CAMPAIGN IN EMIRATES HOSPITAL. BOPOLU CITY, LIBERIA FEBRUARY 1-11, 2024

-TEAM

Second Surgeons in Action campaign, in conjunction with Hernia International, taking place in the city of Bopolu, Gbarpolu County, Liberia. It was scheduled for the end of 2023, but was suspended due to the proximity of local elections, which finally passed without problems.

Bopolu is a small town in Liberia, capital of Gbarpolu County. Emirates Hospital provides
healthcare to a population of 55,000 inhabitants. The local network has 14 basic health clinics, provided with midwives, but the hospital is responsible for all medical, surgical and obstetric
care.

Local coordination, as in previous campaigns, was carried out by Dr. Peter George, County Health Officer of Gbarpolu County, a local surgeon very involved in assisting and improving the conditions of his hospital and its neighbors.

The surgical team is made up of 12 volunteers:
-Laura Baumgartner Lucero. Anesthesiology. Burela (Lugo)
-Rocio Díez Munar. Anesthesiology. Madrid.
-Pilar Murga Pascual. Anesthesiology. Badajoz.
-Carlos Delgado Miguel. Pediatric Surgery. Madrid.
-Sara Ramallo Varela. Pediatric Surgery. Santiago de Compostela
-Lucía Corrales Fernández. Nurse. Burela (Lugo)
-Maria Jesus Nieto Berrocal. Nurse. Badajoz.
-Monica Ruiz Maleno. Nurse. Almeria.
-Monica Torres Díaz. General Surgery. Cee (A Coruña).
-Estefania Villalobos. General Surgery. Mexico.
-María Quirós Rodríguez. General Surgery. Burela (Lugo)
-Antonio Satorras Fioretti. General Surgery. Burela (Lugo). Coordinator.

The facilities for carrying out administrative procedures on the part of the Liberian Consulate in Madrid were scarce, and on the part of the Liberian Embassy in Paris, non- existent.

We provided a total of twenty-four suitcases of material collected by the volunteers and medication (donated entirely by the Hospital Publico da Mariña of Lugo), weighing 550 kg (two of 23 kg per volunteer).

The departure was on Thursday, February 1 at 6 p.m. from Madrid, with Royal Air Maroc, on a flight with a stopover in Casablanca, a technical stop in Freetown (Sierra Leone) and arrival in Monrovia, two hours late, at 6 a.m. Friday February 2nd. There we discovered the loss of four suitcases of material (one of them with a third of the medication) and the breakage of another.

After the claim procedures, we began the trip aboard three official vans, with a stop at the A La Lagune hotel for breakfast. Then, five and a half hours for 250 miles of travel along roads packed with cars, motorcycles and tuc-tucs, which are transformed into dirt tracks, with more potholes than ground.

After a difficult journey, we arrived in the afternoon at the town of Bopolu, where we were offered a warm welcome by the local population, with endless dances and speeches. Later the material was unloaded and prepared in the hospital facilities to start the next day.

-ACCOMMODATION

*HOTEL

The Lorine Guest House is a hotel that is very close to the hospital. It offers spartan single rooms with mosquito nets, acceptably clean, filled with mothballs to repel insects. They lack running water, so each bathroom has a large basin with auxiliary buckets for washing and using the toilet. Power only runs at night and plugs are compatible with European ones, so no adapters are required.

At night, on the patio, they have cold beers to spend a relaxed time. Collect and wash personal clothing was offered.

*FOODS

-Breakfast and dinner at a location between the hotel and the hospital. Food was based on
vegetables, rice, chicken, eggs and tilapia, all spicy. Various fruits. -Lunch: they bring something frugal and fruit to the hospital. -Water always available. Beer at dinner.

*INTERNET

Connection was offered by the coordinator with a local router that we had with us.
Frequent network loss, but it could be used every day

-HOSPITAL

Emirates Hospital is a new building with 150 beds. It has shared rooms for men, women and children, without air conditioning and poor hygienic conditions of beds and treatments. There are modern facilities but they are not functional (they have an ultrasound, a CT scan or computer equipment that have never been used). The main problem is the absence of supplies and replacements.

Electricity depends on solar panels and is only available from 9 a.m. to 9 p.m. Surgery cannot start earlier and there is no provision to extend the day.

We had a large operating room with air conditioning and a respirator that uses Isoflurane (and could work with Sevorane if available or carried). In that operating room a second table was set up for regional anesthesia. In an adjacent room without an O2 connection (a concentrator is used) a third table was installed. No overhead lamps (there are, but they don’t work). Acceptable lighting with auxiliaries and in some cases with frontals.

A large unequipped resuscitation room was used as a warehouse for storing materials and medications and as living room Problems in the supply of O2. Leak in the main tanks not repaired and absence of spare portable cylinders.

In addition, there was another operating room – which we did not use – used by the local team for cesarean sections with a respirator without O2 intake. It could use Halothane or Isoflurane in pressure control.

Despite their commitment to provide two electric scalpel consoles, we only had one and it worked wrong. Fortunately it was supplied with the two generator we had brought from Spain.

Only very basic boxes for hernias were available (we carry 2 adult hernias and 2 pediatric
hernias). Sterilization in a small steam autoclave in the surgical area itself was at least rapid
although very limited.

There was a minimal laboratory (hemoglobin, glucose, serology). The scheduled patients had previously been tested for HIV, hepatitis B, malaria and syphilis. If needed, there was the possibility of a blood bank.

The staff, who are largely volunteers, are quite disorganized. Difficulty in knowing the location of each patient, whether it is pre- or postoperative or whether it requires special attention. The medical records must be marked to avoid repeating patients.

The commitment to provide surgical gowns and drapes was initially fulfilled until stocks of sterile material were exhausted. At that time we were offered non-sterile examination gowns (insisting that this is what they use there) that did not meet the minimum conditions of asepsis. Thanks to the experience and expertise of our veteran nurse María Jesús, the material could to be sterilized, which allowed the campaign to be completed.

The training of local personnel was scarce, with hardly any medical personnel attending our daily activities. Auxiliary personnel were trained in material sterilization techniques.

-DAILY ACTIVITY

At 7:50 a.m we met in the hotel courtyard to walk in five minutes to the place (a fenced warehouse) where they served us breakfast. In another ten minutes we walked to the hospital around 9 a.m.. We changed and did the first visit with the headlights until the light came on. It was then when the operating room began to activate and surgery was started around 9:30.

During the morning and afternoon, with a brief break for eating, three tables were non- stop
operated. In addition, patients previously selected by the local team were assessed and daily programming was carried out. On the third day, some patients who were scheduled for follow-up were reviewed. In addition, discharges were given providing doses of analgesia for the immediate postoperative period.

It didn’t end before 8pm, occasionally extending the day until the power went out. If we could, we took the opportunity to shower in the hospital itself. Later we returned by car (the lighting was non-existent and we were not advised to go walking) to the place where we had dinner and then to the hotel, where we took advantage of some time to relax with a cold beer.

-SURGICAL ACTIVITY

During the campaign we worked for seven days, in morning and afternoon shifts with a short break in between, on three simultaneous surgical tables. 173 patients have been operated on, with a total of 223 procedures, which makes an average of eight patients per table per day.

*ADULTS:

A total of 131 adults, 97 men and 34 women, aged between 16 and 80 years. In 22 cases they had several associated pathologies, so 153 procedures were performed.

98 inguinal hernias have been operated on (17 inguinoscrotal, 12 bilateral, 11 recurrent and two emergency due to strangulation that did not require intestinal resection although an appendectomy was required).

Other pathologies were umbilical/supraumbilical and epigastric hernias (11) and incisional hernias (4) for which mesh plaacement was mostly performed, hydroceles (11, two bilateral), large lipomas (22) and other soft tissue tumors (6 cysts and keloids).

82 regional anesthetics were used, 41 local with sedation and 8 pure local. Most patients were discharged the next day and no complications were recorded other than a hematoma that drained.

It should be noted that several patients were rejected, due to questionable diagnostic indication or anesthetic risk, who were later operated on by the local team, and whose evolution is unknown…

*CHILDREN

42 patients were operated on, 22 boys and 20 girls, aged between 6 months and 17 years, all under general anesthesia. In more than half, two or even three procedures were carried out, which raised the number to 72 procedures.

34 inguinal hernias (5 bilateral), 16 umbilical hernias, one hydrocele, two cryptorchidisms, one cord cyst, 4 circumcisions, 3 appendectomies (due to discovery of appendix in hernia sacs) and 4 soft tissue tumors (one of them a large cervical lymphangioma).

Furthermore, the two longest and most complex interventions were a pelvic burn involving the thighs, anus and genitals, and a burn with foot retraction. Both required laborious surgeries with skin grafts, with an initially very satisfactory result.

No significant complications were recorded. Two other cases of complex burns that had been scheduled were operated on without prior notice by the local team, to our great astonishment.

-RETURN

On Friday the 9th we finished the campaign, materials were collected and loaded into the cars. On Saturday morning there was a farewell event in the town hall, with a new session of lively and colorful local dances, endless speeches and delivery of thank-you gifts. Finally we left Bopolu and returned along another somewhat better but also heavy road to Monrovia.

Our idea was to do some sightseeing, but since the city offered nothing to see, we returned to the Hotel A La Lagune where we took some rooms that allowed us to use the pool, take a shower and rest for a while in the afternoon, before leaving. at 23:30 towards the airport. The night trip of more than an hour was bumpy, with one of our cars colliding although without any consequences.

The return flight took off on Sunday the 11th, delayed, at 4:30 a.m. and after making a stopover in Casablanca we arrived in Madrid at 6:30 p.m. without further incidents. A suitcase with a generator was lost, but luckily it turned up a few days later.

-BILLS

From the initial budget for accommodation, food and transportation that was proposed to us and seemed exaggerated by the forecasts, as it really was, a reduction of almost 50% was negotiated.

-Health Material: ……………………………………………………..……, Donation
-Medication:…………………………..…………………………..($ 1,635) Donation

-Visas: $100 per person……………………………………………..…………$1,200
-Madrid/Monrovia/Madrid plane tickets
960 ticket + 40 insurance: $1,000 per person………..………………..$12,0000
-Accommodation
*Bopolu: $25 per person per night (8): …………………………….……… $ 2,400
*Monrovia: $90 for a room of four and pool……………….…………………. $360

-Meal
*Monrovia Breakfast (10 $ x12)…………………………………………….…. $ 120
*Bopolu: $225 per person 8 days:……………………………………………$ 2,700
*Monrovia Food: ………………………………………………….………….… $ 215
*Various:…………………………………………………………………….….… $ 270

-Transportation: $50 per person…………………………………………… .… $750

TOTAL…………………………………………………………………….… .. $ 20,015 EXPENSE PER VOLUNTEER: $1,670

-PROPOSAL FOR NEXT CAMPAIGNS

The Emirates Hospital in Bopolu is a center well equipped to carry out surgical campaigns. There is a good selection of patients and the facilities are appropriate. Looking ahead to future actions, teams should make certain considerations.

-Absence of sterile conditions in their usual practice.

-Lack of gowns and cloths. Disposable sterile gowns were initially used (they were even cut down to use as a drape) until they ran out. Disposable non-sterile gowns were offered. They can be resterilized in an autoclave. Laundry and autoclave in the hospital. Consider bringing cloth material, if they can offer resterilization.

-Few surgical instruments. Boxes must be brought

-The agreed electric scalpel generators were not provided, so they must be brought.

-Anesthesia equipment that could work with Sevorane.

-A full-time nurse is needed to manage sterilization.

-Loss of luggage with Royal Air Maroc. Distribute materials/drugs to minimize the
consequences of loss.

REPORT

GATUNDU-KENYA CAMP 2023

1 – 10 December 2023

TECHNICAL REPORT

DATES AND DEPLOYED LOGISTIC

The team of collaborators began to be formed in the month of August 2023 under the coordination of Dr. Teresa Butrón and the Non profit organization Cirujanos en Acción (Surgeons in Action) with the collaboration of Hernia International Foundation. It was prepared in two months and a half and it was made possible with the help of Lizz Beth, secretary of the Gatundu Hospital Director.

She responded very quickly and clearly to all questions related to documentation needed to obtain the temporary permissions (Passports, VISA, C.Vitae, diplomas and profesional certificates of professional suitability).  The  hospital provided transport from the airport to the hotel in Tikka and daily from the hotel to the hospital in the morning an back to the hotel in the evening.

All volunteers collected all the consumable material needed for the campaign, including surgical gowns, drapes, surgical fields, sutures, meshes of different types and sizes, bladder catheters, sterile and operating gloves as well as drugs (anesthetics, muscle relaxants, antibiotics, analgesics and anaesthetic material such as spinal needles, epidural catheters, endotrachael tubes and rest of the material.

MBA company in Madrid donated 3108€ in laryngeal maks of differents shapes and sizes. 

It is very remarkable that the team components could get 3 electrosurgical units to be used during the campaign and one of those was delivered to Gatundu hospital after the end of the working period.

The air tickets were taken through Angelis (freelance of Halcon Viajes Company) with the company Turkish Airlines, which allowed the transport of 2 bags of 23 kg per person + cabin bagage.

The group left from various parts of Spain on Friday, November 24, 2023. The whole group gathered at Istanbul Airport to leave for the 12 members of the expedition to Nairobi. The campaign ended on Saturday, December 2, 2023 and we arrived Spain Sunday 3th.  

PATIENTS.  A total de 118 patients  were operated on during the campaign period

ADULTS PATIENTS:  A total of 60 surgeries were done on adult patients with the following procedures performed:

Hernioplasty prefascial 31 cases

Lichtenstein 25 cases

Incisional hernia 3 cases (Rives Stoppa, resection and resection plus reconstruction)

Preperitoneal hernioplasy plus left PSC  1 case

PAEDIATRICS PATIENTS. 58 cases in infants and children; 10% female and ranging from 1 to 14 years of age (median age 4 years).

Undescended testicles: 31 cases, two of them bilateral

Inguinal hernia: 15 cases

Umbilical hernia: 6 cases

Supraumbilical hernia 1

Hydrocele: 4

Ectopic testis: 1

COMPLICATIONS: Once the team left Gatundu Hospital, the follow up of patients was done by Dr Chacha.  There were no relevant complications in the first 30 days after surgery

CAMPAIGN REPORT

THE PLACE. Kenya is a big country located in the east central coast of Africa. Kenya’s population was reported as 47.6 million during the 2019 census compared to 38.6 million inhabitants in 2009, 30.7 million in 1999, 21.4 million in 1989, and 15.3 million in 1979. This was an increase of a factor of 2.5 over 30 years or an average growth rate of more than 3 percent per year. The population growth rate has been reported as reduced during the 2000s, and was estimated at 2.7 percent (as of 2010), resulting in an estimate of 46.5 million in 2016. According to the 2022 revision of the World Population Prospects, the total population was 53,005,614 in 2021 compared to 6,077,000 in 1950, and around 1,700,000 in 1900. The proportion of children below the age of 15 in 2010 was 42.5%, 54.9% between the ages of 15 and 65, and 2.7% of the population was 65 years or older. Worldometers estimates the total population at 48,466,928 inhabitants, a 29th global rank. Kenya’s GDP per capita, an indicator of its standard of living, was 2.081 in the year 2022 (Spain $30.103), and it ranks 152nd out of 192 countries, what means a very low standard of living.

Gatundu is a small town of about 20,000 people located at 1600 meters de altitude in Kiambu County with a population of 1,600,000 habitants and is situated about an hour’s drive from Nairobi. The town’s infrastructure is very poor, with most of the houses and shops located on both sides of the main road. The population lives on a dollar a day. Rice, vegetables and other farm produces are the staple food. The V Level Gatundu Hospital was built in 2013 with the financial support of the Chinese Goverment. In 2016, its clinical activity began and in recent years there has been a very evident deterioration in the architecture with structural repairs currently underway.

 Another wing is currently under construction and will be used for oncology. It is an annex to the old Gatundu Hospital, consisting of several single-storey pavilions connected to each other, with large green areas.

The hospital has 5 floors and, in the third floor is the surgical area with two large operating rooms which are called theatres 3 and 4.    There are two anesthesia machines fully operational but with basic monitoring that does not include capnography or inspired gas analysis.The post-anesthesia recovery area is very poor, consisting only of 3-4 beds without any monitoring and with the possibility of administering oxygen through a facial mask or nasal cannula. Surveillance in this space by local staff is quite limited but, due to the proximity to the operating rooms and the work of Dr Amanda García with the pediatric population, we were able to do direct clinical surveillance of the patients and intermittently monitor SpO2. using portable pulse oximeters brought from Spain

THE TEAM was composed by a total number of 12 volunteers:

• General Surgeons: Teresa Butrón (team leader). María del Mar Viana Miguel. Juan Pablo Alarcón Caballero. Jesús Manuel Bollo Rodríguez.
• Neurosurgeons. Alina Costache
• Pediatric surgeons. Alejandro Unda Freire
• Pediatric intensivist. Amanda García Palencia,
• Anesthesiologists. Irene Merino Martín. Santiago García del Valle
• Nurses. Patricia Arenas Suarez, María Cristina Gutiérrez Moreno. Marina Remesal Oliva.

                     LOCAL STAFF. Dr Clifford Chacha Mwita, Gatundu hospital’s surgeon, our contact there and and the person responsible for coordinating all the clinical activity that we carry out there,  actively participated as a surgeon in several cases, teaming up with Dr Butrón.  We had support, both in the operating room and in the hospitalization ward, from local general medicine doctors. Since we were able to have 3 operating room tables from the first moment and there were only two anesthetists in the volunteer team, we were able to count on the collaboration of a team of local anesthesiologists, some displaced from Nairobi like Dr Ruth Muiruri, Dr Eric Karuri and Dr Isaack Karaba. We also have the help of nursing and auxiliary personnel in the 2 operating rooms used

EQUIPMENT.  The surgical instruments available at the Gatundu hospital such as forceps, retractors and scissors are not in very good condition and there are not adequate sizes for some of the longer and more aggressive interventions performed. There was no diathermy generators available although fortunately the team was able to transport 3 units from Madrid.

ANAESTHESIA. The paediatric population was operated under general anesthesia in most cases by the Dr Irene Merino. The anaesthesia in the adults patients was done by Dr Santiago Gª del Valle and the local anesthesiologists and it was general anesthesia in 17, cases, general plus epidural in one case and spinal anesthesia in the remaining 42 cases.

ASEPSIS AND SURGICAL MATERIALS: Sterilisation was carried out with a heat-operated autoclave.

OUR DAILY LIFE

We arrived at Nairobi International Airport on Saturday 25 November at 3:00 am. There were no difficulties with customs formalities and from there we were transferred to the Maxland Hotel in the town of Tikka, about 60 minutes from Nairobi.  Maxland hotel is very secure as it is within a fenced compound with access controlled by security guards. The rooms are single, with en-suite bathrooms and beds with mosquito nets, and are very clean and hygienic. It has wifi which works very well both in the rooms and in the common areas (hall and dining room). Breakfast is buffet style. There is a shopping centre next to the hotel with small shops, a pizzeria and a big supermarket with a great variety of products

After resting for a few hours, we travelled to the Gatundu Level V Hospital, 20 minutes away from Maxland hotel, for what would be our transport and driver (Mr Samu Macharia) for the duration of the campaign. We arrived at the hospital and we were wellcome by Dr Chacha. That same day we started unpacking the equipment and organised it in the two surgical rooms available as well as to check the monitors and anesthesia machines available.  Surgeons and anesthesiologists we went with Dr. Chacha to see the patients ready to operate the following day. This clinical visit was repeated every day in the evening. At the end of the day we came back to the hotel to buy some food and drinks in the market near the hotel before dinner.

We worked during 6 days (Sunday to Friday inclusive) from 8:00 -19:00, even later several days. The last surgery performed ended at 18:00 the Friday, december 1, 2023. On Saturday 3rd, 4 volunteers left the hotel to visit the Masai Mara Park to return to Madrid on the 5th of December, the rest of us went to Nairobi National Park a wonderful place where we saw a great variety of big wild animals such as rhinos, Monkeys, buffaloes, etc.

CONCLUSION                       Strengths of this place: Very good organization in the selection of patients to prepare the daily surgical report, both in the pediatric population and in adults. Possibility of having three surgical tables throughout the period. It is very important to have the collaboration of local professionals, both surgeons, anesthetists and nurses.       Improvement objectives: It would be very useful for future campaigns if the Gatundu hospital could have an electric scalpel unit and Dra. Butrón made this known to both Dr. Chacha and the hospital director during a small farewell ceremony.

BUDGET:

COST FOR PERSON:  Flight ticket 650€, Hotel (room plus half board) 340€ (42€ per day x 8 days). VISA 60€.  Total amount 1050€ per volunteer.

TOTAL CAMPAING COST:  12.600 €

 SIGNED:   Santiago García del Valle

         Volonteer

                      Surgeons in Action Foundation

Cooperation Korogwe 28 Oct – 5 Nov 2023

PREPARATION: The campaign took place from October 28th to November 5th. To accomplish this, a Spanish team consisting of a general surgeon, a urologist, two anesthesiologists, two final-year general surgery residents, and four nurses traveled to Korogwe. For the preparation of the expedition, we had Dr. David Siwiti as our contact. The organization began almost a year before carrying out the mission. Via email, we provided him with the relevant documentation for each volunteer: passports, resumes, good practice documents, a list of the materials/drugs we were carrying, etc. The process was laborious, and we had to send that documentation on different occasions. Another setback that arose was the creation of a technically governmental tax, for which both doctors and nurses were required to pay extra fees to be able to practice. After negotiating for months, the hospital in Korogwe took on those charges.

Simultaneously, we sought funding to acquire surgical consumables and inventory material for the group: a charity concert was held in May 2023, and we requested hospital material from the University Hospital of Vic. The donation of material was valued at approximately 3000 euros from the social responsibility fund. Regarding inventory material, a basic hernia kit was purchased at factory prices through the collaboration of Sucmosa SA (Medicon®).

The purchase of tickets was kindly managed by Cirujanos en Acción, and subsequently, we made a donation for the corresponding amount to the NGO.

Finally, weeks before the expedition, Dr. Siwiti reserved a minibus for the journey from Dar-es-Salaam to Korogwe for 1000 euros round trip. He also reserved the number of rooms we specified at the Korogwe Executive Lounge hotel.

Although there is the option to obtain the visa online, the website did not function correctly, so we completed the procedures upon arrival in the country. We did not encounter any issues in this regard.

THE COUNTRY:

The United Republic of Tanzania is a country located on the east coast of Central Africa. The name originates from the union of the words “Tanganyika” and “Zanzibar.” The current United Republic of Tanzania was formed on April 26, 1964, when Tanganyika, which had been part of the German colony of German East Africa and later came under British rule at the end of World War I, gained independence on December 9, 1961. The Republic of Zanzibar, which achieved independence from the British crown on December 10, 1963, joined in a single state. The capital is Dodoma, although the most populous city is Dar es-Salaam. There are 120 Bantu groups that make up the majority of Tanzania’s population (61,741,120 inhabitants). Swahili and English are spoken.

Its economy is based on agriculture, which represents half of the GDP. Fishing, especially in Lake Victoria, is also one of the most widespread occupational activities in the country.

The doctor density is 0.03 per 1000 inhabitants. The mortality rate is high, particularly among children due to malaria and among adults due to HIV. 43.74% of the population is concentrated between 0 and 14 years, and the average age is 17.6 years. 14% of children are malnourished. School life expectancy does not exceed 8 years, and child labor accounts for 21% of the population aged 5 to 14.

THE LOCATION:

The cooperation took place in Korogwe, a city of approximately 60,000 inhabitants located in the Tanga region (Northwest Tanzania). To reach it, volunteers flew to Julius Nyerere International Airport, from where they traveled 300 km on sparsely paved roads to reach Korogwe Town Hospital in Magunga (founded in 1952). In Korogwe, there is a significant Catholic congregation, the Congregation of the Sisters of Our Lady of the Mountain of Usambara, created in 1954, playing a crucial role in assisting the local society, including coordinating healthcare through Dr. Avelina Temba, who is also a surgeon. The hospital is a single-story building:

1- New part used for emergencies

2- Old part, which includes:

   * Floors divided into male, female, and pediatric sections. All beds have mosquito nets. Each room has a table serving as a nursing control station.

   * An office for outpatient consultations where patients were assessed and selected for the interventions we performed.

   * A surgical area with 3 operating rooms. The smallest was used by the local medical team for cesarean sections and some other gynecological surgeries. Our group used the other two operating rooms, rudimentary but suitable for the type of surgery we conducted.

THE TEAM:

– Raül Guerrero (Expedition Leader – General and Digestive System Surgery)

– Víctor Parejo (Urology)

– Sara Fernández (Resident Physician in General and Digestive System Surgery)

– Wassim Al Ashtar (Resident Physician in General and Digestive System Surgery)

– Pau Benet (Anesthesia and Resuscitation)

– Anna Casanova (Anesthesia and Resuscitation)

– Marta Guitart (Nurse)

– Núria Soler (Nurse)

– Judit Masramon (Nurse)

– Carlota Andreu (Nurse)

OUR OBJECTIVES:

– Provide medical-surgical assistance to patients in the targeted area who require it.

– Preoperative optimization of patients when deemed appropriate during the preoperative visit.

– Postoperative monitoring of patients and resolution of any complications.

– Ensure proper follow-up once the surgical team returns to the home country.

– Identify unfavorable points for improvement.

– Training of general surgery resident physicians.

– Training of local healthcare professionals through active participation.

– Cultural exchange between the local and European cultures.

THE OPERATING ROOM:

It is worth highlighting some peculiarities of the operating rooms so that those who come after us know what to expect:

– Both operating rooms have a rudimentary but acceptable surgical table. The armrests are two wooden planks.

– General anesthesia cannot be performed. There are two ventilators that, at the time of our mission, were not functioning.

– Between the two operating rooms, there is a handwashing area, but there is no iodine soap or chlorhexidine. Surgical washing had to be done with regular hand soap.

– Electric scalpels can be used, although, as expected, their functionality is not the same as in our environment. The scalpel plates have been reused so many times that they don’t stick, so it would be interesting for future groups to bring some replacements.

– Before our contribution, the hospital had very basic and outdated inventory materials (forceps that don’t grip, needle holders that don’t hold the needle properly, Kocher or Crile forceps that don’t close well, etc.). Regarding sutures, they have some that are rarely used in our environment, such as Catgut®, Dexon®, Nylon, and Silk.

– Regarding lighting: one of the operating rooms has a lamp with a halogen bulb that functions well, although it breaks down repeatedly. The other operating room is equipped with a floor lamp that does not provide much illumination. Both operating rooms have windows that help mitigate the lack or inadequacy of lighting.

– The temperature is quite correct, as there is air conditioning.

– It is not customary to clean the operating room after each surgery. Before starting the day, the hospital staff mops the floor with bleach, but due to the humidity in the environment, most days, we had to start surgeries with a wet floor. Additionally, the smell of the surgical area at the beginning of the day resembled a mixture of chemicals and blood.

– Worth mentioning: the surgical gowns are reusable cloth. They are washed and left to dry outdoors. Since we went during the rainy season, we usually had to put on damp gowns to comply with the surgical schedule for the day.

– It is common to find multiple insects inside the operating room.

– There is a barrier between the surgical area and the rest of the hospital, although it is not always respected. In fact, the stretchers entering the operating room to take out patients come from outside the surgical block.

PATIENTS:

63 patients were operated on (48 men and 15 women) between 3 and 83 years old.

Pediatric patients: 7

After filtering patients in consultations, 6 interventions were canceled due to comorbidity (severe heart or respiratory failure) or non-surgical pathology.

– Inguinal hernias: 30 (22 unilateral, 8 bilateral)

– Recurrent inguinal hernias: 3

– Femoral hernia: 1

– Umbilical hernia: 9

– Epigastric/supraumbilical hernia: 8

– Incisional hernia: 3

– Cryptorchidism: 1

– Cord cyst: 1

– Epididymal cyst: 1

– Lipoma: 2

– Orchiectomy for testicular tumor: 2

Total procedures: 82

Total patients operated on: 63

ADVERSE EFFECTS:

3 scrotal hematomas

1 inguinal hematoma

None of the patients required re-intervention.

DAY TO DAY:

Upon arriving at Dar es-Salaam airport, we collect our luggage, go through passport control, and pay for visas (they accept dollars and euros). Dr. David Siwiti awaits us outside the airport: through a contact of his in customs, we have no problems entering the country with all the material and drugs we are traveling with. After that, we get on a cramped minibus with barely functioning air conditioning to go to Korogwe: we are charged 100 dollars for the round trip, a price we find abusive. After a long 8-hour journey (the distance is 280 km, but dense traffic and dilapidated roads don’t help), we arrive at the Korogwe hotel on October 29th at 23:00. It takes almost 24 hours to reach the destination from Barcelona.

The hotel is more than decent. In addition, the half board we chose includes breakfast and dinner in a buffet style. The Wi-Fi connection is valid for sending text messages but not much more.

The next day, we head to the hospital, and after a brief visit to the center, we proceed to prepare the surgical rooms where we will perform the procedures for the next 5 days. Simultaneously, two doctors from the team reassessed the patients who had been previously selected by the local team.

From October 29th to November 3rd, our routine was as follows: breakfast at the hotel at 7:00 am. Transfer to the hospital at 7:30 am. While anesthesiologists and nurses prepare the operating rooms, surgeons check the condition of patients operated on the previous day. After that, surgeries begin in both operating rooms.

The lunch break takes place around 1-2 pm, at the entrance to the surgical block. One cannot be very demanding with the diet since it is based only on chicken and rice. The expenses for lunch were covered by the hospital as well, which we appreciated. We are aware that groups that came before us had to pay high amounts for this reason. We also used the lunchtime to socialize and fraternize with the local staff. Afterward, interventions continue until late afternoon. Some days, the local staff asked us to finish earlier (5 pm), and we agreed.

After arriving at the hotel, there is little usable time left. In the best-case scenario, if there is still sunlight, you can walk around the area and see how teenagers play soccer during sunset or how some adults pick oranges from the trees.

Then, there is only time for a shower, a briefing of the day during dinner, and rest.

It is worth mentioning that in various surgeries, the local medical team collaborated with our group by assisting in surgeries and performing some anesthetic techniques. For us, the teaching of local healthcare staff is almost as important as the patients who undergo surgery. It should be noted that the ultimate goal of cooperation should be that local people can function independently.

As compensation for the intense work, on Saturday, November 4th, thanks to Dr. Siwiti’s management, we visited Mkomazi National Park, where we spotted various animals such as giraffes, gazelles, zebras, rhinoceroses, …

On Sunday, November 5th, we left very early in the minibus for Dar es-Salaam airport for the return to Barcelona.

PROS/CONS:

Pros: The local staff is attentive and pleasant, always trying to help and solve problems if they arise.

To improve:

– The circuit and communication for managing/sending data with the local link should improve.

– In the operating room: lighting; scalpel plates; repair the ventilator to be able to perform surgeries under general anesthesia.

– Improve hygienic measures in the operating room.

FINANCIAL REPORT

Below is a breakdown of the individual economic cost associated with the project:

**BREAKDOWN OF INDIVIDUAL PERSONAL EXPENSES:**

– Flight ticket: 837 euros/person

– Visa: 50 euros/person

– Meals and accommodation: 350 euros/person

– Transportation: 100 euros/person

– Standard medical insurance (IATI SEGURO®): 36.90 euros/person

**TOTAL: 1373.9 EUROS/PERSON**

Raül Guerrero

HERNIA INTERNATIONAL MISSION

Austrian-Swiss-Liechtenstein-Slovenian Team Mission 2023

Ngarenairobi Tanzania, Oct. 28^th-Nov 5^th, 2023

The Ngarenairobi Health Centre (NHC)in Siha District in Tanzania hosted a Hernia International Mission for the second time. Again, it was organized by the Congregation of Spiritus Sancti Fathers (ALCP OSS), especially Father Damian, who has similar organization skills as Rev. Sister dr. Avelina Temba in Korogwe.  On the other side, the organizer was Dr. Gorjanc from Krankenhaus der Elisabethinen in Austria. Our Tansanian surgical and anaesthesiological friends dr Kombo, dr. Joseph, dr. Cosiano, Fanuel and others were again helpful in preparing enough patients for a successful mission.

The travel from our homes to NHC took us 12-24 hours, according to flight connections. Michael, Katalin and Wolfgang are not just skilled anaesthesia team but also keen mountaineers and summited Mt. Meru Mountain (4566m) in the days before the mission. Some members of the team were on Zanzibar island on deserved holidays just before the mission.

We all met on Sunday on October 29^th at the Provincial house of the Congregation and from there and back we were transported to the NHC daily (about 30 min one way by minibus). Our team consisted of 12 members: 3 surgeons-consultants, 1 plastic and reconstructive  surgeon, 2 anaesthesiologists, 1 radiologist, 2 scrub nurses, 1 nurse anaesthetist, 2 medical students (one from Mwanza, Tanzania).
Additionally, 4 local doctors from Tanzania were present on different days of the mission. We imported 300 kg of medical equipment and drugs in 15 bags. Again, there were no difficulties at the customs due on-time application of our gear at the TMDA (Tanzanian Medicine & Medicine Devices Authority), but still additional help of father Damian was required at customs of the entry airport (Kilimanjaro) for some of us.Checking patients for surgery was our first task on sunday evening and monday morning. There were more patients than the year before. There were many thyroid patients, we operated on all who were euthyrotic. The turnover of the patients was fluent.
Parallel operations on 2 and sometimes 3 tables, enabled 57 procedures on 54 patients in 5 days. Twelve patients were children (22%) and 42 were adults (78%). 31 patients (57%) were female. The most frequent operations were hernia repairs (inguinals, umbilicals and epigastrics), followed by thyroid resections, lipoma excisions, Jaboulay`s (Winkelmann) procedure for hydrocaele operation and other smaller operations (one orchidopexy due to undescended testicle in child. Other diagnoses/operations were operations for benign lesions and other smaller excisions. In inguinals in children, Mitchell-Banks repair was performed and Lichtenstein repair with LDPE mesh was performed in adult patients with inguinal hernia. The youngest patient was 3 years old. Thanks to the excellent anaesthesia team and Ligasure device (which we brought with us) we performed 6 subtotal goiter resections in big benign goiters and unfortunately had to cancel 4 more due to untreated hyperthyrosis. All resected thyroid glands were histologically examined (costs are 30$/specimen in Tanzania). The resections were subtotal in order not to demand postoperative hormone substitution. In case, this might still be necessary at T3/T4 check in 3 months, it will be provided (in Tanzania costs for oral Levothyroxine are 20 $/month/patient). Maria performed 58 ultrasound examinations with her potable US (32 in women, 26 in men). She did the interpretation of abdominal X-ray in a patient with acute abdominal pain and in a patient with hand problem. Again, ultrasound enabled exact diagnosis in many patients and made many decisions easier. In patients with goiter this was the only way to plan the exact extent of the resection.

In OT 1 (good lights, diathermy which we brought last year is working), mainly general anaesthesia was performed, while procedures in OT2 (head lamps, diathermy) were first spinal anaesthesia, but then our anaesthesia team used a mobile respirator that they brought along (Oxylog 3000) for general anaesthesia. In OT 3 (improvised from recovery room), we used head lamps and local anaesthesia and did not have diathermy available.

Scrub nurses Manuela and Sofi prepared tables and selected instruments and material in 3 Ots. Manuela is experienced from many missions and always scrubbed in for thyroid operations.  HI- missions with possible large/complex hernia- and other operations should always have an experienced scrub nurse in the team.

Lea as plastic surgeon together with Christoph mastered some reconstructive surgeries (contractures) after burns and performed many aesthetic excisions of skin disorders.

We had one postoperative haemathoma after lipoma excision –   it was evacuated surgically on the same evening. Again, we took enough time for every single procedure, without hurrying, which was important in all and not only in HIV-positive patients. A normal working day started at 8 am and ended at 4-6 pm. Normally, after a good breakfast we did not take lunch break (some biscuits, soft drinks, coffee and tea were sufficient between operations). We all met every day again at dinner at 7pm.

Team Members:

Dr. Michael Wirnsperger – consultant anaesthesiologist, LKH Bludenz, Austria

Dr. Katalin Wiese-consultant anaesthesiologist, Krankenhaus Feldkirch, Austria
Wolfgang Walser – anaesthesia nurse, Feldkirch, Austria

Dr. Marija Jekovec – consultant radiologist, Ljubljana Medical Centre, Slovenia
Manuela Logan, scrub nurse, Liechtenstein

Prof. Mirko Omejc, MD, PhD – consultant surgeon, Ljubljana Medical Centre, Slovenia

Andrej Omejc – medical student, Ljubljana, Slovenia

Edward Edmund  – medical student, Mwanza, Tanzania

Dr. Christoph Sträuli, MD-consultant surgeon Grabs, Switzerland

Dr. Lea Lisborg Mračević – resident plastic and reconstructive surgeon

Assist. prof. Jurij Gorjanc, MD, PhD, FRCS, FEBS AWS – consultant surgeon, team leader, Krankenhaus der Elisabethinen Klagenfurt, Austria

Our sponsors:

Krankenhaus der Elisabethinen Klagenfurt

Medical Center Gorjanc

Implantoloski institut / Implant Institute

LKH Bludenz

LKH Feldkirch

Spital Grabs

Kirurgija Bitenc

University Medical Centre Ljubljana

Medtronic Austria

Dahlhausen

Gynäkologie Dr. Alberer, Klagenfurt

HERNIA INTERNATIONAL MISSION NIGERIA.

OCTOBER 11-19, 2023

STATUS: COMPLETED

Coordinator: Dr. Austin Ella (Nigeria), Dr.Ini (Nigeria) Thorbjorn Sommer (Denmark)

General Surgeons: Steve Lindley, (UK)  Alan Kravitz (USA) , Thorbjorn Sommer (Denmark)

Nurse: Lene Scheffmann Gosvig (Denmark)

Total: 4 volunteers

TECHNICAL REPORT:

DATES AND LOGISTICS DEPLOYED:

Campaign conducted October 11-20, 2023,

ADULT PATIENTS: Hernias (inguinal, umbilical, ventral, inguinoscrotal), lipomas, hydroceles.

PEDIATRIC PATIENTS: Hydroceles, umbilical hernias, inguinal hernia.

CONSULTATION AND SURGERY PERFORMED:

Total procedures: 99 patients (105 procedures)

Total operated patients: 99 patients (of which 40 were pediatric patients, aged from 20 months to 17 years)

Patients seen in consultation: 130

Complications (within 7 days of our arrival):

– none seen, patients came back day 3 post operatively for check-up.

CAMPAIGN SUMMARY

THE LOCATION

Sisters of Nativity General Hospital was established 2006 by Bishop Athanasius Atule Usuh (Bishop Emeritus of Makurdi Diocese) and went into operation on 1st May, 2006. The hospital is located in Jikwoyi Phase 1, a suburban area south-east of the Federal Capital Territory, and an under-served area with a fast-growing population. It is roughly 15-20km from the City Centre in the outskirts of the town of Abuja with bustling life just outside the compound. The Compound is secluded and a safe place to be in. The nuns live here and took great care of us.

The hospital consists of different departments: Surgical department, emergency department, medical care, HIV projects, vaccinations center, facilities for child-mother care, maternity, laboratory and testing etc.

Concerning the surgical department there were two operation theatres. One was reserved for the current Hernia mission, the other was used for acute surgery, for cases such as caesarean sections.

We created a three-bed operating theatre, making it possible to perform 3 operations simultaneously, which we found very efficient, also making it possible to collaborate with each other with difficult cases.

The operating theatres were equipped with air conditioning, allowing for a comfortable work environment. We were intermittently affected by short power outages, before the hospitals generator kicked in – so our headlamps became crucial to allow us to continue operating.

We brought 2 diathermy machines, one of which one was donated to the Hospital (by funds from Hernia International).

All adult and teenage patients (youngest was 14 years) underwent operation under local anesthesia, – so all these patients walked in and out of theatre without the need of stretchers, making the turnover quick and easy.

Pediatric surgery was performed using a combination with ketamine sedation and local anesthesia. The local Dr. Ini assisted brilliantly with ketamine, love, romantic music and good humour.

In between surgery we saw patients who requested screening for a variety of surgical/non -surgical diseases, and patients coming for check-up after surgery.

The patients were seen dressed in gowns ready for surgery in a room in front of the theatre where they were marked at the operation site, and informed about surgery, sitting ready for surgery when the first patient left the room. Peripheral venous access was established for children undergoing ketamine sedation before entering the operating room, facilitating the start of surgeries.

Cleaning between the shifts were swift and we developed a fast track way of washing, putting local anesthesia, and getting all ready for surgery.

Almost all patient went home the on the day of surgery and came for check up 2-3 days later in the outpatient department.

Our dear hosts: Sisters of Nativity

THE TEAM

The team consisted of three surgeons: Steve Lindley (UK), Alan Kravitz (Washington DC) and Thorbjorn Sommer (Team leader Denmark). Anesthetic Nurse Lene Scheffmann Gosvig (Denmark) assisted with the procedures together with the local nurses.

Two months before departure we had 2 virtual Zoom meetings, the first including our African colleagues, where we were introduced to each other, discussed the mission, the need of equipment and had a very good introduction by Dr. Austin and Dr.Ini (who actually took us on a virtual tour with his mobile on facetime around the Hospital – super nice !).

LOCAL STAFF

In the corridor nurse Benita made sure to list all the patient for each day, kept a very strict protocol ensuring a good overview of patient flow. She knew exactly where the patients were, when they should be operated and for what, which created a swift flow of patient and very short intervals between operations. Lead scrub nurse Rose was phenomenal, managing many different members of staff who came to help in theatre. The nurses, some of whom had limited theatre experience did a very good job assisting us, and we tried to share as much knowledge with them as we could – Steve didn’t let up in his teaching, with very rewarding results.

EQUIPMENT

Concerning Equipment, we brought two Diathermy Machines,  drapes, gowns, sutures, meshes, gloves, masks, drains and surgical instruments (the latter was also left at the hospital for future use).

There was one monitor with a pulse oximeter and a blood pressure cuff, without an ECG, which were used when patients received Ketamine (kids).

The last days we used the local textile gowns and drapes which we found very usable. In future missions it seems more sustainable to bring new textile gowns and drapes which can be used after the mission, minimizing the amount of waste of single-use gowns and drapes.

ANESTHESIA

The operating room was equipped with oxygen supply and a ventilator which we did not use. We did not use any spinal anesthesia.

Ketamine was available at the hospital as well as Lignocaine. We used our own Marcaine with adrenaline the first days and Lignocaine for the last days and found either very affective when applied in steps of cutaneous, subcutaneous, and subfacial injection steps before washing and draping, making the effect of local anesthesia maximal before commencing surgery. That strategy made it possible also to do inguinoscrotal hernias as well under local anesthesia.

ASEPSIS AND SURGICAL MATERIAL

All patients had washed before arrival for surgery. At the hospital they were washed with appropriate antiseptics, hair was removed, the site of operation marked on the skin and local anesthesia was applied.

Basic surgical material boxes were available, however a lot of the instruments were not appropriate, so we had to sort out small instruments for the kids, and fortuitously, we brought a few appropriate sets of instruments, which were left for future use by the local staff.

ACCESSIBILITY FOR THE POPULATION

Before our arrival, the Hospital had conducted an information campaign with information about the possibility of hernia surgery. The patients paid what they could afford, some came a long way to be operated (7-8 hours of transportation).

The patients had preoperative pain killers (Paracetamol+NSAID) and postoperatively they were given a single dose of antibiotics. We recommend bringing NSAIDS , antibiotics and Paracetamol.

ACCOMODATION IN ABUJA

We stayed within the Sisters of Nativity Compound, where the Hospital was situated, a 1 hour drive from the international Airport. It was a perfect and very safe place to be located in. We were greeted with flowers, songs and dance and a nice meal when arriving. The sisters were amazing hosts, providing us with food and beverages, good company, love and smiling faces every day, – such an encouragement. The rooms were nice and spacious with a private bathroom. Laundry was offered as well.

Our routine included Breakfast at 7AM before starting surgery at 8-8.30 AM.

We had a lunch break at 2 PM, and finished the last surgery between 4 and 8 PM, depending on the number of cases scheduled.

On the first Sunday we were joined by Dr. Austin in Harvest mass at the Catholic Church and had Lunch with Leaders in the organization, – a memorable event to participate in.

The last evening the sisters had invited us to a Party in the Compound with dances, food, heartful moving speeches – and they dressed us in beautiful traditional Nigerian dress as a gift to bring home with us. We are so grateful for the opportunity to be a part of this, and we all expressed our mutual gratitude for the successful campaign.

The reason for this was first of all Dr. Austin Ella and the staff at the Hospital and Sisters of Nativity. They ensured that the logistics worked, they were prepared with patients on the line when we arrived and working together was a lifetime experience for all of us. We left a piece of our heart with them.

CONCLUSION

Strengths of this location:

The Hospital is close to the Airport, reducing time for transportation to a minimum. Patients came from far away, and the standard at the facility makes it easy to do high-volume Surgery with good quality in every aspect.

You can`t find a better host than Sisters of Nativity – they were everything from caring hosts, joyful company, incredibly good cooks taking care of our needs.

The Hospital is 30 steps from accommodation – so no time is wasted on transportation.

We had a very good collaboration with the staff in assisting us with everything.

There is a very good opportunity to continue and develop the work in this place with the local staff and contribute with surgical expertise.

We highly recommend Hernia Missions conducted on a regular basis to Sisters of Nativity in Abuja!

Things we might do differently:

Thinking sustainability from the start when doing the campaign, avoiding the heavy loads of single use gowns and drapes. Provide equipment that can be used further on.

Bringing more local anesthetics, antibiotics, painkillers and dressings.

We had to pay for registration to the Nigerian Medical Association which we hope can be negotiated at a reduced rate for future doctors.

We found (some of us) that diathermy was very useful and can recommend bringing it with you.

On behalf of the Team 2023

Yours sincerely,

Thorbjorn Sommer

Head of the Hernia International Mission to Abuja November 2023

FARAFENNI CAMPAIGN (GAMBIA). OCTOBER 20-29, 2023

STATUS: COMPLETED

Coordinators: Inma Giménez, Jose Mª Guallar

General Surgeons: José Mª Guallar, Berta Lluch, María Dolores Periañez, Ainhoa Andrés, Enrique Colás

Paediatric Surgeon: Rocío Lizarraga

Anesthetists: Francisco Llácer, Inma Giménez

Nursing Team: Javier Madrazo, Esperanza Galarza, Míriam Martínez

Total: 11 volunteers

REPORT

Given that Dr. Eduardo Perea’s report from last year was very helpful, I am borrowing his structure and incorporating common aspects for future missions.

TECHNICAL REPORT:

DATES AND LOGISTICS DEPLOYED:

Campaign conducted from October 20 to October 29, 2023

ADULT PATIENTS: Hernias (inguinal, umbilical, ventral, and inguinoscrotal), hydroceles, supernumerary breasts, ganglions, condylomas, lipomas, and sebaceous cysts.

PAEDIATRIC PATIENTS: Hydroceles, umbilical hernias, keloids ear/circumcisions, prepucial cysts, inguinal hernia, retractile scars, colostomy prolapse.

CONSULTATION AND SURGERY PERFORMED

Total procedures: 101 procedures

Total operated patients: 96 patients (including 33 paediatric patients, aged from 9 months to 11 years)

Patients seen in consultation: 161

Complications (within 7 days of our arrival):

– 2 seromas in inguinoscrotal hernias

– 1 seroma in supernumerary breast

– 1 folliculitis

– 2 cellulitis in pediatric umbilical/inguinal hernias

CAMPAIGN SUMMARY

THE LOCATION

Farafenni General Hospital was established in 1999 as part of the Gambian government’s effort to create a healthcare center of reference in the eastern part of the country. It is a well-equipped and organized large center with 250 beds, of which 175 are currently occupied, due to human resource limitations.

Farafenni is a small inland town strategically located next to the only bridge across the Gambia River, making it a transit point for local trade and travel between different parts of Senegal.

The population is approximately 25,000, providing services to both Gambian and Senegalese residents. While English is the official language, Wolof and Mandinka are the commonly spoken languages among the population.

The hospital is divided into an initial area for administrative offices and emergency care, and a nearby building for laboratory and testing, which connects to different wings for surgical patients, maternity, pediatrics, internal medicine, and dentistry, each with two floors.

In the surgical wing, there is a clean circuit with two large operating rooms, one dedicated to maternity and the other for general surgery. Each operating room is equipped with a basic ventilator capable of using halothane and an diathermy generator.

The operating rooms are equipped with split air conditioning, allowing comfortable work despite the high outdoor temperatures.

Obstetric material is not used due to the high number of emergency cesarean sections.

The surgery room can be configured to accommodate three tables simultaneously while allowing for easy patient entry and exit on stretchers.

THE TEAM

This time, we had a larger team than usual, consisting of five general surgeons, one pediatric surgeon, two anesthesiologists, and three nurses (you can find their names at the beginning. ( See Photo 2).

LOCAL STAFF

The hospital has a competent local staff that has been of great assistance. Thanks to our contact with a Cuban surgeon based there (Dr. Alain), we were able to operate on 16 patients on the first day (this would not have been possible without his prior patient selection).

Local nursing and auxiliary staff, including instrument specialists, anesthesia nurses, circulating nurses, orderlies, and cleaning staff, proved to be highly competent (see Photo 3).

The hospital also has a reception/recovery room where peripheral venous access is established before entering the operating room, facilitating the start of surgeries, especially for younger children.

EQUIPMENT

Given our larger team and the fact that it had been done in previous campaigns, we requested to work with three operating tables.

The hospital has one diathermy generator that can accommodate only one terminal. We brought various sutures from previous campaigns, but there were no meshes available.

There was only one monitor with a pulse oximeter and a blood pressure cuff, without an ECG.

ANESTHESIA

The operating room is equipped with a ventilator and two vaporizers for halothane and isoflurane, but only the first gas was available.

We primarily used the table where the ventilator was located for paediatric surgeries.

 We could work with manual and controlled IPPV ventilation, although monitoring the method of ventilation was not easy, we could assess tidal volume and respiratory rate, but there was no capnography.

Additionally, there was an oxygen condenser that could be used with a Mapelson if two general anesthesias coincided.

They had normal saline, abocaths, spinal anesthesia needles, and bupivacaine with dextrose available.

ASEPSIS AND SURGICAL MATERIAL

Basic surgical material boxes were available, with sufficient but deteriorated instruments. There was a laparotomy kit with more equipment than was used during the campaign. Surgical gowns and cloth drapes were sterilized using an autoclave.

Because we had a large team and considering the advice from the previous team, we decided to bring two additional diathermy generators, which allowed us to work on three operating tables simultaneously, even for procedures requiring electrical devices.

Bringing complete surgical drapes, gowns, and other disposable surgical materials and medications was very useful.

ACCESSIBILITY FOR THE POPULATION

The hospital is affordable and accessible to the population, with a charge of 40 Euro cents for Gambian residents and 80 Euro cents for Senegalese residents upon admission. Imaging and laboratory tests are charged separately, but the fees are not excessively high, although some patients may have difficulty paying.

OUR LIFE IN FARAFENNI

We traveled via Barcelona-Casablanca-Banjul, arriving in the capital at 1:30 AM. Mr. Sainey Dibba, the hospital’s logistics officer who helped with hotels, meals, and transportation, was waiting for us at the airport, along with other hospital staff.

 This made it much easier for us to clear customs and exit.

From there, we went to a nearby hotel (Lebato Hotel) to rest for a few hours before heading to Farafenni. The rooms had fans and allowed us to take a shower. They also had a beachfront view.

The following morning, we left for Farafenni with two cars. The journey took 3-4 hours on well-paved roads, but it was time-consuming due to traffic.

 In Farafenni, we stayed at the Wallyman Hotel, which was a 10-minute walk from the hospital and had a pleasant garden leading to individual air-conditioned rooms (the cost was approximately 110 euros per person for the entire stay).

It’s worth noting the sounds of the nearby mosque with repeated prayers at 5 in the morning :).

Upon arrival on Saturday afternoon, we began unpacking our luggage, which included 22 bags of material and medication. Dr. Alain had already prepared a list of patients for us to assess, but it was mostly on Sunday that they arrived, allowing us to start surgeries on the same day at 9 AM.

Our routine in Farafenni included walking to the hospital in the mornings at 7:45 AM for breakfast before starting surgeries.

Once at the hospital, the surgeons made rounds with patients who had been operated on the previous day, while the anesthesia and nursing teams prepared the surgical tables.

Surgeries would begin, and they continued until 2 PM, when we stopped for lunch at the hospital.

Afterward, we resumed surgeries from 3 PM until 6-7 PM (although some days we finished later, it was not the norm). It was several days of very satisfying work alongside the competent local staff.

On the last day, we met with Dr. Kebba Manneh and the rest of the hospital staff for a debriefing session, where we expressed our mutual gratitude for the successful campaign.

We believe it was successful based on the number of patients operated on and the opportunity to operate on pediatric patients.

Our flight departed in the early hours of Sunday at 2:30 AM, so we traveled in two cars to Banjul after the hospital meeting, accompanied by Mr. Sainey.

We decided to rest for a few hours in a beachfront hotel with a pool. From there, at 10 PM, we headed to Banjul Airport, en route to Casablanca.

CONCLUSION

Strengths of this location:

– Strategic location with a significant population in need

– Presence of a Cuban community with which communication and patient follow-up is easy

– Strong collaboration from the local hospital and its staff in assisting us with transportation, accommodations, and other logistics

– A significant number of Spanish foundations and NGOs working in Banjul and other rural areas can help access the needy population (it would be important to contact them well in advance of the campaign)

Areas for Improvement:

– Difficulty in filling out and sending forms, data, photographs, and other documents in the months leading up to the campaign.

– Creating an inventory of all materials and medications with expiration dates, manufacturers, and quantities is a challenging task when you are carrying 400 kg of luggage like us.

– It is impractical to pay 400 euros for medical registration to work in the campaign (initially requested, but we were later granted scholarships, and it cost us only 30 euros with expenses).

– If possible, bring both an endocrine surgeon and a pediatric surgeon.

– Bring an additional source of energy (electrocautery or Ligasure for thyroidectomies). Note that there is only one available, and we can work on three surgical tables simultaneously.

– The hospital accommodates a large multidisciplinary team.

– Improve patient recruitment so that surgical schedules can be created in advance (in the final days of our campaign, we ran out of patients. We were informed that the best period to go is in the last two weeks of November or the first week of December due to the employment situation of the population).

BUDGET:

COST PER PARTICIPANT:

– Round-trip flights with checked luggage: 480€

– Hotels: 120€

– Food: 100€

– Approx. Transportation and airport fees: 190€

– Miscellaneous: 150€

– Total: 1040€ per participant

TOTAL CAMPAIGN COST: Approximately 11,440€

Yours sincerely,

Inma Giménez Jiménez

Head of the Farafenni Campaign October 2023

Surgeons in Action

POLICE HOSPITAL CAMPAIGN REPORT – Oct 27-Nov 5 – FREETOWN, SIERRA LEONE

1. TECHNICAL REPORT:

DATES AND LOGISTICS DEVELOPED: The dates of the campaign were from 23 September to 1 October. The organisation of the campaign was easy because Dr. Paul Fillie put us in contact with the Medical Superintendent Medical Services of the hospital, Dr. John M Konteh (ASP), Resident Endocrinologist, who was quick to respond to emails and whatsapps. The director of the hospital, Dr. Mohamed Jalloh, agreed to the campaign and then all the emails went to Dr. Konteh.  We sent the volunteer certificate and with it we received the invitation letter. We sent the documentation for the temporary permits from the Medical Council and John processed it without the need to go for the interview of previous years. We also got our VISA online.  John booked the hotel for us, the same as on previous occasions, The Jam Lodge. Air tickets through a freelance agent of Halcon viajes (Angelis).

The material was collected by volunteers (I would like to thank the operating theatre staff of H U 12 de Octubre for helping me to collect a lot of material), and we must thank the effort made by the anaesthesiologist Rocío Armero who collected most of the anaesthetic material. Also to Dr. JM Morán Penco, a volunteer from Badajoz, who has participated in several campaigns, including the first one in Sierra Leone, and who obtained the autoclave that has been donated to the Police Hospital.  We received a donation of 600 € from the Centre de Diagnosi per la imatge de Tarragona, at the initiative of Francesc Marsal.

ADULT PATIENTS: A total of 77 patients (17 women) between 11 and 75 years of age were operated on.

Inguinal hernias 53, recurrent 6, bilateral 4. (Lichtenstein and Want techniques)

Femoral hernia 3

Umbilical hernia 5 (recurrence 1)

Epigastric/ supra-umbilical hernia 2

Hydroceles 4 (1 recurred)

Testicular tumour 2

Undescended testicle 1

Cord cysts 2

Lipomas 5

Facial tumour 1

Sebaceous cyst 1

Anal fistula 1

          Total procedures: 81

          Total patients 77

COMPLICATIONS: There were only 1 scrotal haematoma which resolved with conservative treatment.

2. CAMPAIGN REPORT

THE LOCATION: The hospital is located in the capital of Sierra Leone, Garage Road, Western area, Freetown. It is a 2-storey building that has a surgical area with 2 operating theatres, a larger one with a surgical table, standing lamp (low light), respirator (not working), O2 concentrator and scalpel generator (working), and the other smaller one with a surgical table, a photophore that was not working, a standing led lamp, scalpel generator (not working because the cable for the plate is missing),  between the two, a small area for surgical washing and washing of instruments and sterilisation in a small vertical autoclave, a room where we left the material on the upper floor and 2 other rooms on the ground floor with a table for consultation (anaesthesiologist’s room) and another adjoining an operating theatre that was fitted out for eating. It has 5 hospitalisation rooms, 3 on the ground floor with 8-10 beds each for men and women, with beds with mosquito nets and a nurse’s control table, where the patients stayed after the operation. In the room on the upper floor, the patients were prepared for the operation and then brought down to the operating theatre with their IVs in place. Several consultation rooms of different sizes where on Sunday we evaluated all the patients who had been previously recruited.

THE TEAM of volunteers was made up of

– General surgeons: Teresa Butrón (team leader), Francesc Marsal, Enric J Caubet, Rocío Fernández Sánchez.

– Anaesthesiologists: Eugenio Briz, Rocío C Armero.

– Nurses: Pilar Martínez Párraga, Carme Bordoy.

LOCAL STAFF.

A team of surgical staff from the hospital was assigned to carry out the campaign.

Hospital Director, Dr. Mohamed Jalloh, provided us with a letter of invitation to conduct the campaign. 

The Medical Superintendent of the hospital, Dr. John Konteh, accompanied us to the airport on arrival and departure and was always ready to help.  He processed the permits from the Medical Council after we sent him the documentation.  He booked the hotel for us.  He was very good at recruiting patients.

 Resident doctor: helped and assisted in some surgery.

Surgical area nurse supervisor: Mr. Unisa who facilitated everything and solved the problems in the daily work.

Nurses and others: Fatmata, Abdudakar, Samuel, Icanu, Anna, Francis, Mohamed, etc.  All with great interest, helping and participating in everything that was done.

This year the surgical technician was absent: Mr. Kelly Jalloh who assisted in the operating theatre in 2022.

EQUIPMENT (equipment of operating theatres, surgical instruments, fungible material): This year they had improved the equipment in the operating theatres. The ceiling lights were LED, the air conditioners were working, one of the diathermy generators was working, the other lacked the cable for the plate and so we had to use one of the two generators that we brought with us, the ventilator was still not working, there was an O2 cylinder and O2 concentrator.   It had a small vertical autoclave for sterilisation of the instruments; last year they brought sterilised instruments from another hospital due to the lack of their own autoclave.  We brought an autoclave (Matachana type) which Dr. Caubet, accompanied by Mr. Unisa, put into operation and its proper functioning was checked with the control strips that were placed inside. This autoclave was donated to the hospital (we and they are grateful to Dr. JM Morán for obtaining it).

There are enough instruments to make several hernia kits. There is a lack of suitable separators. The nurses, together with the local staff, made kits for hernias and other pathologies, so that the kits were optimised to fit the pathology for which they would be used and the packages were checked as they were prepared.

ANAESTHESIA regional and local anaesthesia with sedation was performed, only 2 patients had to be put to sleep due to pain/bleeding, as local anaesthesia and sedation was not sufficient. All the material was carried by the volunteers, as anaesthetic material is lacking or scarce in the hospital.

ASEPSIA AND SURGICAL MATERIALS the hospital has a small vertical autoclave and all instruments are washed and prepared in packages to be sterilised there. This meant that this year the kit was always available and a greater number of patients could be operated on each day.

OUR LIFE:  We had left the day before from Barcelona (Francesc, Enric and Carme) and the rest from Madrid; Roberto, Faustino Santisteban’s nephew, brought us some of the material (6 large packages including an autoclave and 2 electric scalpel generators).  The whole team of volunteers met in Casablanca and from there we flew together to Freetown.  Dr. Konteh was waiting for us at Freetown airport, before we picked up all our luggage and went through passport control (an anecdote is that some of them were asked for dollars / euros, we didn’t have to give in and give as the VISA is paid through the Internet). Dr. Konteh arranged for us not to pay a security fee of 25 dollars that has been introduced this year when entering and leaving Sierra Leone. It should be noted that the international airport is new, it was under construction last year.  With all our luggage we went to take the fast ferry (Seacoach) at a cost of 45 dollars per person  (we used the money donated for the campaign) and after the crossing, we were welcomed at the port with a big sign announcing the free campaign and a bouquet of flowers. We all travelled to our hotel, The Jam Lodge, in a police van driven by Samuel, a policeman who had accompanied us throughout the campaign and who was Dr. Konteh’s assistant. After a short rest, shower and light breakfast, we drove to the hospital where all the equipment had been brought. The nurses tidied up and the rest of us set about seeing all the recruited patients waiting in the hospital courtyard and finally preparing the surgical schedules for the following days.

On Monday at 8 am we went to the Police Headquarters where we were received at the official ceremony by the Inspector General of Police William Fayia Sellu, with the presence of the media who recorded everything with the words of him, Dr. Konteh and us who referred to the campaign and the donation of the autoclave, we were also interviewed and the news of the campaign appeared on the news.

Our daily routine from 25-30 September was breakfast at the hotel at 7:00. Transfer to the hospital where we changed and the anaesthesiologists and nurses prepared the operating theatre and the surgeons (with one of the nurses and local staff) visited the patients who had remained from the previous day. We would start operating in the large operating theatre and the smaller one in the established order, with a photophore in the latter and sometimes in the other. We ate in an adjoining room, food brought by a lady from there, based on pasta, rice, fish or chicken, spices and water. Between operations, we would occasionally assess patients and they would be included in the report. In general, every day the schedules was not completed because of a longer operation, and the next day we would start with those patients. The simplest pathology (lipomas) were scheduled for the last day and this meant that all the patients seen were operated on except for 4-5 patients with small lipomas.

The activities after finishing sometimes late, focused on the dinner at the hotel, 2 days with charcuterie, cheese and scoldings that Kiko brought and in one of them were John Konteh and Samuel. On the last night, Friday, we had a tour of the beach and tourist district, there were checkpoints and it was very crowded, it was late and we returned to the hotel. On Saturday morning the 30th we visited the remaining patients and collected all the material: we packed the diathermy generator and some of the anaesthetic material that was not going to be used there. We said goodbye to all the staff. Dr. J Konteh and Samuel gave us a daytime tour of the beach, a souvenir shop, lunch at a local restaurant and finally we went to a handicraft market and had some rest at the hotel before we were picked up again. We went to the hotel where the official farewell dinner was to be held from 7pm until after 9pm, presided over by the Inspector General of Police William Fayia Sellu and all the staff we had worked with. There we had a plentiful dinner with different starters and skewers of meat and fish, they thanked us and gave us a plaque and several personalized gifts, they invited us to do more campaigns and told us that they were going to improve the operating rooms to operate on children and other pathologies such as goiters, finally the dance, we all danced and the last dance was with the Inspector General. It was all very emotional and a good end to the campaign.    At 11 pm we were picked up at the hotel to go to the ferry&water to the airport. We told Dr. Konteh that there was no need for him to accompany us, he told us to call him from there and we did so because of a small inconvenience with the departure security fee of 25 dollars, the exemption letter had not arrived. It was all over with the objectives achieved.

3. CONCLUSION

                  Strengths of this place: location in the capital. Willingness of all local staff at all levels to help and solve problems if they arise. Security as it is a police hospital and they provide transport and permanent accompaniment. Good patient recruitment.

                     Objectives for improvement: Equip the operating theatres: improvement of lighting, plate cable of a diathermy generator, fix the respirator if they want us to operate on goitres and children.  Adjusting the kits to the pathology to be operated on so that there is a greater number and more patients can be operated on in a day.

                                                                                      Optimisation of time: Involve all staff so that there is synchronisation and preparation and time between patients is reduced.

4. BUDGET:

COST PER PARTICIPANT: Air ticket 800 € + Hotel single 450 €, double 350 € + meals and ferry airport: 140 € + VISA 80 € = 1470- 1370 €.

TOTAL COST OF THE CAMPAIGN: 8 volunteers: 11.500 €.

+ cost of medical supplies.

                                                 Teresa Butrón

                                                 Team Leader

                                 Surgeons in Action/ Hernia International

HERNIA INTERNATIONAL MISSION TO KOROGWE, TANZANIA. JUNE 2023

THE TEAM

John Hobbiss. Surgeon

Fernando De Santiago Urquuijo. Surgeon

Steffen Rose. Surgeon

Kristof Nemeth. Surgeon

Jenny Hobbiss. Surgical Assistant

Ajaiya Mull. Anaesthetist

Claire Fenn. Operating Department Practitioner

Olivia Sibly. Nurse

THE HOST

We were welcomed at Dar Es Salaam Airport on our arrival in Tanzania by Dr David Siwiti, who works with Sister Avelina at Korogwe District Hospital and who had done all the organising of our mission from the Tanzanian side. About two months previously, Dr Siwiti had requested lists of all the medical equipment and drugs that we were planning to bring, so that he could forewarn the Tanzanian customs about our visit. At that stage, the lists that we produced were inevitably provisional. These provisional lists, along with Dr Siwiti’s presence, were sufficient and all our bags were allowed through Customs without undue delay. After a night in an airport hotel, we set out on the six hour journey to Korogwe. The road is now tarmacked all the way to Korogwe. The minibus that Dr Siwiti had hired for us was air conditioned, the scenery was varied and full of interest and we had a pleasant stop for lunch half way there. Our journey was nothing like the ordeal that previous missions seemed to have experienced.

Korogwe is a market town on the road to Arusha and Kilimanjaro. It is described in Lonely Planet as a “scrappy” town, to be passed through rather than to stay in. We found it to be crowded and vibrant, busy with traders, market stalls and motor bikes. In the market there was a great variety of locally grown vegetables for sale as well as sacks full of dried fish, from Tanga and other coastal towns. Korogwe is situated in a picturesque region, surrounded by cultivated fields and overlooked by rolling hills. At the time of our visit, everything looked lush and green. Maize was the most abundant crop but we also saw oranges being harvested, fields of pineapples and rice was being cultivated in paddy fields within the town itself.

Korogwe District Hospital is the main provider of hospital services within the town, with general medical, surgical, paediatric and maternity wards and an Emergency Unit. The surgical services are provided by Sister Avelina, supported by Dr David Siwiti and others.

There have been regular Hernia International missions to Korogwe since 2014, the most recent being a Spanish mission in 2022.

OUR WORK

We had made it clear prior to our arrival that we wished to restrict our work to hernia surgery. This was in contrast to the Spanish team that visited Korogwe last year, who undertook thyroid surgery in addition. We were greeted on the Sunday evening at Korogwe District Hospital by Sister Avelina. There was a queue of patients waiting to be seen. Whilst some of the party organised the equipment and drugs in the operating theatre, the rest of us assessed the patients, marking the surgical sites of those that we agreed to proceed with over the next few days.

We spent five days operating in the two theatres provided. These were roomy theatres with some air conditioning, functioning electrocautery and reasonable theatre lighting. There is a small third operating theatre that was used for caesarean sections whilst we were there. We were told that we could use this if needed but the two main theatres were adequate for us.

On most days, we were asked by Sister Avelina to see patients who had presented urgently to the hospital. A number of these required surgery and we were able to help Sister Avelina with these cases and to operate on them when appropriate.

We operated on 42 patients. There were 16 inguinal hernia patients, 4 of whom had bilateral hernias, making a total of 20 inguinal hernias repaired. Using The Kingsnorth Classification, nine were classified as Grade 1, seven Grade 2, one Grade 3 and three Grade 4. There were nine midline abdominal wall hernias, four umbilical hernias and three incisional hernias. The three incisional hernias were in women with lower midline incisions from previous Caesarean sections. We operated on six patients with hydroceles. One of these, a 63 year old man with a long history of a scrotal swelling, had a swollen irregular feeling testicle within the hydrocele. Dr Siwiti advised us that this was probably due to filariasis. He recommended orchidectomy, to which the patient readily consented.

In addition to the “hernia” cases, we undertook two laparotomies for ovarian cysts. One was a massive cyst, very symptomatic due to its size, in a 40 year old woman. It was full of thick mucus and presumed to be a mucinous cystadenoma. There were no macroscopic stigmata of malignancy and we hope that she has been cured. The other ovarian cyst was in a 22 year old lady, who presented acutely with pain and had an easily palpable, very tender abdominal mass. This was a large, tense cyst that was filled with chocolate fluid from a bleed. Again, there were no stigmata of malignancy.

Sister Avelina asked us to see a 16 year old girl with a discrete swelling the size of a large walnut in the right submandibular salivary gland. It had been present for at least a year. We thought that it was probably a pleomorphic adenoma. It was mobile on bimanual palpation and we decided that it was potentially curable if removed now, but perhaps not if it was left for several more months. The anaesthetic presented a problem as we had no facilities for general anaesthesia with intubation. Local anaesthetic was used with intermittent boluses of ketamine.  A discreet tumour was removed intact. There will be no histological confirmation, but if it was a pleomorphic adenoma then we can expect a cure.

On our final morning we were asked to see an 80 year old man who had presented with intestinal obstruction. Clinical examination and a plain abdominal x ray confirmed the suspicion of a sigmoid volvulus. We were surprised to find that there was no rigid sigmoidoscope in the hospital with which to attempt deflation and that the usual management would be to proceed to laparotomy. This, with a certain degree of consternation, we agreed to do but only after speaking to the patient’s son about the potentially fatal outcome. We found a large, very tense sigmoid volvulus, which was resected. Intestinal continuity was restored with a primary anastomosis.

Although we were a five surgeon team with only two operating theatres, we were all kept busy for most of the time. If we weren’t operating, we were assisting and, if we weren’t assisting we were acting as scub nurse. It was, perhaps, no bad thing for us surgeons to acquire experience of working as the scrub nurse, even if it was, for some of us, at least, rather late in our careers.

A special mention must be made of our anaesthetic team of Ajaiya and Claire. Ajaiya anaesthetised all the patients with the invaluable assistance of Claire. All our patients were given spinal anaesthetics apart from the girl with the submandibular tumour. The laparotomies required lengthy incisions and considerable intra-abdominal manipulation. Boluses of ketamine were given as required. Without the skills and positive attitude of our anaesthetic team, our surgical activities would have been considerably restricted. In addition to providing the anaesthetics for our patients, Ajaiya and Claire also gave spinal anaesthetics to four caesarean sections that were performed in the third operating theatre during the week of our stay.

The role of the nurse in our team, Olivia, was to act as co-ordinator between the operating theatres and the wards. She ensured that each patient received their pre-op antibiotic and had the correct antibiotics and analgesics on discharge. .In hospital practice in the UK, medication for in patient use is provided by the hospital and the administration of it is strictly controlled by the ward nursing staff. In Korogwe, where the patient or their relatives have to buy and keep their own medication at the bedside, there is a different emphasis on the responsibility of drug provision. It was very helpful, therefore, to have a team member to organise the drugs that we had bought with us and make sure that each patient received the correct medication.

COMPLICATIONS

One 60 year old man who had surgery for a hydrocele developed acute urinary retention overnight. Dr Siwiti was unable to pass a catheter and had relieved his symptoms by suprapubic aspiration. We had a stiffer, non-retaining catheter in our equipment. This we were able to pass and with the dilatation that this provided, it was then possible to pass one of our Foley catheters. If he requires a prostatectomy, it will be done as a trans-vesical procedure by Sister Avelina in the hospital close to her convent.

Another patient, who had an irreducible direct hernia containing bladder had required a repair of her bladder. She was sent home with an indwelling catheter with instructions to return for removal in ten days’ time.

Otherwise we were not aware of any complications. We were pleased to see a symmetrical smile on the face of the girl who had the submandibular tumour excised. We had a message from Sister Avelina a few days after we had left that all patients were doing well. This was accompanied a day or two later by a photograph of the man who had the sigmoid colectomy, sitting at the side of his bed, looking well and drinking from a cup, with Sister Avelina standing at his side.

EQUIPMENT

Each operating theatre had a diathermy machine which worked well. The operating lights were satisfactory. We used a sterile glove tied around the light handle to allow manipulation by the surgeon. The electricity supply was fairly consistent but there were times when we had short-lived black outs and, on those occasions, it was very useful to have a headlight as an independent light source.

The quality of the surgical instruments provided by the hospital was generally poor. The scissors were blunt and very often an inappropriate size. Many of the needle holders functioned badly and failed to grip the needles adequately. We had some of our own instruments brought by Fernando and Steffen. These were used for the more challenging cases and proved very useful. The ladies working in the sterilising department, next to the operating theatres, helped to keep these instruments together as a separate set and not mix them with the hospital instruments. Identification marks on these instruments would have helped with this. We had brought some disposable operating gowns with us and some disposable drapes, but not in sufficient quantity for all our cases. We, therefore, had to use those provided by the hospital for some cases later in the week. These were satisfactory.

We had brought some disposable operating gowns with us and some disposable drapes, but not in sufficient quantity for all our cases. We, therefore, had to use those provided by the hospital for some cases later in the week. These were satisfactory. Future missions need not feel that they need to provide enough gowns and drapes for all their cases although some sterile drape packs would be useful for selected cases.

ACCOMODATION AND SUBSISTENCE

Dr Siwiti arranged accommodation for us at the Korogwe Executive Lodge, a fairly new hotel about ten minutes by car from the hospital. The rooms were clean and comfortable, the food (breakfast and dinner) was good and the cost was reasonable. We had dinner there every night apart from on our last day, when Sister Avelina invited us to visit the Convent, where she has lived for more than thirty years. We were shown the hospital close to the convent where she works in addition to Korogwe District Hospital. We were very kindly provided with dinner at the convent.

EXPENSES

We were confronted with two expenses on this mission, which we had not anticipated. Firstly, we were asked to pay for our Temporary Registration Certificates from the Tanzanian Medical Council and, secondly, we were asked to pay for food (breakfast and lunch) for those members of the hospital staff involved with our mission.

We had been informed by Dr Siwiti about the need to pay for our temporary registration applications several weeks before we travelled. The costs were $200 for each doctor’s registration and $100 for each nurse. Dr Siwiti informed us that the Medical Council of Tanzania had changed their policy and now insisted that all doctors who came to work in Tanzania, should have formal temporary Registration, for which they would be charged the standard rate. This was irrespective of whether they were being paid for their work or whether they were working free of charge for a charity. It was also irrespective of how long they would be working in Tanzania, and applied even if it was only for five days.  Previous missions have not paid a fee for temporary registrations and, as far as I know, nor has the hospital. I think that, in the past, the Tanzanian Medical Council did not ask for payment from volunteer doctors working for a short period of time. 

Andrew Kingsnorth agreed that Hernia International would pay the registration fees on this occasion. The money was sent to the Tanzanian Medical Council, along with the application forms, by Korogwe District Hospital and we took $1400 in cash, which we handed over to Dr Siwiti on our arrival.

The other unexpected expense was money for breakfast and lunch to be supplied by the hospital for the eight members of the mission and the hospital staff associated with the mission. Dr Siwiti had posted a WhatsApp message to the group two days before our departure, telling us that a meeting had been held and it had been decided that food would be provided for both us and the other hospital staff. The total cost would be $1600 and, please, would we agree to pay for it? We said that $1600 seemed a lot for hospital food for five days. Dr Siwiti said that they had worked out that there would be forty people to feed, eight of us plus thirty-two members of the hospital staff, including nurses, doctors and sterilizing unit staff.

We agreed that we would pay for this food on the first day and then decide whether to continue after that. The food that was provided for us on that first day was much more than we wanted and we told Dr Siwiti that we only wanted a snack at lunchtime. However, the food provided for the hospital staff was clearly much enjoyed by them and it continued to be supplied for the whole week. On the final day Dr Siwiti asked us whether we would pay $800, half the original sum, for the food. This we did, each contributing $100.

We were happy to provide some sort of reward for the staff who were having to do extra work on account of our mission, in particular the staff on the wards and the staff in the sterilising unit. We were, however, surprised to be confronted with this request for a significant extra payment immediately before the start of our mission.

When the Spanish Mission, led by Cesar Ramirez visited Korogwe last year, they elected to work late into the evenings. As a way of compensating the hospital staff, who were required to stay late on account of this, the Mission made a contribution of $1000 to the hospital. It may be that this gesture has set a precedent and that in the future, missions to Korogwe will be expected to make a contribution for the additional workload that is created. This is something that should be discussed and agreed with the hospital before the start of a mission.

CONCLUSION AND ACKNOWLEDGEMENTS

As we sat on the quayside looking out over the bay after our journey back to Dar es Salaam, we were able to reflect on what had been a very fulfilling time for each of us. We had left Korogwe and the hospital with a feeling of affection for the place and its people. We were inspired by the work that Sister Avelina has done, and continues to do there and we have great admiration for all who work in Korogwe District Hospital, often under very difficult circumstances.

Many thanks to Dr David Siwiti for all the time spent organising our mission, particularly with regards to the problems posed by the policy change by The Tanzanian Medical Council. We would also like to thank him for meeting us at the airport, facilitating our bags through customs and then transporting us from and back to Dar es Salaam. Thank you also to Dr Siwiti for transporting us on a daily basis between the hospital and the Korogwe Executive Lodge and for his practical help in the operating theatre and on the wards.

Thank you to the ladies in the Sterilising Department, who worked hard to keep us supplied with instrument sets, gowns and drapes.

Thank you to the nurses on the wards and to all who were involved with the care of our patients.

Thank you to Dr Boni, a surgeon from Muheza, who came to the operating theatres every day and accompanied us on our daily ward rounds. In both settings his presence was most helpful.

Thank you to Sister Avelina, without whom there would have been no mission and who provided support in the operating theatre in whatever capacity that was required, be it scrub nurse, surgical assistant, runner or patient organiser. A particular thank you to her for inviting us to her convent after our last day’s work and for the hospitality that was provided for us there.

PEDIATRIC SURGERY CAMPAIGN GAMBIA APRIL-MAY 2023 SURGEONS IN ACTION–ASEDA-CHOSAN

DATE 23 May 2023

1. TECHNICAL REPORT:

a. DATES AND LOGISTICS DEVELOPED: The campaign was held at Bundung Hospital in Serkunda from 30 April to 8 May 2023.
▪ The group of volunteers consisted of 5 pediatric surgeons, 3 pediatric anesthesiologists and
3 operating room nurses, all SAS personnel.
▪ The project was supported by the work of local volunteers from the Chosan Charitable
Foundation, many of them Bundung Hospital staff and volunteers from Aseda Gambia.
b. PEDIATRIC PATIENTS:
▪ Umbilical hernias
▪ Inguinal hernias
▪ Testicular maldescent
▪ Soft tissue tumor removal
▪ Circumcision (in patients included for any of the other pathologies)

Total procedures: 168

• Inguinal hernia 78
• Umbilical hernia 61
• Orchidopexy 7
• Circumcision 18
• Tumor excision 2
• Urethral meatotomy 1
• Hydrocelectomy 1

Total patients: 132

c. COMPLICATIONS: in the days following the campaign have been documented:
▪ Surgical wound infection in 4 patients, one of them required drainage, the rest were treated
with oral antibiotics.

2. CAMPAIGN REPORT

a. THE PLACE:
▪ Bundung Maternal-Children’s Hospital in Serekunda. Monographic maternity and children’s
hospital with obstetrics, gynecology and pediatrics hospitalization area. It has a consultation
area, several laboratory facilities, emergency area and surgical block. It also has a private
obstetrics wing that is currently unused.

1. The SURGICAL AREA has a wake-up room/area, two operating rooms, office (for local staff), rest
   room (for local staff) and dressing room with toilets. It has a reception area, instrument washing
   and preparation room, sterilization room (with non-functioning equipment) and a lobby. The area has
   two operating rooms, separated by a door.
   a. Endowment of the awakening/area:
   i. 5 beds
   ii. A single working oxygen inlet
   b. Operating room facilities: The two operating rooms are in very condition, have sufficient
   electrical outlets, are spacious and neat. They have tables for instrumentation as well as some
   work/intrumentation tables. In the area there is a medication cart, which is not up to date, and
   there is no crash cart or defibrillator.
   i. Air conditioning
   ii. Operating Room 1:
2. Respirator with sevofluorane vaporizer, without adapter (the sevo is “poured” directly into
   the vaporizer), halothane.
3. Monitoring: EKG, blood pressure and pulse oximetry
4. Oxygen from bottles
5. Operating room table
6. Light
7. Vacuum cleaner
   iii. Operating Room 2:
8. Respirator for halothane and isoflurane gases.
9. Monitoring: electro, tension and pulse oximetry.
10. Oxygen in wall outlet
11. Operating room table
12. Light
13. Vacuum cleaner
    c. There is a sterilization service, where we were able to sterilize the instruments.
14. OUTPATIENT CONSULTATIONS: We had two consultation rooms in a pediatric outpatient area. Only one
    of the rooms has a couch for examination.
15. Preoperative preparation:
    a. Patients waited for surgery in the outpatient waiting room or in the corridor leading to the
    operating room. There is no specific area, since Bundung only performs surgery on a regular basis
    on women.
16. Postoperative care: patients were transferred to the “High Dependency Unit” ward until they
    were ready to be discharged. It is a shared hospitalization room with 8 beds, annexed to the
    postpartum admission room.
    b. RECRUITMENT: It was carried out by Dr. Sanyang, Chosan and Aseda- Gambia. A campaign was
    conducted through radio and Lamin’s school (Aseda). More than 200 child candidates were recruited,
    many of them are still pending for future campaigns.
    c. SURGICAL CIRCUIT: The work dynamics were established following the CMA circuit:
    ▪ Assessment of patients in consultation
17. The initial plan was to review the patients recruited on the first day, which was lost when
    our arrival in Banjul was delayed.
18. Patients pre-selected by the local team (Dr. Sanyang (surgeon) and Ebrima Fatty (pediatric
    nurse) were assessed for surgery and anesthesia and scheduled each day at the beginning of the day.
19. Patient registration, medical record documentation provided by Bundung/Kanifing hospital,
    identification.
20. Preanesthetic assessment, patient marking, informed consent.
21. Patients with suspected hernias or other pathologies were reviewed and scheduled for
    subsequent dates or registered for future campaigns.
    ▪ Preanesthetic evaluation: Together with the surgeons, and with the help of nursing students
    who acted as interpreters to facilitate communication with the families, a preoperative evaluation
    of all patients recruited for the campaign was performed. Patients with intercurrent respiratory
    processes, probable difficult airway, or unfiliated heart murmurs were qualified as ineligible.
    ▪ Preparation of the surgical report: Given the resources available in the operating room, and
    the unavailability of sevoflurane in one of them, an attempt was made to schedule patients of
    lesser age or greater complexity in the operating room with sevoflurane vaporizer.

▪ CMA Circuit

1. Waiting room
   a. Attempts were made to maintain patients on oral hydration until two hours before surgery.
2. Anesthesia room
3. Operating Room
4. Wake-up room
5. (HDU), some patients stayed overnight because of difficulties in returning home or because
   they were operated on very late.
   ▪ Review of surgical patients:
6. Some patients who consulted for postoperative pain or suspected complications were reviewed.
   No patient presented complications during our stay in Bundung.
7. Appointments at Kanifing Hospital in 7-10 days after surgery.
   3.

b. THE TEAM (group members):

1. (brief description of the hospital and the area in which it is located, surgical equipment,
   post-surgical and hospitalization rooms, how we have found it, operation of the practice,
   recruitment,….)

▪ Team leader: Rosa M Romero Ruiz
▪ Pediatric surgeons: Rosa M Cabello Laureano, Rocío Vizcaíno Pérezo, Eloísa Díaz Morenoo,
Constanza Valenzuela López.
▪ Pediatric anesthesiologists: Felisa Marin Hernándezzo, Rosario Picón Mesa, Álvaro José
Sepúlveda Iturzaeta.
▪ Nursing: Rosa María Soldevila Rodríguezo, María del Rosario Gil Muñoz, Rocío Sanjusto Bravo.

c. LOCAL STAFF
▪ Chosan Charitable Foundation: (Haruna Jallow) The Chosan Charitable Foundation, formed by
health professionals with the aim of improving the health system in The Gambia, was responsible for
the organizational tasks in The Gambia. Its president Haruna Jallow was in charge of the
legalization of the volunteers of this project at the Ministry of Health, College of Doctors and
Nurses of The Gambia. Her organization was responsible for the transportation of volunteers from
accommodation to the hospital, food on working days and relations with local professionals and
patients. They were instrumental in the recruitment of patients, organization of the working days
and support work.
▪ CEO of Bundung Hospital (Dr Mamady Cham) made available to us the consultation rooms,
surgical block and HDU for the development of the campaign.
▪ Health personnel Bundung Hospital:

1. Outpatient clinics: Ebrima Fatty (Bundung nurse and Chosan volunteer) was instrumental in
   recruiting, organizing the clinics, administrative work and patient assessment.
   a. The percentage of patients who do not read or write and only speak local languages is very
   high. The nursing students and other volunteer nurses and

laboratory scientists (Chosan) were instrumental in enabling us to communicate with patients and
families.

2. Operating room: Betts Rikiatou (nurse anesthetist, responsible for the surgical block). She
   supported us at all times in the organization of the operating room and cooperated clinically with
   our team.
   a. All the operating room staff (nurse anesthetists, orderlies/cleaners, nurses) were involved
   and collaborated with our team.
   ▪ Kanifing Hospital. Kanifing Hospital was the place where this campaign was to take place.
   However, our dates coincided with the dates of a group of Canadian volunteers (Doctors in Action).
3. Visit to Kanifing Hospital: it is a general hospital, which has two operating rooms, one for
   emergencies and one for emergency. The most frequent urgent procedure is cesarean section.
   a. Respirators: only one of the respirators can be used with sevoflurane.
   b. Electric scalpel: available in both operating rooms.
   c. Smaller operating rooms and generally not in such good condition.
   d. During our stay, the Canadian volunteers informed us that they had to interrupt their activity
   due to ventilator malfunctions.
   e. This hospital has an ophthalmology operating room that looks pretty good, albeit with a very
   old ventilator. Monitoring?

f. EQUIPMENT:

• Operating rooms:

1. Operating Room 1:
   a. Boaray 600D Respirator with halothane and sevoflurane vaporizers
   b. Standard monitoring (ECG, SpO2, PANI)
   c. Wall-mounted oxygen intakes. Portable aspirators. Portable oxygen concentrator.
   d. General anesthesia was performed with induction and maintenance with inhalation anesthetics.
2. Operating Room 2.
   a. Dräger RIMAS 2000 respirator with halothane and isoflurane vaporizers. This ventilator has a
   connection for external circuit that, in order to use it, it is necessary to disconnect a piece
   that cancels the

possibility of alternating with mechanical ventilation. It does not have a pediatric mode.
b. Standard monitoring (ECG, SpO2, PANI)
c. Wall-mounted oxygen intakes. Portable aspirators. Portable oxygen concentrator.
d. Both general anesthesia (TIVA) and neuroaxial anesthesia were performed.

3. Shortcomings in the surgical area:
   a. Anesthesia machines should undergo daily calibration to ensure adequate ventilation of the
   patient.
   b. Capnography not available in any of the operating rooms.
   c. Defibrillator
   d. Power outages
   e. Interruptions in oxygen supply
   ▪ Postoperative care
4. Recovery room: Located in front of the operating rooms. It has 5 beds. A single oxygen outlet
   on the wall, which was solved by three-way connectors that allowed having up to three external
   circuits to be used simultaneously. It only has two portable pulse oximeters.
   Postoperative analgesia is prescribed orally with ibuprofen (oral suspension or tablets).
5. High Dependency Unit” hospitalization ward: Once the patient was conscious, with adequate
   muscle tone and controlled pain, he was transferred to the ward (HDU) to continue nursing care and
   start tolerance. The average stay was 4-5h, including time in the awakening room and on the ward.
   The anesthesiologist in charge of the postoperative period assessed the patients prior to
   discharge, and the doctor on duty at the Bundung Hospital signed the discharge home.

g. ASEPSIS AND SURGICAL MATERIAL:
▪ Surgical hand washing: Hibiscrub / alcohol gel
▪ Field preparation:

1. Chlorhexidine wash and dye chlorhexidine
2. Expendable ophthalmology sterile drapes/adhesive drapes.
3. Expendable gowns.

▪ Instrument preparation: scrubbing and washing with instrunet, local steam sterilization.

h. OUR LIFE IN SEREKENDE:

We stayed at the Senegambia Hotel, where we had breakfast almost every day together. The days
started at approximately 8:00 a.m., when we were picked up by the volunteers from Chosan and taken
to the hospital in their vehicles. Upon arrival at the hospital, one team would go up to the
surgical area to prepare the operating rooms and another team would go through the consultation.
Once the operating room was prepared and checked, the surgical activity started and the
consultation continued at the same time until all the patients planned for that day were checked.
The two operating rooms were used simultaneously, sharing the electric scalpel, giving preference
to smaller patients in the operating room with sevo.

We took advantage of the break to sterilize the instruments to eat. The volunteers from Chosan
(Martida, Binta, Timah, Rohey) brought us local food, fruit, drinks….

At the end of the day, the patients who were to remain on the ward were checked and the operating
rooms were tidied and the material was prepared for the following day.

“Normality” was interrupted by urgent cesarean sections, which used operating room 2, limiting us
to a single operating room during those hours.

Once the work day was over, the volunteers from Chosan would take us back to the hotel and we would
have dinner at one of the nearby restaurants.

We had two visiting days, one that we organized ourselves and the day we were traveling back
organized by Haruna Jallow and the Chosan volunteers. On that day we were received by the president
of the Gambian government and visited Lamin Lodge and Senegambia beach.

3. CONCLUSION

Strengths of this place:

o Involvement of the management team
o Involvement of cooperating NGOs in the project:
▪ Aseda: Involvement of NGO management, financing of expenses and relationship with Bundung’s
management.
▪ Chosan: involvement of the president of the association, interest in establishing a long-term
project and involvement of volunteers. It is worth mentioning the collaboration of Dr. Sanyang who,
as a surgeon, is very involved in the diagnosis, recruitment and follow-up of patients for this and
future campaigns.
o Involvement and willingness to cooperate by the Hospital Bundung Leaders. o Involvement and
willingness to cooperate on the part of hospital personnel o Good general condition of the
facilities
o Ability of facilities to accommodate similar campaigns
o Translators: the involvement of volunteers from Chosan, Bundung and nursing students is
essential. Most families do not speak English.

o Good health status of the patients: in general the children were in a good state of nutrition and
health, they were well cared for and family support could be seen. The families were initially
quite reluctant, but later they were very grateful and confident.

Improvement objectives:

• Better adjust the material for the campaign and reduce the material that can be acquired
  locally and that is cheap:
  o Syringes/needles
  o Gowns
• Equipment:
  o Electric scalpel generator
  o Sevofluorane vaporizer: it would improve work dynamics if sevo could be used in both operating
  rooms.
  o Capnograph: would allow for safe surgery on smaller patients than those operated on in this
  campaign
  o Postoperative analgesic medication
  o Maintain the planning of the campaign, with assessment of patients on the first day and
  organization of the reports in a more efficient way.

1. BUDGET: (small breakdown of expenses)
   Concept Amount
   Flights 9 4.183,76
   Flights 2 1.037,72
   Penalty 279,52
   Flights 1 553,79
   Van rental Seville-Malaga 36,1
   Van insurance 10,4
   Travel bags 279,93
   Car rental Seville-Malaga 1 128
   Car rental Seville-Malaga 2 128
   Gasoline 48,04
   Hotel Senegambia 3247
   Other living expenses 250€pp 2750 12.682,26

COST PER PARTICIPANT: 1152,93 €.

TOTAL COST OF THE CAMPAIGN: 12682.26 €.

Fdo: Rosa M Romero Responsible for the campaign Surgeons in Action

HOLY INNOCENT HOSPITAL (HIH) CAMPAIGN, KAMUTUR, UGANDA 17-27 MARCH

The Kamutur campaign is a regular location for humanitarian surgical cooperation within the agreements of Hernia International, Surgeons in Action and the Holy Innocents Hospital (hereafter HIH) located there for years. It usually hosts an average of 2-3 campaigns per year and its local coordinator, Moses Asia, is a person highly regarded by our organisations for his leadership capacity in the local community of Bukedea County, for his good work in the coordination of the campaigns and for his determination to build a health care space in a geographical area in Uganda with very difficult access to health care. In addition, Moses Asia enjoys the confidence of the regional and national health authorities in the country.

This campaign was organised from the end of 2022 and the objective was to be able to recruit a significant amount of surgical pathology focused on goitres, hernias of all types (including children), splenomegaly, minor general surgery and everything that could be susceptible to being safely treated surgically after its evaluation in consultation by our team. Moses Asia’s estimates, reflected in writing in our whatsapp conversations, were to recruit 68 large goitres, more than 100 hernias and hydroceles and other pathologies to be able to consider 200 cases for surgery.

With this objective, the Surgeons in Action team was sized with three general surgeons (César Ramírez, team leader, Marta Roldón and Jorge Verdes), a 5th year resident in General and Digestive Surgery (Dr. Ainhoa Maestu), two anaesthesiologists (Javier Mora and Carlos Ávila) and three nurses (Francisco Gómez, Sara García and Leire Gascón) in order to work simultaneously on a minimum of two
operating tables and, if available, an additional third one). From my previous visit to HIH, I
already know that a minimum of two operating theatres can be used every day (only one of them has a ventilator) and there is a third table in another room that can be used to operate with spinal anaesthesia and minor surgery. Therefore, based on the estimates that Moses Asia had given us, a team capable of working on three operating theatres every day was put together. We were also accompanied by a volunteer journalist, Javier Budi, who made a visual documentary report of the work carried out.

With these objectives in mind, the departure and arrival at Malaga airport was planned for 17 and 27 March 2023, respectively, with a healthcare activity schedule that included the assessment of patients in the outpatient clinic on the afternoon of 18 March in 2-3 physical spaces and the start of surgical activity on Sunday 19 March without interruption until Sunday 26 in the afternoon at 17:00 hours, thus allowing 7.5 full working days to be completed. The travel plan was as follows: Departure from Malaga on Friday 17/03 in the morning (12h local time), arrival in Istanbul (16h local time) for boarding transit to Entebbe and arrival in this city at the foot of Lake Victoria at 3h a.m. on 18/03, also Ugandan local time. Once in Entebbe, we were picked up by a bus that took us on the 7-hour journey of irregular and intermittent tarmac roads from Entebbe to Kamutur, where we arrived at 3pm Ugandan local time on the same day, 18 March. A member of Moses Asia’s administrative staff at HIHC was waiting for us at the airport.

Compared to my visit just 3 years and 3 months ago to Kamutur on the campaign I coordinated in December 2019 (just pre-pandemic Covid) few things have changed at HIH. It still retains its rural and cosy feel, there is still no running water in the taps and no showers either, being necessary to use water drawn from an underground well every day and stored in vats of all kinds by HIH for daily washing and hygiene by dragging from the toilets, which drain into a septic tank. However, Moses has set up an enclosed shower area as a changing room so that daily washing does not have to be in the open air. The huts used for volunteer accommodation still have comfortable bunk beds, individual mosquito nets and a small towel was available each day, which was changed by the health
support community there. The resuscitation and post-surgical recovery ward attached to the surgical area that was started 3 years ago with the contribution of the Bisturí Solidario Foundation is only half built, as the arrival of the pandemic and the lack of funds have prevented its completion.

The availability of electricity in the operating theatre area continues to be a major handicap, as it is limited and dependent on sunlight, it frequently gives out and once the sun goes down it starts to fail quite a lot. The use of the anaesthesia machine for this reason is very limited, so that almost 90% of the surgeries, including those of giant goitres, have been performed with spontaneous ventilation (thanks to the great effort and support of the anaesthesiologists), leaving spinal anaesthesia for the rest of the pathologies.

The total number of patients operated on in this campaign was 91, for a total of 102 surgical
procedures performed, and can be listed as follows: 41 cervical endocrine surgeries (21 unilateral subtotal thyroidectomies, 19 total thyroidectomies and one thyroglossal cyst), 15 hernia surgeries (10 inguinal hernia surgeries and 5 midline hernia surgeries), 2 hydrocele surgeries, one splenectomy for giant splenomegaly, 11 total hysterectomies with double anexectomy (for tumours or pelvic inflammatory disease), one gastrostomy for a patient with oesophageal cancer, one gastrostomy for a patient with oesophageal cancer, and one gastrostomy for a patient with oesophageal cancer, one feeding gastrostomy for a patient with oesophageal cancer in aphagia, one palliative colostomy for a patient with a locally advanced and stenosing rectal neoplasm (frozen pelvis), 10 proctological surgeries (fissures, haemorrhoids and tag-skins) and 9 patients with various procedures performed under local anaesthesia (keloids, lipomas and supernumerary fingers).

The evolution of the patients has been correct, with no perioperative mortality and only two reoperations after thyroid surgery (one for superficial haemostasis of the wound and the other for deep exploration due to evolving haematoma); in the follow-up, Moses Asia has informed us of 5 patients with superficial infection of the surgical site that we have helped to treat via whatsapp. All thyroidectomies were discharged the following day and no cases of hypocalcaemia were reported.

The collaboration of the operating theatre staff has been extraordinary, so that we have had three nurses and three cleaners who have been highly efficient in their performance and who have worked tirelessly every day. With the volume of surgical activity and the
complexity of post-surgical recovery of thyroidectomy patients, the nurses were unable to scrub with us during the surgeries, as they were always busy with patient transport, circulation cleaning of equipment and anaesthetic recovery.

We would have loved it to be otherwise, but technically it was impossible. On the fourth day of our stay, we received a protocol visit from the county health authorities, who evaluated the functioning of the work circuits and gave a positive assessment. I myself explained everything about our activity, how we organised the campaign and what we were doing there, and the feedback was very good.

From Malaga, the team’s departure point, 21 packages have been transported to carry 430 kg of material, including a Ligasure donated by Medtronic that accompanies us every trip, more than 300 meshes and hundreds of sutures, of which more than 75% have returned to Spain with us (HIH is a medical centre where there is no routine surgical activity outside the cooperation campaigns and they were not going to be used there in the near future). Similarly, many surgical gowns, gloves, anaesthesia equipment and sterile drapes have returned with us.

With the support of the Bidafarma Foundation, a total of 24,000 tablets of Levothyroxine 100 micrograms have also been transported, which will make it possible to supply the 19 women undergoing total thyroidectomy for more than 3
years. Due to the absence of surgical activity for the 7th and 8th days of our stay, and given that for the 6th day of surgery there was only activity for one operating theatre and for half of the team that day, some members of the expedition have brought forward our return trip by 72 hours and we have returned on Friday 24th March in the afternoon, and the rest of the team have spent the weekend in Entebbe doing activities in Lake Victoria and leisure, returning on the flight plan initially planned (on the 27th March in the afternoon). We all arrived without incident.

The expenses of the campaign can be summarised as follows: 7.000 Euros (airline tickets for the whole team); 2.300.000 Ugandan shillings (650 Euros) for the round trip transfers for the whole team and material; and 5.600.000 Ugandan shillings (1600 Euros) for the living and accommodation expenses of the whole team for 8 days. A total of 9.250 Euros, 50% of which was financed by the Fundación Bisturí Solidario, a partner of Cirujanos en Acción.

The food has been very good, being always products derived from nature (pineapple, potatoes, tomato, avocado and cabbage basically) and some chicken, liver and pasta on occasion. Throughout the whole time we had cold bottled drinks on demand (beer, water and carbonated drinks).

Holy Innocents Hospital is a very suitable place to carry out surgical cooperation campaigns, as its coordinator Moses Asia has extensive experience in this field. On this occasion, the patient recruitment process was not in line with the expectations that Kamutur had given us, which meant that 51.12% of the time we had set aside for surgery could not be carried out, a circumstance that can be very frustrating for the volunteers when it happens, and this was the reason why three members of the team brought forward their return trip by 72 hours. For my part I have sized a team to attend over 200 patients as proposed and knowing that there were 3 operating tables available; this means for 7.5 days of work the unique opportunity to have 24 morning and 21 full afternoon operating room sessions, of which a total of 22 sessions were actually covered (48.8% of the total
possible!).

I think that the fact that a Hernia International campaign was held only a mont
before may have conditioned the “n” of recruitment, so I think that campaign should not
be organised so closely together unless it is very clear that an adequat number of patients for the cooperating team is ensured; otherwise, it is not easy t explain that in a Hernia International campaign 15 hernias are operated on in almos a week. In the same way, and in order to be able to work better in the future, it is priority to fix the issue of electricity, because not all anaesthetists can have th ability and capacity to cope with such precarious working conditions, and this i something that all of us from abroad must help with and provide financial support The Bisturí Solidario Foundation is proposing to support HIH with 20,000 Euros ove the course of this year in order to complete the electrical installation that will finall improve the working conditions in the operating theatre, as well as to purchase new general anaesthesia machine that will allow at least two operating theatres t be 100% operational for all types of pathology.

On the other hand, it would b desirable for the local HIHC coordination to improve the recruitment criteria an better adjust the expectations of patients to be faced in the cooperation campaigns in order to optimise the resources provided by the volunteers to the maximum.

My congratulations to the whole team, the campaign with this volume of work in days and a half has been a great success and almost 100 patients have benefite from surgeries, many of them complex and unusual in cooperation with excellen results, superimposable to those of our environment, which is the most importan and what motivates us. Thank you all and see you next campaign!

César Ramírez