron Medical Centre is an amazing hospital which started as a small house in 2007 and has progressed to a 70 bed hospital which has 3 operating theatres and sees over 40 visiting teams per year. It is a Korean missionary hospital and has many missionaries that stay on the grounds for years dedicating themselves to the people of Cambodia. The team worked well with the local staff and managed to treat over 60 patients performing 70 hernia operations on mostly children; some under 1 year of age. Other interesting cases included some recurrences in children and a complex re do inguinal hernia in an older gentleman which had previously been operated on 5 times. Both the patients and parents of the children where very happy and we left Phnom Penh planning to return in the near future. All patients we treated were well at the follow up clinic as arranged by our local coordinator Stephen Kim.
Socially we enjoyed very pleasant accommodation and were well taken care of by Hebron Medical Centre with our transport to and from the Hospital daily. We had an amazing dinner with the hospital staff on the last night and tasted alot of the local cuisine. Most team members had planned a few days either side of the mission to see Phnom Penh, visit Ankgor Wat at Siem Reap and pay their respects at the Genocide Museum and mass burial site from during the reign of the Khmer Rouge.
Hernia International and I would personally like to thank Menaka Thomas from Samaana Yoga, Australia, and others who personally donated $1000 to support the mission. It was greatly appreciated and very generous. Hernia International is excited and dedicated to its long-term commitment to the Hebron Medical Centre and the Cambodian people.
We are just back from our last mission of Hernia International Foundation and Surgeon in Action Foundation in Mongolia. The team was made up by Martin Kriz (surgeon) and Christian Andersson (urologist) from Sweden, Hugh McGregor (surgeon) from Australia, J. A. Pascual and T. Butrón (surgeons) and Faustino Santisteban (business) from Spain. This was the fifth mission in Mongolia.
We all arrived on different flights on 14 and 15 June. Martin and Christian remained in Ulaan Bataar during the two weeks the mission lasted, as they went to the prison hospital. The rest of the group flew to the city of Khovd in the Northwest of Mongolia on Monday 16. We were met by the driver of the hospital where we were going to operate on the following days. We loaded all our equipment on a Russian van (the hospital ambulance) and we went to the city of Bayan Olgii 200 km north. The road went through the steppe and over some rivers, and we arrived after more than five hours and some incident as when the van stopped in the middle of a river we were crossing. We waited expectantly, and the driver could finally get us through.
We had a picnic in the steppe with all that we had bought in the supermarket. Along the way we saw herds of sheep, goats yaks, camels, horses, cows and some yurta (Mongol tent). All that in the midst of a treeless landscape, pure steppe with mountains on the horizon. On arrival, we went to the hospital where we were introduced to the staff and then we saw the ten patients we would be operating the next day as well as the operating theatres. We ended our day with supper with the hospital director, two residents (Bota and Satu) and Sanchin in a Turkish restaurant.
Next day we started operating. We were able to get more instruments and so we could place two operating tables in one of the theatres. Thus we operated 12 patients. We had lunch and dinner at the hospital. Every day we did the rounds in the wards, and then we operated on three different tables. At the end of the day we saw the patients to be operated the next day. We were daily helped by the surgeons and residents of the hospital, and on Friday evening we gave two lectures.
On Saturday we went for an outing with some of the surgeons and anaesthiologists of the hospital. We went to a valley surrounded by mountains where the Mongols spend their summer. In the midst of that impressive landscape we were invited for dinner inside a Mongol tent. On Sunday morning Hugh operated on the last child. We then went round the city and had lunch with some surgeons and doctors of the hospital. Then we took our leave.
We came back again to Ulaan Bataar where we spent our second week. We arrived on Monday evening and we went to the hospital where we saw the patients we would be operating next day. The following days we followed the same pattern as in Bayan Olgii. At the end of the week we had operated more than one hundred patients.
In the evenings we walked around the city, we went to see a show of Mongolian folklore, and we had dinner in a Mongol restaurant. We hardly realized when the last day arrived. We had had a TV interview. Our mission was over, and we had come up to all our own expectations: 20 patients operated in the prison hospital, 52 patients in Bayan Olgii, and 29 in the second hospital of Ulaan Bataar. (101 patients, 29 of them children.)
