Author: akingsnorth

CAMPAIGN: BENIN. DANGBO. HOPITAL ALBERGUE D’AMOUR REDEMTOUR.

DATE: 28 SEPTEMBER TO 6 OCTOBER 2024.

Content

TECHNICAL REPORT: 1

DATES AND LOGISTICS DEPLOYED: 1 ADULT PATIENTS: 2

PAEDIATRIC PATIENTS: 2

Total procedures 2 Total patents 2 COMPLICATIONS: 2 CAMPAIGN REPORT 3 THE PLACE 3

THE TEAM 3

THE LOCAL STAFF 4 THE EQUIPMENT 4 ANAESTHESIA 5

ASEPSIS AND SURGICAL MATERIAL 5 OUR LIFE AT DANGBO 6 CONCLUSION 7

• Strengths of this place: 7
  • ObjecAves for improvement: 7 BUDGET: (small breakdown of costs) 8
  • COST PER PARTICIPANT: 8
  • TOTAL COST OF THE CAMPAIGN: 8 SIGNATURES 8

1. TECHNICAL REPORT:

1.   DATES AND LOGISTICS DEPLOYED:

The Surgeons in Action Foundation (SAF) has deployed a team of 9 volunteers to carry out a campaign in Benin, at the Hopital Albergue d’Amour Redemptour in Dangbo.

We had 7 members from Madrid and 2 from Zurich on the 28th of September 2024, meeting in Paris. In total, we have transported 200kg of medical material for the campaign, including 23 medicines with export authorisation no. 37587/24 from the AEMPS.

The journey to Dango is reasonably good. The flight, with Air France, via Paris, takes about 10-12 hours depending on the connection. From the airport to Dangbo it is about 2 hours by car, which we have in two vans organised by Sister Opportune.

It is important to note the issue of luggage. Air France allows a 23kg baggage allowance. They are strict about the weight, and, more importantly, they have been quite strict about the weight. importantly, they gave us a lot of trouble in Cotonou to check in some of the bags we were bringing (electrodiathermy and harmonic generator). For future SAF campaigns, I think it is important to  stop carrying ‘Chinese’ bags, which are becoming more and more problematic at airports and the airlines do not allow us to check them in. They will have to be replaced by more robust travel cardboard boxes.

We worked at the hospital from 29 September to 5 October inclusive.

The return trip to Madrid and Zurich took place on 6 October 2024.

2.   ADULT PATIENTS:

80 surgical procedures have been performed on 75 patients. An excel file with the complete database is ajached.

Breakdown by pathology: 10 total thyroidectomies 16 hemithyroidectomies

37 inguinal hernioplasties (Lichtenstein), 4 of them bilateral. 3 midline hernias (Rives)

1 umbilical hernia (preperitoneal hernioplasty)

1 bilateral and 1 unilateral hydrocele (hydrocelectomy). 6 soft tissue tumours.

• PAEDIATRIC PATIENTS:

No paediatric patints were treated in this campaign.

• Total procedures

80

• Total paJents

75

• COMPLICATIONS:

1 patient with immediate surgical reoperation for cervical haematoma. The patient developed a cervical haematoma during anaesthetic awakening. Reintubation, exploration of the surgical field, and haemostasis were performed without further incident.

• patient had an intraoperative haemorrhage of about 700cc during a difficult total thyroidectomy. The postoperative course was unevenful.
• patients with inguinal hernioplasty developed a haematoma in the surgical wound, which was treated conservatively, with good evolution after our departure.

2. CAMPAIGN REPORT

• THE PLACE

Hopital Albergue d’Amour Redemptour in Dangbo is a location that SAF has been very familiar with f many years, regularly conducting campaigns. This hospital, run by Sister Opportune, maintains constant activity of collaboraAon with different organisations, which allows them to carry out surgical campaigns in their hospital on a regular basis. Our campaign was the seventh this year at the centre bringing the total to ten by the end of the year.

Dangbo is a small town in southern Benin, an hour’s drive from the capital, Portonovo, and about ten hours from Cotonou airport. It has a central area, crossed by the dirt road that connects it to the rest the country, where the most important part of the town lives in small buildings. It has a market, which we were only able to visit on Sunday afternoon after work, when it was empty. The rest of the village made up of houses scattered around the countryside.

It has a hotel, the Behova Hotel, where we stayed in reasonable comfort. It has air-conditioned rooms with cold running water. It also has a small restaurant where we had breakfast daily.

The hospital consists of a group of small single-storey buildings within a fenced enclosure.

Our activity has been developed in a small surgical block, which has an operating theatre in which we have arranged two surgical tables. It also has a small cleaning and sterilisation room, a room used for storage, and an entrance that serves as a post-anaesthetic recovery room. The adjoining building houses the hospital wards. In the style of other places in Africa, they are open-plan rooms with bed where patients and their families spend time from the time they arrive unyil they are discharged.

In this area there is also the house where the nuns live in community, which is where we have had a daily lunch and dinner, generously served by them, with impressive affection and dedication.

Another  building  is  used  for  outpatient  consultations.  For  our  campaign,  Sister  Opportune  had previously selected the patients we were going to operate on, with a solvency and organisation that unusual in other locations we work with .It was only necessary to use Sunday morning to consult all the patients and organise the surgical plan for the whole week. All the patients have a small folder with the medical  history,  with  a  brief  description  of  their  medical  history,  clinical  diagnosis,  and  medications. Some patients bring an imaging test performed in the capital.

• THE TEAM

The team is made up of 2 nurses, 4 surgeons, 2 anaesthetists and 1 biomedical engineer: David Fernández Luengas: Team coordinator. Surgeon.

Sandra del Barrio Anaya: Surgeon. Ana M Gay Fernández: Surgeon.

Fátima Sánchez-Cabezudo Noguera: Surgeon. Rocío Díez Munar: Anaesthetist.

Katharina Wentkowsky: Anaesthetist. Nuria Agulló Marín: Nurse.

Silvestra Barrena Blázquez: Nurse. Michael Wentkowsky: Engineer.

It is very important to highlight the good atmosphere in which our activity and coexistence has developed. This is undoubtedly due to the enormous human quality of the members of the group, to their great professional training.

The language barrier between Katharina and Michael, volunteers from the NGO Hernia International northern Swiss, German-speaking and fluent in English, and the rest of the Spanish team, has been overcome thanks to the collaboration of all. Michael’s fun and open attitude is very remarkable, as he has constantly encouraged has constantly encouraged the group, favouring that connection, sometimes difficult when the largest part of a group speaks a different language. The collaboration with Hernia International is very important for the SAF, and it is great news that, once again, a joint team has developed a campaign in such a good working atmosphere. I think K&M have learnt more Spanish than we have learnt English!!! Katharina and Rocío worked very well together to perform the general and spinal anaesthesia, and brought a lot of security to the team. All patients have received anaesthetic treatment of the highest quality.

The team of surgeons worked very closely together, in alternating pairs that allowed us to share our work with each other. We have performed some fairly complex procedures in a good atmosphere of collaboration, and we have been very effective in achieving the planned plan of interventions, at a very high pace.

Silve and Nuria have worked very hard in the operating theatre, from organising the material, circulation and instrumentation in the operations, supporting the anaesthetists and taking care of the patients in the pre- and immediate postoperative period.

Michael, a biomedical engineer who always accompanies Katharina on the campaigns, has carried out repairs on several devices in the operating theatre (notably the repair of two monitors for intraoperative control), and has been appointed Celador Jefe of the team, thanks to his great willingness for all the tasks we have asked him to carry out.

• LOCAL STAFF

The daily work on this campaign would not have been as effective if we had not been able to count on the collaboration and hard work throughout the week of the hospital’s local team.

First of all, Sister Opportune, the real heart and soul of the hospital. She has been responsible for the recruitment of patients, and for organising all the activity of the hospital so that we could work at such a high pace.

Her colleagues in the community have taken care of us during the lunches and dinners, which they have prepared for us with great dedication, even late at night, as we have finished several days later than 22h. Our thanks to Nadine for taking such good care of us.

Gavin, the nurse, spent the whole week at the hospital, with full dedication to the operated patients, helping us with dressings, medication and communication with the patients.

Silvie, Filomene, Protector and worked alongside us in the operating theatre, developing a very efficient activity of patient flow, cleaning and sterilisation of material and operating theatre.

This place has many advantages for the realisation of surgical campaigns, but its greatest strength is undoubtedly its human team.

• THE EQUIPMENT

Expendable material: We have used all the material we brought with us, about 200kg. The hospital has a lot of material that has been contributed by previous campaigns, well organised and handy in the warehouse, which we have tried not to use. There are disposable surgical drapes, sutures, various operating theatre materials. There are also cloth pyjamas and clogs which are washed daily.

Surgical equipment: There are 3 electrosurgical units in good working order (Michael did some repair work to get them in good working order). Michael tried to fix a fourth device (Valleylab) but it is beyond repair. In any case, with these three devices, we can work perfectly well.

We also brought an ultrasound generator for the thyroid surgery, loaned by the company Medical Cañada, with enough consumable forceps for all the procedures.

Anaesthesia: We used a Drager Fabius ventilator which had been repaired in the weeks prior to our arrival, and which worked correctly, with no problems. There is no capnograph. There are two vital signs monitors, which Michael managed to repair and get working. We have used portable pulse oximeters brought by us, a portable automatic blood pressure cuff and a portable infusion pump. On the day we were leaving, the new Mindray WATO EX-35 ventilator arrived, which has been funded by the Bisturí Solidario FoundaAon and the Asociación Infancia y Cirugía en Dangbo. It has already been installed and can be used in the coming campaigns. It is a great leap in quality, firstly because it is more modern and complete than the other ventilator, and secondly because it will allow us to have two general anaesthesia stations.

• ANESTHESIA

During the Campaign we performed 26 thyroidectomies under general anaesthesia, with orotracheal intubation, mostly using 7.5 tubes (almost all patients were women). On 4 occasions we used a Mcgraph video laryngoscope, which we carried specifically for this purpose, due to the expected difficulty in the airway. No awake patient was intubated. We did not have capnography or an oxygen sensor, although we did measure volume curves. We had several filters that changed colour on contact with CO2, useful for checking correct intubation in case of doubt.

Approximately half of the cases were performed with Sevorane, there are several bojles there, and the other half with percussion of propofol in an infusion pump that we carry.

We also performed 3 general anaesthetics with a laryngeal mask, for a fibroadenoma and 2 large lipomas.

There were 2 local anaesthesias with sedation for neck lipomas, and the rest of the anaesthesias (44) were spinal, for inguinal, umbilical and epigastric hernias. For the larger, isobar bupivacaine had to be used.

Patients operated under general anaesthesia stay 1-2 hours in the room next to the operating theatre, on a stretcher that allows for some back support (although it is in poor condition) with a pulse oximeter and oxygen when necessary. Silvie and Filomene helped us to keep an eye on them. We took almost all the material we used ourselves, and left what we had left over there. It is worth noting that there is a large amount of hyperbaric bupivacaine and levobupivacaine. We also left about 40 bojles of cefazolin 2g, and 5 bojles of clindamycin 600mg. We left over 20 ampoules of propofol and 10 bojles of 50 ml 2%. The 45 ampoules of fentanyl that we did not use were left with Soster Opportune for safekeeping. As for monitoring, despite Michael’s help with the arrangement of 2 monitors that have EKG, pulse oximetry and blood pressure, more need to be carried. The cuffs are badly damaged and leak or fail constantly. Also, for the patients we left on the stretcher outside, there is no monitoring. We carried 3pulse oximeters and a portable automatic blood pressure cuff which helped us a lot.

• ASEPSIA AND SURGICAL MATERIAL

Instruments: For this campaign we have brought 5 boxes of instruments from the SAFA, two for thyroid and 3 for hernia. We also used instruments available in the hospital, which are in a reasonable state of conservation, although they are very limited. This allowed us to have a quick rotation, which is essential to be able to operate on an average of 15 patients per day.

They have a small autoclave machine (Matachana, modern, in perfect condition), which can hold 2-3 small boxes of instruments. They have another autoclave next to, which they use as a deposit for sterilised material.

The local team constantly washes and sterilises the material, in order to maintain a high rate of replacement. The sterile, disposable operating theatre linen, gowns, sheets and drapes, were brought by us.

• OUR LIFE IN DANGBO

This week in Dangbo has been very intense. We have worked hard, and the whole group has been living together in a very healthy atmosphere. The alarm clock goes off at 7AM. At 7:30AM we are having breakfast in the hotel restaurant. Soluble coffee, tea with lemon, condensed milk, and a plate of omelette with vegetables and a roll of bread. The last few days, they even served us croissants and chocolate breads.

It is a pleasant 10-minute walk to the hospital and the day begins.

On Sunday morning we went to see the patients, and we organised the whole plan on two surgical tables, with about 5-6 patients with goitres on the general anaesthesia table, and about 8-10 patients with wall pathology on the spinal anaesthesia table, each day.

The only ‘down time’ we enjoyed was a walk around town on Sunday afternoon, and a quick visit to the beach on the Cotonou coast on Saturday afternoon, before embarking for home.

From Monday to Friday, our day basically consisted of operating from 8:30-14:30h and 15.30-22H. We stopped for an hour for lunch in the nuns’ dining room, and another hour at the end of the day for dinner. They served us a wonderful meal, salads for starters and a variety of dishes for main courses – they even made a Spanish omelette! And, of course, there was always cold beer, something that could be considered a basic necessity, considering the heat and the risk of dehydration associated with the intense work.

At the end of the day, we went for another night walk back to the hotel. Before falling asleep at around 23:30-24h, we only have time for a wonderful shower with buckets of cold water.

During the working day, it is quite hot inside the operating theatre. The only place where it is more comfortable is in the operating theatre, thanks to two air-conditioning units that run all day long.

All in all, our life in this campaign has been very pleasant, with a good atmosphere, a lot of work, and with the feeling that in Dangbo everything is ‘easy’. We leave with the feeling of having worked hard, of having participated in a great project, Hopital Albergue d’Amour Redemptour, led by Sister Opportune, and with the desire to return again. SAF will not miss its appointment, and I hope that we will be able to carry out more campaigns there next year.

3. CONCLUSION

3.1 Strengths of this site:

-Local organisation and staff. This is undoubtedly one of the best locations for SAF to work with.

-Recruitment.

-Quietness of the location.

-Short’ travel time from Spain.

3.2. Objectives for improvement:

-I believe that, with the acquisition of the new ventilator, a new room could be set up as an operating theatre for spinal anaesthesia, allowing 3 patients to be operated on at the same time.

-One or two stretchers in the room next to the operating theatre to make the transfer of patients and their stay there during post-anaesthesia recovery more comfortable. At present there is one transfer stretcher with wheels and one stretcher without wheels, with a broken backrest.

-New blood pressure cuffs on the monitors.

-Fix the air-conditioning unit in the operating theatre storeroom.

The Hernia International Mongolia 2024 mission was conducted over two weeks from 8 to 21 September.

The team consisted of members from Australia (Noha Ferrah, Cameron Dunlop, Richard Turner) and the UK (Steve Lindley, Bohdan Smajer). The first week was spent at Choir Hospital in Govisümber province situated in central-east Mongolia; the second at the Second State Central Hospital (a.k.a. National Diagnostic and Treatment Center) in capital Ulaanbaatar. Pre-mission liaison with the Mongolian surgeons was comprehensively handled by Dr Enkhee, who has vast experience in dealing with foreign teams and was always available to deal with any issues that arose.

The work experience

In Choir, our team conducted 17 consultations, leading to 14 operations on patients aged from 12 months to 72 years.

At the Second State General Hospital, we conducted 28 consultations and 19 operations on patients aged between 31 and 80 years. Patients at this hospital were admitted the day before proposed surgery, which enabled us to develop a team consensus on their management after we finished our day’s operating.

Days typically commenced with a ward round of previously operated patients. Aftercare was generally very good. We were impressed by the general stoicism of the patients, and the fact that all of those with incisional hernias came with their own fitted corsets.

Details of the operations performed are shown in the Table below. Incisional hernias predominated, with only 5 inguinal hernia repairs performed over the 2-week period.

Laparoscopy was available in both hospitals and local surgeons were keen to develop their skills in this; however, only a minority of cases were deemed suitable. Of note, 6 paediatric herniotomies were performed in Choir, due to a visiting Paediatric Anaesthetist.

Cases were generally cancelled if the team felt that the hernia was too complex for local capability, including the unavailability of optimisation techniques such as botulinum toxin. On departure, we were not aware of any significant postoperative complications.

At both hospitals, the program included dedicated teaching time, which included lectures with slides or videos, as well as an introductory session with the laparoscopic trainer. All operations performed were assisted by at least one local surgeon or trainee, who were keen to gain operative tips.

The visitor experience

Our Mongolian hosts, Drs Naraa and Sonor, Residents Tenuun and Miga, and many others, went to no end of trouble to provide us with a comprehensive cultural immersion, including:

• An afternoon spent in a ger on the road to Choir – sharing fermented horse milk and watching traditional sports.
• An excursion to the Chinggis Khaan memorial outside Ulaanbaatar – with forays into camel/horse riding and archery

• A visit to a Buddhist temple in the beautiful Terelj National Park
• A variety performance with traditional music, singing, dancing, and eye-watering contortionism
• A copious Mongolian Chinese banquet, hosted by Second State Central Hospital Director Dr Byambadorj – with vodka shots in the VIP room of a restaurant with possibly the largest self-revolving “lazy susan” in Asia.

We were most grateful for the transfers between Chinggis Khaan International Airport and our Ulaanbaatar hotel that were kindly provided by hospital staff. This must have been a considerable impost, given the permanently grid-locked nature of traffic in that city!

Advice for future teams

We were advised from the outset that the Mongolian health authority would not accept the low-cost sterilised mosquito net mesh usually provided by Hernia International – although in retrospect, this may not have been suitable for most of the hernias we were required to repair. Donations of commercial prosthetic mesh products must therefore be sought. Other key materials such as specific suture types and mesh fixation devices may also be lacking, especially in the rural hospitals. It is therefore advisable to bring supplies of these as well and liaise in advance with the Mongolian colleagues to ascertain precise requirements.

In our case, we owe thanks to Medtronic (prosthetic mesh), UPC Renewables (funding for purchase of laparoscopic trainer and sutures), the Royal Hobart Hospital (laparoscopic fixation devices), and the Bolton Hospital NHS Foundation Trust, UK (meshes and fixation device).  The team leader should also confirm with the Mongolian side that Mongolian Customs has received documentation of what supplies are being brought into the country by HI team members – otherwise unwanted delays on arrival at the airport may occur.

Given the volume of incisional hernias presented to us, and that some were deemed out of scope for our mission, pre-assessment by the whole team is desirable. Ideally, this should be as early in the week as possible, so the whole week’s program can be planned and operations allocated according to expertise. It may even be possible to request advance e-referrals from local surgeons for complex cases, with CT images and clinical photographs.

As noted above, the Mongolian surgeons and resident doctors are keen for teaching both inside and outside the operating theatre, particularly for minimally invasive surgery and complex hernias. It is advisable to come prepared with a few PowerPoint lectures and videos, if possible. In theatre, be prepared to talk through the operations step by step, and supervise the assistant doing sub-tasks wherever possible.

In conclusion, the HI Mongolia 2024 mission was an excellent experience in collegiality and knowledge sharing. I daresay we would all be happy to do it again – and with each other!

Richard Turner

Team leader, Hernia International Mongolia 2024.

Table 1: Hernia operations undertaken at the Choir and Second State Central Hospitals, September 2024

Hernia type	Operation	Number
Incisional	Retro-rectus/sublay	6
	Retro-rectus + TAR	2
	Pre-peritoneal skirting mesh	2
	Direct suture + onlay	2
	Laparoscopic IPOM	1
	Reinforced direct closure	1
(Para)umbilical/port-site	Direct suture	6
	e-TEP	1
Adult inguinal	TEP	2
	TAPP	1
	Open Lichtenstein	2
Paediatric inguinal	Herniotomy	6
Other	Diagnostic laparoscopy only	1
TOTAL		33

Comprehensive Report on the Outreach by Liberia Physicians and Surgeons Without Borders (LPSWB) in Collaboration with Hernia International UK at C.B. Dunbar Government Hospital

Introduction

From June 25 to June 29, 2024, the Liberia Physicians and Surgeons Without Borders (LPSWB), in collaboration with Hernia International UK, conducted a free hernia surgery campaign at C.B. Dunbar Government Hospital in Banga City, Bong County, Liberia. This outreach aimed to provide essential surgical care to patients suffering from hernias, thereby improving their quality of life and reducing the burden of untreated hernias in the region. This mission marked the first collaboration between Hernia International and C.B. Dunbar Government Hospital.

Team Composition

The medical team comprised highly skilled professionals from various specialties:

• Dr. M. Peter George – Consultant Surgeon, Team Lead
• Dr. Ayun Cassell III – Consultant Urologist Surgeon
• Dr. Abraham Ajami – Specialist Internal Medicine & Emergency Response
• Dr. Michael Kempeh – Specialist General Surgeon
• Dr. Arthur Wuoh – Specialist General Surgeon and Medical Director
• Dr. Ambrous Fawenneh – Medical Officer
• Dr. Brooks – Medical Officer in Rural Rotation
• Momoh Sonnie – Nurse Anesthetist
• Roger Corcor – Operating Theatre Technician

Mission Overview

• Arrival and Preparation: The team arrived on June 24, 2024, and began preparations for the surgeries.
• Surgical Campaign: Surgeries commenced on June 25, 2024, and continued until June 29, 2024.
• Patient Recruitment: Dr. Arthur Wuoh, Medical Director and Specialist General Surgeon, was responsible for recruiting all patients who underwent operations.

Data Collection

Data collected during the mission was categorized to reflect various aspects of the outreach, including patient demographics, types of hernias operated on, surgical outcomes, and postoperative care.

1. Patient Demographics

• Total Number of Patients Operated On: 108 procedures
• Age Distribution of Patients:
  • Mean age: 31.69 years
  • Age range: 0.2 to 73 years

Age Group	Frequency	Percent	Cumulative Percent
0 – <10	23	21.3%	21.3%
10 – <20	15	13.9%	35.2%
20 – <30	14	13.0%	48.2%
30 – <40	16	14.8%	63.0%
40 – <50	16	14.8%	77.8%
50 – <60	9	8.3%	86.1%
60 – <70	10	9.3%	95.4%
70 – <75	5	4.6%	100.0%
Total	108	100%	100%

• Gender Distribution of Patients:

Gender	Frequency	Percent	Cumulative Percent
Female	35	32.4%	32.4%
Male	73	67.6%	100.0%
Total	108	100%	100%

2. Types of Procedures

Procedure	Frequency	Percent
Herniorophy	51	47.2%
Herniotomy	11	10.2%
Lipomectomy	10	9.3%
Cesarian Section	9	8.3%
Hydrocelectomy	9	8.3%
Myomectomy	6	5.6%
Umbilica Hernia Repair	4	3.7%
Cystecyomy	3	2.8%
Hysterectomy	2	1.9%
Fistula	1	0.9%
Mayo Repair	1	0.9%
SUB-TAH	1	0.9%

3. Surgical Outcomes

• Number of Successful Surgeries: 108 procedures
• Complications Encountered: None
• Length of Hospital Stay Post-Surgery: 1 night
• Patient Satisfaction and Feedback: Very Good

4. Postoperative Care

• Postoperative Recovery Protocols: Hernia International Standards
• Follow-up Schedules: Managed by the Hospital Management

5. Anesthesia Given

Anesthesia Type	Frequency	Percent	Cumulative Percent
General Anesthesia (G/A)	36	33.3%	33.3%
Spinal Anesthesia (S/A)	72	66.7%	100.0%
Total	108	100%	100%

6. Diagnosis Percentages

Diagnosis	Frequency	Percent	Cumulative Percent
Adhesion	1	0.9%	0.9%
Bowel Aneste	1	0.9%	1.9%
BIH	5	4.6%	6.5%
Hydrocele	7	6.5%	13.0%
Infected Cyst	1	0.9%	13.9%
LIH	18	16.7%	30.6%
Lipoma	10	9.3%	39.8%
LISH	1	0.9%	40.7%
Myoma	9	8.3%	49.1%
Obstructed Labor	7	6.5%	55.6%
Ovarian Cyst	1	0.9%	56.5%
Previous C/S	1	0.9%	57.4%
RIH	36	33.3%	90.7%
RISH	2	1.9%	92.6%
Testicular Cysts	1	0.9%	93.5%
Umbilical	5	4.6%	98.2%
Umbilical Hernia	2	1.9%	100.0%
Total	108	100%	100%

7. Procedures Performed by Doctors

Doctor	Frequency	Percent	Cumulative Percent
Dr. Cyrus	2	1.9%	1.9%
Dr. Fawsenneh	16	14.8%	16.7%
Dr. George	35	32.4%	49.1%
Dr. Kempeh	35	32.4%	81.5%
Dr. Massaley	11	10.2%	91.7%
Dr. Wuoh	6	5.6%	97.2%
Dr. Yohn	3	2.8%	100.0%
Total	108	100%	100%

Summary of Findings

A detailed analysis of the data collected during the mission indicates a high success rate with minimal complications, reflecting the expertise and dedication of the medical team. Patient satisfaction levels were very high, and there were no significant complications encountered.

Conclusion

The collaboration between Liberia Physicians and Surgeons Without Borders and Hernia International UK at C.B. Dunbar Government Hospital was a significant milestone. This first mission successfully provided much-needed surgical care to numerous patients suffering from hernias, showcasing the importance of such outreach programs.

Prepared By

Dr. M. Peter George (MD, FACS)

REPORT

NIGERIA CAMP 2024

BISHOP MURRAY MEDICAL CENTER. MAKURDI.

Jun-5-2024

TECHNICAL REPORT

DATES AND DEPLOYED LOGISTIC

The team of collaborators began to be formed at the end of February 2024 under the leadership and coordination of Dra Teresa Butrón and under the umbrella of the Non Profit Organization “Cirujanos en Acción” (Surgeons in Action) and the collaboration of Hernia International Foundation. In a very short period of time, it could be formed a team of twelve people, including general and paediatric surgeons, paediatrics intensivist, anesthetists and nurses.                                    

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 (local and general anaesthetics, muscle relaxants, antibiotics, opioids, analgesics, etc) and anaesthetic material such as spinal needles, epidural catheters, Laryngeal masks, endotracheal tubes and rest of the material.

Hospital Vithas in Valencia made a donation in medical equipment to the campaign through Dr Antonio Barrasa Shaw.

The 12 de Octubre University Hospital, in Madrid, donated a large amount of medication including anaesthetics, analgesics, antibiotics and vasoactive drugs through the anesthesiologist of that hospital, Dr. Ana Hermira.

The University Hospital Virgen de las Nieves in Granada, through Silvia Montalbán, a nurse at the hospital, donated a large amount of material, including surgical gowns and sheets, electric scalpels and intravenous access equipment.

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 baggage.

• VISA. Without a doubt, obtaining VISA from Nigeria’s Embassy in Madrid, was the greatest difficulty that we had to face and that seriously jeopardized the completion of the campaign. Thanks to the efforts of Teresa Butrón and Dolores Delgado and their persistence we were able, just three days before leaving, to obtain VISA for Nigeria for all the members of the team. It is possible to apply for the VISA online and make the payment and after that it is necessary to go the Nigeria’s Embassy in Madrid to present the VISA application form, the invoice and the passport.  Therefore, all the cooperators living outside of Madrid had to send their original passports by mail to one of the team members in Madrid to present them all together as a group. We got the VISAS only three days before leaving for Nigeria. For all of those reasons it seems advisable and it is our recommendation, to start the process at least six weeks in advance.

Dr Austin Ella, Associate Director Program Management from Catholic Caritas Foundation of Nigeria (CCFN)  and Catholic Secretariat of Nigeria Building was our local contact in Nigeria and our interlocutor with Bishop Wilfred Chikpa Anagbe.

The group of volunteers left Spain from different cities (Málaga, Valencia, Madrid) between Friday and Saturday, April 19 and 20, 2024. Ten of the team members met at the Istanbul airport while two of our surgeons arrived at Abuja a day before the rest of the team

The campaign ended on Saturday, April 27, 2024 and we arrived to Spain on Monday 29th.   

PATIENTS.  Altogether 155 patients were operated on during the campaign period

ADULTS PATIENTS: A total of 93 surgical procedures were performed in 80 adult patients. There were 14 females and 66 males. Age ranged from 16 to 76 years (median 50; interquartile range 36-62). The following procedures were done:

Lichtenstein:  69 cases

Nyhus: 10 cases

Lipoma removal: 3 cases

Pre-peritoneal mesh repair:  2 cases

Rives-Stoppa:  2 cases

Hydrocelectomy: 2 cases

Reinforced suture + umbilical prefascial hernia repair + fascia plication: 1 case

Nuck’s cyst removal: 1 case

Onlay: 1 case

Orchiectomy: 1 case

Haemorrhoidectomy:  1 case

Most of the cases under spinal anesthesia (77 patients), saddle block (1 patient) and local anaesthesia plus sedation (2 cases)

PAEDIATRICS PATIENTS. 99 procedures were performed in 75 paediatric patients. Seventeen females and 58 males. Age ranged from 3 months to 16 years (median 6; interquartile range 3-10).

Herniorrhaphy: 92 cases

Herniorrhaphy plus hydrocele: 1 case

Hydrocele: 4

Orchidopexy: 1 case

Dermoid cyst resection: 1 case

Several cases of the initially scheduled were left without being operated on due to the lack of enough time.

All the members of the team agreed about the need to know more in depth the scheduled cases to made a more appropriate surgical list of patients. It was the first mission there in Makurdi and probably the situation will improve in future missions.

We also had the opportunity to participate in two cases of urgent caesarean section: fetal distress in one case and previous caesarean section in the other. Both patients were operated under spinal anaesthesia and two general surgeons from CeA helped Dr Thadeus Aende in the surgery and also did it the nurses of the team. It was very gratifying for all of to participate in that task and see the good evolution of mothers and newborns. 

COMPLICATIONS: Once the team left Makurdi Hospital, the follow up of patients was done by Dr Thadeus Aende, a local doctor.  Up to now, there have been four early minor complications: one adult patient experienced a recurrence of his inguinal hernia and, in the paediatric population, a boy developed a wound abscess drained while the team was still in Makurdi, one more a reactive hydrocele and, lastly, a possible recurrence of a hernia or simply a local edema difficult to know from the pictures Dr Thadeus Aende sent to the paediatric surgeons.

CAMPAIGN REPORT

THE PLACE.  The Federal Republic of Nigeria, is a country in West Africa. It covers an area of more than 923.000 square kilometres and with a population of over 230 million, it is the most populous country in Africa, and the world’s sixth-most populous country. Nigeria is a federal republic comprising 36 states and Abuja is the capital even though the largest city is Lagos.  Nigeria became a formally independent federation on 1 October 1960. It experienced a civil war from 1967 to 1970, followed by a succession of military dictatorships and democratically elected civilian governments until achieving a stable government in the 1999 Nigerian presidential election, with the election of Olusegun Obasanjo of the People Democratic Party. Nigeria is a multinational state inhabited by more than 250 ethnic groups speaking 500 distinct languages. The official language is English. Nigeria’s constitution ensures de jure freedom of religion and it is home to some of the world’s largest Muslim and Christian populations. Nigeria is divided roughly in half between Muslims, who live mostly in the north part of the country, and Christians, who live mostly in the south; indigenous religions, such as those native to the Igbo and Yoruba ethnicities, are in the minority.

Nigeria’s economy is the second-largest in Africa, the 39th-largest in the world by nominal GDP, and 27th-largest by PPP. However, the GDP per capita places it in 149th place out of 196 countries and the Human Development Index prepared by UN which shows the standard of living indicates that Nigerians are among those with the worst quality of life in the world.  

                     Benue state was created on February 3, 1976. It lies roughly in the middle of the country. Benue has a population of more than 4,5 millions inhabitants. The state comprises of several ethnic groups being The Tiv the dominant ethnic group, occupying 14 local government areas, while the Idoma and Igede occupy the remaining nine local government areas. Most of the people are farmers while the inhabitants of the riverine areas engage in fishing as their primary or important secondary occupation. The people of the state are famous for their cheerful and hospitable disposition as well as rich cultural heritage. Makurdi, the State capital was established in the early twenties. Being a river port, it attracted the establishment of trading depots by companies such as UAC and John Holt Limited. Its commercial status was further enhanced when the Railway Bridge was completed and opened in 1932. In 1976, the town became the capital of Benue State and presently serves also as the headquarters of Makurdi Local Government Area. 

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

• General Surgeons: Teresa Butrón Vila (team leader). Antonio Rafael Barrasa. Saray Ayllón Gámez. Elena Fernández Segovia.
• Paediatric surgeons. Alejandro Unda Freire. Mª Dolores Delgado Muñoz.
• Paediatric intensivist. Emilia María Tallo Martínez.
• Anaesthesiologists. Ana Hermira Anchuelo. Santiago García del Valle
• Nurses. Mª Josefa Fornier Coronado. Nuria Guardiola Morales. Silvia Montalbán.

LOCAL STAFF. El Dr Thadeus Aende was the only doctor available at the hospital even though there were a large number of volunteers carrying out tasks of organization and identification of the population. Father Peter Paleva was the Area Health Coordinator. Mr Nicholai Ahor was the Administration Secretary. 

HOSPITAL. It is a small building all in a single height, with several wards for adults, men and women, and children. It has a laboratory for basic determinations and a microbiology laboratory with basic capacity to perform cultures and diagnostic test for pathologies such as malaria and HIV. The room we use as an operating room is a large elongated space, equipped with air conditioning (the only space in the hospital except offices), without running water and equipped with minimal material: oxygen cylinders, two basic monitors (ECG did not work correctly) and 3 very rudimentary operating tables, one of then without the possibility of modifying height or changing the position of the patients. There was no anaesthesia machine available. There was no recovery room so the adult patients had to go directly to the ward, not far from the OR. For the children Dr Emilia Tallo created a small room as a space where to look for the children several minutes after the operation. The heat and humidity in that space was terrible and that made Emilia’s work very difficult and to be grateful for all of us. Several portable pulse oxymeters led by cooperators alleviated partially the monitoring deficit.

EQUIPMENT. Surgical instruments available at the Bishop Murray Hospital such as forceps, separators or scissors are not in very good condition and no suitable sizes for some of the longer and more aggressive interventions. It was completed with the paediatric surgical material carried by Alejandro Unda. There were

2 diathermy generators, one from the own hospital and one brought from Abuja and the team could transport 2 more units from Spain even though we have to use only one of them. The surgical lights were scarce and very poor in intensity and difficult or impossible to handle.

ANAESTHESIA. The lack of an anaesthesia machine made the task of Dr Ana Hermira and Dr Santiago Gª del Valle very difficult since they had to combine spinal anaesthesia with regional anaesthesia of the trunk with sedation or even general anaesthesia under spontaneous breathing. We made Dr Ella aware of the need to acquire a simple anaesthesia machine for the future campaigns and, thus, a report was sent to him with a description of the minimum characteristics and capabilities that anaesthesia should have.

ASEPSIS: Sterilisation was carried out with a heat-operated autoclave in a room adjacent to the operating room.  

OUR DAILY LIFE

We arrived at Abuja International Airport on Saturday 20 April at 20:00. There were no difficulties with customs formalities and from there we were transferred to the Catholic Residence from Bishop Office and Caritas Organization only a few kilometres away from the airport where we met the rest of our colleagues. In that residence we had dinner and spent the first night.

Early in the morning of Sunday 21th April we went to Makurdi by car and it took 4 four and a half hours to made the 280 kilometres. Once at the hospital we had a colorful and pleasant welcome ceremony after which they offered us a meal to, immediately afterwards, inspect the operating rooms and the rest of the hospital, review the available material and unpack and organize the large amount of material that we moved from Spain.

We had lunch in the hospital and the food was of good quality but it is important to warn the cooker, Rosario Joyn Egbol and Dr Celeste Conde (also Medical Director of the Hospital), not to add spice. Delicious were also the great variety of mangoes we could taste.

After the daily work we took dinner at the residence. The rooms were comfortable with shower and, most importantly, air conditioning. It is important to take with you some towels.

We worked during 6 days (Monday to Saturday inclusive) from 8:00 to 20:00 or even later several days. On Wednesday 24^th the Bishop offered us a nice dinner in the garden of the residence.  We had no time even to visit the city center neither the riverside of the imponent Benue River.

On Sunday 28^th we were invited to a religious ceremony and after that we came back to Abuja’s airport. The trip was made difficult by two car breakdowns that delayed our arrival at the airport to such extent that we almost missed our flight and were allowed to carry only our hand luggage and had to leave the rest of the equipment in Abuja under the care of Dr Austin Ellla who was later in charge of sending all the material back to Spain several days later.  

CONCLUSION

                  Strengths of this place: Probably there is a huge amount of population who would benefit of a surgery from CeA. The people were very warm towards us and expressed continuously their gratitude. A lot of local volunteers, poor organized ass it was the first mission but they helped us a lot with the management of patients and families. 

                  Improvement objectives: It would be very useful for future campaigns to have an anaesthesia machine and a new basic monitor of vital signs. It is desirable to improve the surgical lights as well as the surgical tables because they must have the capacity to vary their height and change the position of the patients during surgery. Also is important to improve the cars for the transport from Abuja to Makurdi and back to the airport since the space for the people and equipment was very limited. Have running water in the operating room, as occurs in other areas of the hospital, could facilitate work and help reduce the chance of surgical infections.  

BUDGET:

COST FOR PERSON:  Flight tickets between 600 and 750€. Hotel and maintenance provided by the local organization without cost. VISA 100€.  Total amount around 700-850€ per volunteer.

Signed in the name of all the team members:

 Santiago García del Valle Manzano

Camp: Police Hospital Freetown, Sierra Leone

DATE:  27 April – 4 May 2024

1. TECHNICAL REPORT:

1.1   DATES AND LOGISTICS DEPLOYED:

We started the trip on the morning of 27/04. 7 members of the group will leave from Vigo and 1 from Gran Canaria. We have a long journey to our final destination, the Police Hospital in Freetown, Sierra Leone. We meet in Madrid, where David and Nuria are waiting for us to deliver the diathermy  generator that we have to take with us. In the end we check in 11 bags of between 20 and 23Kg of material. We fly with Royal Air Maroc, with a stopover in Casablanca.

We bought the plane tickets through Angelis, an agent of Halcon viajes.

To enter the country you need a Visa, which can be easily obtained online via the link on the Spanish foreign ministry’s website. It costs $85 and takes a few days to be issued

1.2 ADULT PATIENTS:

As a ventilator was not yet available, only pathologies that were amenable to spinal anaesthesia and local anaesthesia and sedation were performed.

Surgery was mainly performed on abdominal wall pathology, hydroceles and large lipomas.

1.3 PAEDIATRIC PATIENTS:

No paediatric patients were operated on in this campaign, as general anaesthesia cannot be performed.

1.4 Total procedures

152 procedures

                 Inguinal hernia: 91, all repaired with Lichtenstein technique

                 Epigastric hernia: 8

                 Umbilical  Hernia 3

                 Femoral Hernia 2

                 Hydrocele: 20

                 Testicular tumour: 2

                 Lipomas: 19

                 Mandibular tumour: 2

                  Sebaceus cyst: 1

                 Oral mucosal lesion: 1

                 Urgent reviews: 3

1.5 Total patients

1.6 COMPLICATIONS:

As complications, 3 patients required immediate postoperative reoperation: 2 haematomas in giant inguinoscrotal hernias and 1 seroma of 1 giant sebaceous cyst on the scalp. All complications resolved without further incident. To date, one month after our return, we have not been informed of any incident.

2. CAMPAIGN REPORT

2.1. THE PLACE

The hospital has 2 operating theatres, including a sterilisation room. The surgical material available is sufficient for hernias and other simple pathologies, but there is no material for laparotomy, thyroid surgery or surgery on children.

There is air conditioning in the operating theatres, which is to be welcomed, although due to the constant power cuts, it does not cool as much as we would like.

They have an autoclave for sterilisation, which they hardly use, because they find it too slow. They use pressure cookers, which worked correctly, except for one day, when we were stopped for 3 hours due to a problem with the closure of the cooker, which was finally solved.

It has 2 diathermy generators that work correctly, but only one of them can be used, because the other one does not have a grounding plate (it is an old, metallic plate). We used the generator we took with us and the other one, which worked properly for 4 days. Then the connection to the plate broke and they couldn’t fix it, so we spent 1.5 days with only one scalpel.

They have 3 mixed rooms, where patients are accommodated before and after the operation. There is a permanent nursing staff there, although the care is quite poor, given the poor training of the local staff and the limited means available.

2.1. THE TEAM

General surgeons:

                 Ana María Gay Fernández

                 Enrique Moncada Iribarren

                 Cristina Roque Castellanos

                 Paula Fernández Rodríguez

Anesthesiologist:

                 Miguel Ángel Pereira Loureiro

                 Yolanda Sanduende Otero

Nurses:

                 Verónica González Casal

                 Eva Sánchez Hernández

2.2. THE LOCAL STAFF

Dr Konteh, the hospital director, who is in charge of organising the campaign.

A surgical assistant (Kelly), who can help in the surgeries.

A preventivist, who is very helpful, and who helps us a lot in the operating theatre, especially in speeding up sterilisation and getting supplies when we run out.

The male nurse Francis, a hard worker, is also a great help in everything.

The nurses in the rooms are in charge of taking IVs from the patients before the operating theatre and post-operative care.

2.4 EQUIPMENT

Diathermy generators: 2. Neither of them have a plate and ours cannot be attached.

Operating theatre lamps: they have 2 lamps, which are quite deficient. One of them stopped working on the 3rd day of the campaign, and it was not possible to fix it. It is essential to carry a headlamp for the surgeries.

Consumables: sterile surgical gowns and drapes are not available. They have equipment to take peripheral lines and IV systems.

Medication: poor availability, although some things we ran out of they did get, such as antibiotics.

2.3. ANAESTHESIA

In the surgical block we had only 1 monitor that allowed us to measure O2 saturation and PANI, but it did not have electrocardiographic recording.

For this reason, we brought an automatic blood pressure monitor and a portable pulse oximeter that allowed us to have minimal monitoring on the second operating table, material that we left at the hospital in Freetown.

This double monitoring allowed us to tansfer 2 patients simultaneously to the 2 surgical tables that we placed in the same operating theatre, where we proceeded to perform spinal anaesthesia and some deep sedation, in cases of supra-umbilical pathology (some lipomas).

There were 2 oxygen concentrators that worked properly and an oxygen bullet to which we connected the ambu, but which we did not have to use at any time.

In the operating theatre there was also 1 very old aspirator.

Outside the operating theatre they had a NON-functioning Aestiva Datex-Ohmeda ventilator, so no other anaesthetic option other than local or regional, or light sedation, was ever considered. Stored in a corridor, there was another older ventilator which was also non-functional.

On arrival, the equipment available was generally scarce: some O2 goggles and ventimask, and little else. 

The campaign brought from Spain all the material and medication necessary to perform intradural anaesthesia/local infiltration (lidocaine, bupi isobara and hyperbara, mepivacaine, prilocaine), sedation (propofol, ketamine, fentanyl, midazolam), as well as iv/vo antibiotics, and general emergency medication (atropines, adrenalines, amiodarone, antihistamines, corticoids in different doses, antiemetics). As for analgesics, in addition to opiates, we carried conventional IV analgesia for each operation, and oral analgesia for the first 24 hours postoperatively.

There was no stock of medicines. 

As we had calculated the campaign for about 100 patients, and we exceeded expectations, we ran out of spinal needles, antibiotic prophylaxis and benzodiazepines, material and medication provided by the hospital itself, although the prophylaxis had to be done with ceftriaxone, and the needles were 24G-25G thick gauge without an introducer, which posed us greater technical difficulty on occasion.

The activity we carried out was:

Type Anaesthesia			Type of surgery
A. Spinal	Intradurals	110	Hernias and infraumbilical abdominal wall
Sedation	Local + Sedation	16	Lipomas, epigastric hernias
	Deep Sedation	4	large and/or deep supra-umbilical or dorsal lipomas
Total		130

Tras la intervención incluíamos analgésicos (2 AINES y opiaceo o asociacion de rescate) para las primeras 24 h del posoperatorio.

No tuvimos complicaciones importantes y entre las leves, escasa o nula hipotensión con algún episodio de náuseas/vómitos, y algún caso de analgesia insuficiente.

2.6. ASEPSIS AND SURGICAL SUPPLIES

Sterilisation: autoclave. Pressure cookers

Surgical instruments: there is material for small operations, such as hernias. There are few separators. There is no Roux type. There is also no specific material for thyroid or child surgery, so if at any time this type of surgery is considered, it will be necessary to bring material.

2.7. OUR LIFE IN FREETOWN

We land at Freetown airport at 2:00 a.m. Dr Konteh, director of the hopistal and organiser of the campaign, is waiting for us there with Abu, a security policeman who accompanies us to the hospital every day. We collect our luggage and pass through customs without incident thanks to Dr Konteh’s help. Then we go to catch the bus (about 15 minutes), which takes us to the ferry, which takes about 45 minutes. We arrive at the hotel at about 5am. After a few hours rest we head to the hospital. While the nursing and anaesthesia team open the material packs and get everything ready for the surgeries, the surgical team is ready to see the potential surgical patients. Patient recruitment was extensive. On arrival we had more than 300 surgical candidates. However, no one had done a screening, so we saw many non-surgical pathologies, or pathologies that could not be operated on in a campaign where general anaesthesia is not possible. Finally, after many hours of seeing patients and after recruiting 145 patients for surgery, we decided not to continue with the screening, so that we could start operating that same day, late in the afternoon, almost at night. We scheduled the surgeries for later days.

The day after our arrival we were received by the Chief Inspector of Police (Mr. William Fayia Sellu), in a brief ceremony held at the police headquarters, and he gave us our permits to work in the country.

Thus began a very hard campaign, with intense heat during the day and night, working daily from 8 in the morning, extending most days until more than 9 at night, since an average of 25 patients were operated on per day. In the end, despite having two operating theatres, we decided to use only one, with two tables, to speed up the work.

We started the day with breakfast at the hotel. They provide coffee, powdered milk, juice and you can order omelettes and pancakes. At 8 a.m. we are picked up by Dr Konteh with Abu, a 15-minute drive to the hospital.

On arrival, while the first patients are being anaesthetised and everything is getting underway, the surgeons visit the patients from the previous day, so that they can be discharged and make room for the patients who will be operated on that day.

We make a short stop for lunch. Pizza, chicken, pasta and a few other things can be ordered from a nearby restaurant. The local staff bring them every day, although you have to order well in advance, so on many days we just ordered bread and fruit and added cold meats that we had brought in our suitcases.

In the evening we dine at the hotel, having ordered our orders in the morning before we left. The offer is similar to that of the lunch restaurant: rice, pizza, chicken or pasta.

On the 4th day of the camp, the connection of the scalpel plate they have in the hospital broke, and it was not possible to fix it, so we were left with only one scalpel. We decided to continue on 2 tables, exchanging the scalpel that we had brought with us, as one surgery was finished, we started on the next table, with everything already prepared. This, of course, delayed us a lot, and it was impossible for us to keep to the schedule, which was already complicated to carry out. Therefore, we prioritised patients with hernias and suspended several lipomas that do not pose any risk and can be operated on in successive campaigns.

Finally on the last day they got another generator that worked properly and we operated on the remaining 11 patients, somewhat simpler hernias than in the previous days, to avoid complications. After finishing all the work, we collected and packed the diathermy generator and some more material to take back to Spain.

After resting for a while at the hotel (they let us stay in the rooms until the afternoon), Dr. Konteh and Abu picked us up to take us to the beach area, where they had prepared a farewell dinner for us. Beforehand, we met up at the hotel with my colleague and friend, Dr Marta Lado, an internist working in Sierra Leone, with whom it was impossible to meet for the rest of our stay, as our working days were too long. I met Dr Lado almost 20 years ago when we were both training in Spain. Her eagerness to train in infectious diseases took her to Sierra Leone 10 years ago. She came for a few months, but stayed during the Ebola outbreak at the time, and the country and its people got to her. She works with an American NGO (Partners in Health), carrying out health plans, as well as participating in the WHO’s outbreak emergencies group. By coincidence, Dr Lado was Dr Konteh’s mentor, so she is also joining us for the farewell dinner. It is a great pleasure and honour to have her and her knowledge of medicine and the country we are in. She can certainly be a support in future missions if needed.

During dinner, we are given gifts: a police T-shirt and a notebook with our name engraved on it. After dinner they play music and we dance until it is time to leave for the airport.

Dr Konteh accompanies us there, and thanks to his contacts, we avoid paying the departure tax, which is about 100 euros per person.

The return journey is uneventful until we arrive in Madrid, where we realise that one of the checked-in bags has not arrived. We recover it in Vigo that same week.

And now back, with the satisfaction of a job well done, we bid farewell until the next one. This mission has been particularly hard at times, with many hours of work, more than expected, with a lack of means and material, as well as a lot of heat. But as always happens in this type of campaign, the team spirit and mutual support, makes us draw strength from nowhere, to continue and that everything runs smoothly. Thanks to all the team, for the effort and the desire, and above all for coming back for another year…

• CONCLUSION

3.1 Strengths of this place:

Sierra Leone is a country with a very poor health system. There are few doctors, and especially few surgeons and almost no anaesthetists. As a result, there is a huge number of patients, adults and children, who are potentially surgical. The Police Hospital, despite its shortcomings, is prepared for such campaigns. Dr Konteh is able to organise the campaigns and solve problems as they arise. The hospital staff is well adapted to the work, improving as the campaign progresses.

3.2. Improvement objectives:

– Prior screening of patients is essential. To rule out non-surgical pathologies and inoperable surgical pathologies during the campaign. It is very difficult to see such a large number of patients in such a short time, and above all, it is a significant waste of time, as more than half of the patients we screened in this campaign had no surgical pathology, or were not susceptible to surgery during the campaign due to the type of pathology.

– Improve pre- and post-operative care: in future campaigns it would be interesting to have nursing staff who can instruct local staff in this care: post-operative analgesia, wound care, correct channelling of IVs, taking of vital signs, etc., especially if the aim is to operate on more complex pathologies, as the knowledge of local nursing staff is very limited.

– Obtain a respirator that works properly.

– In future campaigns, if a respirator and a monitor can be obtained, three simultaneous operating tables could be set up.

4. BUDGET:

4.1. COST PER PARTICIPANT:

Participants travelling from Vigo, single room hotel: 2.021,10

Participants from Vigo, double room: 1.839,25

Participant from Gran Canaria, single room: 2.009,26

4.2. TOTAL COST OF THE CAMPAIGN:

Flight tickets Vigo/Gran Canaria-Freetown round trip: 10.654,08

Visas: 640 euros

Hotel: 2 double rooms, 4 single rooms, 6 nights: 2.635,48 euros

Meals: 500 euros

Ferry: 1000 euros

TOTAL COST OF THE CAMPAIGN: 15.429,56

5. SIGNATURES

                                                                               Signed: Ana Gay

                                                                             Responsible for the campaign

                                                                             Surgeons in Action

THE TEAM

John Hobbiss. Surgeon

Fernando De Santiago Urquuijo. Surgeon

Steffen Rose. Surgeon

Paul Robinson. Surgeon

Jenny Hobbiss. Surgical Trainee

Insiya Susnerwala.  Anaesthetist

Danni Volling-Geoghegan.  Anaesthetist

Claire Nuttall. Operating Department Practitioner

Jaime Owen. Operating Department Practitioner

THE HOST

The Anglican Church Diocese of Tanga,

St. Augustine Muheza Designated District Hospital, 

P. O. Box 308,

Muheza,

Tanga Region,

Tanzania.

E-mail: [email protected]

Host Surgeon. Dr Michael Boniface

This was the first Hernia International team to visited Muheza. Dr Michael Boniface, a surgeon working at St. Augustine Hospital, had joined the Hernia International mission to Korogwe in June 2023, where his contribution had proved invaluable. It was at his request that this mission to Muheza was organised.

Muheza is described in Lonely Planet, as a “scrappy junction town” on the road to Tanga. We found it to be a lively market town with bustling stalls selling locally grown produce, including pineapples, bananas, rice and, we were surprised to see, potatoes. The abundant motor bikes made crossing the road from one market stall to another particularly hazardous.

Muheza is situated on the coastal plain, just south of the Usambara mountain range that stretches across northern Tanzania from near to the Indian Ocean coast in the east to Mount Kilimanjaro in the north-west. The hills are visible to the north of Muheza, but the surrounding countryside is relatively flat and not as scenic as the rolling hills around Korogwe, 60 km to the west.

CUSTOMS AND TRANSPORT

We were met at Dar Es Salaam airport by Dr Boniface, whose presence proved to be invaluable in enabling us to bring our equipment and medicines through customs.  Fernando and Steffen came on a Turkish Airlines plane via Istanbul. Their four large cases, full of equipment and drugs, were not transferred onto their flight from Istanbul. They arrived in Dar Es Salaam the next day, by which time we were all in Muheza. Turkish Airlines agreed to fund a taxi to transport them to Muheza but persuading the airport customs department to allow them through proved to be more of a problem. It required a member of staff from St Augustine Hospital (a hospital pharmacist was “volunteered”) to travel from Muheza to Dar Es Salaam airport, a day’s journey by bus, with a letter from Steffen which explained the contents of the cases and authorised the customs personnel to open and inspect them. The Customs Officers must have accepted what they found, as all the bags and their contents arrived in Muheza on Thursday, our fourth working day. Their arrival was timely, as we had just about run out of the antibiotics and analgesics that the rest of us had brought.

On the night of our arrival at Dar Es Salaam, we stayed at an airport hotel (the Transit Hotel had functioning air conditioning and was perfectly satisfactory) and travelled to Muheza the next day in the St Augustine minibus, arranged by Dr Boniface. It was a six-hour journey on a tarmacked road, with a pleasant stop for lunch halfway there.

We arrived in the late afternoon, in time to organise our equipment in the operating theatres and to see the patients that Dr Boniface had arranged to come to the hospital for consideration for surgery the next day.

THE OPERATING THEATRES AND THEATRE STAFF

We had the use of two spacious, air-conditioned operating theatres. Both had a single but satisfactory overhead operating light. Power cuts were common, however, and although they were usually short lived, headlights were essential. There was only one diathermy machine, so that all the surgery in one of the theatres was done without the use of diathermy.

Both theatres had anaesthetic machines, and monitoring equipment (pulse oximetry and ECG trace). Bottled oxygen was available. None of our patients received a general anaesthetic. Nearly all patients had a spinal anaesthetic only. A few patients required supplementary boluses of ketamine. This was required when the procedure was unusually lengthy and in the one patient in whom both bupivacaine and lignocaine were ineffective. The one child, who underwent groin surgery, had local anaesthetic and ketamine.

We had specified that we planned to operate on hernia cases only and that we did not wish to operate on young children. We worked in the two theatres for the five days. We aimed to arrive at the hospital at 8 am each day and were asked by Dr Boniface to finish our day’s work by 6 pm.  This was to allow the significant number of theatre staff, including the sterilising unit personnel, who were required to support our mission, to leave the hospital in reasonable time. The hospital provided a cooked lunch in theatre for all the theatre staff, including us. We were asked to contribute to the cost of this food, which we were very happy to do.

THE WORK

We operated on 51 patients, repairing 41 inguinal hernias, of which 31 were primary and 10 were recurrent. Nine were irreducible inguino-scrotal hernias (Kingsnorth grade 4). None of the recurrent hernias had had a previous mesh repair, but in many of them we encountered intense fibrosis. It was the recurrent hernias that provided us with the biggest surgical challenges of the week. There was one incarcerated inguinal hernia in a man who had presented urgently the previous day.

There were 4 umbilical hernias and three midline hernias. We were also asked to see a 47-year-old lady with a large discrete mass at the top end of a previous caesarean section wound, almost certainly an endometrioma. This was excised.

We operated on 13 hydroceles and undertook one ligation of a patent processus vaginalis on a 13-year-old boy.

PERIOPERATIVE MEDICATION

Our intention was that all patients who were to have a mesh repair, should have an oral dose of broad-spectrum antibiotic at least half an hour before their procedure and then a two-day course of antibiotics and oral analgesia (a paracetamol / ibuprofen combination) postoperatively. Each patient was given an envelope containing their post-operative medication as they left theatre. Instructions on how to take the medication was written on the envelope in English and Swahili. When we saw the post-operative patients on the morning ward round, we discussed their medication with them and examined the envelopes. It seemed that most of them were taking their medication appropriately.

ACCOMMODATION

We were initially told that we could stay in residential accommodation within the hospital complex. At the time of our visit, however, this accommodation was being prepared for visiting medical students.  We were booked into The Sige Lodge, one of the few hotels in Muheza. It proved to be very satisfactory. There were enough rooms, all of which had air conditioning, although the intermittent power cuts meant that the air conditioning didn’t always work. As we arrived, a router was being installed to provide us with wi-fi, but that, at best, only provided a weak signal, which was usually inadequate. There was a pleasant open air dining room in which we were served omelettes for breakfast each morning. Dinner was provided by an external caterer. A lady, with whom, by the end of the week, we felt we were good friends, would arrive at the hotel each evening by tuktuk, bringing the food that she had cooked during the day with her. In spite of the wet and muddy dirt road to the hotel, she was always smartly dressed, spotlessly clean and greeted us with a smile. She took great pride in her cooking and with her food and the bottles of Kilimanjaro beer provided by the hotel, we had no complaints.

EXPENSES

By far the largest individual expense for future missions to Tanzania is likely to be the cost of temporary registration with the Medical Council of Tanganika. The Council have changed their policy on this and now charge medical staff on short term charity work the same as those doctors and nurses applying to do full time work. For us this was $200 per application.

Otherwise, Tanzania is not an expensive country. The minibus transfer from Dar Es Salaam to Muheza was $500, in our case split between the nine of us on the way there and seven on the way back. Dinner, bed and breakfast cost $30 a night. The Sige Lodge required payment in cash (US dollars). The Dar Es Salaam hotels accepted credit card payment.

REST AND RELAXATION

One of the bonuses of a mission in Tanzania is the variety of leisure activities that can provide relaxation afterwards. Two of our team travelled to Arusha at the end of the week and went on safari in the Ngorongoro Crater before flying back from Kilimanjaro International Airport. Three of the team travelled back to Dar Es Salaam and then took the ferry to Zanzibar for a short holiday there. Some of us were content to have one very comfortable night at The Slipway Hotel in Dar Es Salaam before flying home the next day.

CONCLUSION

We all agreed that we had a very worthwhile week at the St. Augustine Hospital and would strongly recommend Muheza as a venue for future Hernia International missions. Dr Boniface understands the work of Hernia International, he communicates well and can be relied upon to provide efficient organisation at the host hospital.

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