HERNIA INTERNATIONAL MISSION NIGERIA.

OCTOBER 11-19, 2023

STATUS: COMPLETED

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

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

Nurse: Lene Scheffmann Gosvig (Denmark)

Total: 4 volunteers

TECHNICAL REPORT:

DATES AND LOGISTICS DEPLOYED:

Campaign conducted October 11-20, 2023,

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

PEDIATRIC PATIENTS: Hydroceles, umbilical hernias, inguinal hernia.

CONSULTATION AND SURGERY PERFORMED:

Total procedures: 99 patients (105 procedures)

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

Patients seen in consultation: 130

Complications (within 7 days of our arrival):

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

CAMPAIGN SUMMARY

THE LOCATION

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

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

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

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

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

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

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

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

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

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

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

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

Our dear hosts: Sisters of Nativity

THE TEAM

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

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

LOCAL STAFF

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

EQUIPMENT

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

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

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

ANESTHESIA

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

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

ASEPSIS AND SURGICAL MATERIAL

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

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

ACCESSIBILITY FOR THE POPULATION

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

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

ACCOMODATION IN ABUJA

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

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

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

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

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

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

CONCLUSION

Strengths of this location:

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

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

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

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

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

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

Things we might do differently:

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

Bringing more local anesthetics, antibiotics, painkillers and dressings.

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

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

On behalf of the Team 2023

Yours sincerely,

Thorbjorn Sommer

Head of the Hernia International Mission to Abuja November 2023

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

STATUS: COMPLETED

Coordinators: Inma Giménez, Jose Mª Guallar

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

Paediatric Surgeon: Rocío Lizarraga

Anesthetists: Francisco Llácer, Inma Giménez

Nursing Team: Javier Madrazo, Esperanza Galarza, Míriam Martínez

Total: 11 volunteers

REPORT

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

TECHNICAL REPORT:

DATES AND LOGISTICS DEPLOYED:

Campaign conducted from October 20 to October 29, 2023

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

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

CONSULTATION AND SURGERY PERFORMED

Total procedures: 101 procedures

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

Patients seen in consultation: 161

Complications (within 7 days of our arrival):

– 2 seromas in inguinoscrotal hernias

– 1 seroma in supernumerary breast

– 1 folliculitis

– 2 cellulitis in pediatric umbilical/inguinal hernias

CAMPAIGN SUMMARY

THE LOCATION

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

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

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

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

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

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

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

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

THE TEAM

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

LOCAL STAFF

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

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

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

EQUIPMENT

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

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

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

ANESTHESIA

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

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

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

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

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

ASEPSIS AND SURGICAL MATERIAL

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

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

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

ACCESSIBILITY FOR THE POPULATION

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

OUR LIFE IN FARAFENNI

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CONCLUSION

Strengths of this location:

– Strategic location with a significant population in need

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

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

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

Areas for Improvement:

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

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

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

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

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

– The hospital accommodates a large multidisciplinary team.

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

BUDGET:

COST PER PARTICIPANT:

– Round-trip flights with checked luggage: 480€

– Hotels: 120€

– Food: 100€

– Approx. Transportation and airport fees: 190€

– Miscellaneous: 150€

– Total: 1040€ per participant

TOTAL CAMPAIGN COST: Approximately 11,440€

Yours sincerely,

Inma Giménez Jiménez

Head of the Farafenni Campaign October 2023

Surgeons in Action

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

1. TECHNICAL REPORT:

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

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

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

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

Femoral hernia 3

Umbilical hernia 5 (recurrence 1)

Epigastric/ supra-umbilical hernia 2

Hydroceles 4 (1 recurred)

Testicular tumour 2

Undescended testicle 1

Cord cysts 2

Lipomas 5

Facial tumour 1

Sebaceous cyst 1

Anal fistula 1

          Total procedures: 81

          Total patients 77

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

2. CAMPAIGN REPORT

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

THE TEAM of volunteers was made up of

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

– Anaesthesiologists: Eugenio Briz, Rocío C Armero.

– Nurses: Pilar Martínez Párraga, Carme Bordoy.

LOCAL STAFF.

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

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

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

 Resident doctor: helped and assisted in some surgery.

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

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

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

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

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

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

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

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

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

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

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

3. CONCLUSION

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

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

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

4. BUDGET:

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

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

+ cost of medical supplies.

                                                 Teresa Butrón

                                                 Team Leader

                                 Surgeons in Action/ Hernia International

HERNIA INTERNATIONAL MISSION TO KOROGWE, TANZANIA. JUNE 2023

THE TEAM

John Hobbiss. Surgeon

Fernando De Santiago Urquuijo. Surgeon

Steffen Rose. Surgeon

Kristof Nemeth. Surgeon

Jenny Hobbiss. Surgical Assistant

Ajaiya Mull. Anaesthetist

Claire Fenn. Operating Department Practitioner

Olivia Sibly. Nurse

THE HOST

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

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

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

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

OUR WORK

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

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

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

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

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

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

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

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

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

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

COMPLICATIONS

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

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

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

EQUIPMENT

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

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

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

ACCOMODATION AND SUBSISTENCE

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

EXPENSES

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

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

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

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

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

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

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

CONCLUSION AND ACKNOWLEDGEMENTS

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

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

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

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

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

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

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

DATE 23 May 2023

1. TECHNICAL REPORT:

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

Total procedures: 168

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

Total patients: 132

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

2. CAMPAIGN REPORT

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

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

▪ CMA Circuit

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

b. THE TEAM (group members):

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

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

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

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

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

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

f. EQUIPMENT:

• Operating rooms:

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

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

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

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

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

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

h. OUR LIFE IN SEREKENDE:

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

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

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

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

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

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

3. CONCLUSION

Strengths of this place:

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

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

Improvement objectives:

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

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

COST PER PARTICIPANT: 1152,93 €.

TOTAL COST OF THE CAMPAIGN: 12682.26 €.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

César Ramírez

Mission to Senegal, West Africa 16-20 January 2023

It was a real pleasure to be asked to join a group of Urologists planning a teaching course in Senegal. It had been a long time since I had travelled to West Africa. The course and the visit was organised via Zoom by the renowned Prof Serigne Magueye Gueye based in Dakar. His generosity was immediately obvious when our suitcases were ‘stranded’ in Madrid; we need not have worried!

As usual the first day of the mission allowed us to examine our patients. One was pleasantly surprised that I did not think an operation was necessary as his groin hernia hadn’t changed significantly since a prostatectomy – and he had walked 8km a day since then! I explained that was more than I walked in a week and so this was clearly a successful outcome from a ‘watch and wait’ approach. This formed an ‘educational nugget’ for the attending trainees. Lectures followed in the afternoon on the cost effectiveness of mosquito net mesh in the groin hernias. This was a new concept and I was later able to leave 30 prosthetics at the end of the visit when I did stress that correct/accurate steam sterilization is paramount. I performed 12 hernia repairs (1 ventral) all but one with spinal anaesthesia, over three days. As usual they were large (not always reducible) and often had a sliding component! Welcome back to the ‘neglected’ African groin I pondered. None were performed as day cases per se but all went home the next day.

As always we were spoilt with most generous hospitality. The local shopping was colourful, not duty-free but always hassle-free!  Finally we were reminded of the victims of the Atlantic slave trade on visiting Goree Island and the House of Slaves with its infamous Door of No Return.

We all relished our (too) short a stay and hope to return in the future.

Team Members:

Ayo Kalejaiye (Urologist)

David J Ralph (Urologist)

Brian M Stephenson (General surgeon)

([email protected])

Team: Arun Baskara (Leader), Paul Skaife and Michael Wong (trainee)

Dates; November 12-20 2022

The mission to Bopolu in the Republic of Liberia was carried out through Hernia International, the UK’s premier hernia charity which was initiated by Professor Andrew Kingsnorth. The surgical team for Nov 2022 comprised of Mr Paul Skaife, General Surgeon from the UK, Mr Michael Wong, senior trainee Surgeon from the UK and myself. Dr George Peter, who is the Medical Director at Jallahline Government Hospital, Gbarpolu, guided us through the mission. The mission was carried out from November 14 2022 to November 18 2022.

We flew in to Monrovia on different days and Dr Peter was kind enough to pick us up from the airport personally and drove us from Monrovia, the capital city of Liberia, to Bopolu in his pick- up truck. Though the distance from Monrovia to Bopolu was only 70 miles, it took nearly 5 hours for us to reach Bopolu. It was quite an experience for it was more an off-roading than driving on a road.

Bopolu is a beautiful small town with limited basic amenities for ones’ living. Generators were used for power and there was no running tap water. Life seemed to be simple and calm in the small town. People looked happy and contented.

During our mission, we did 51 surgeries which included inguinal, umbilical, ventral hernia repairs, keloid excisions, excision of benign skin lesions. The patients were from all age groups. Mr Skaife operated on pediatric and adult patients whereas Mr Wong and I took care of adult patients. We performed all the procedures either under local or spinal anesthesia.

Dr Peter arranged his staffs to assist us in the Operating Room. The staffs were kind, cheerful and curious. As we expected, the resources were limited in the Operating Room. We managed to give our best care to the patients with the available limited resources. Mr Wong was kind enough to bring 2B pencils to donate to the local primary school. He was an instant hit with the school and the students.

Bopolu trip was eye opening. The trip was challenging but, it gave us a humbling and rewarding experience. Our team is thankful to Professor Kingsnorth and Dr George Peter, his staffs and everyone involved for giving us an opportunity to serve the people at Bopolu.

Michael Wong received a Travel Award from the Royal College of Physicians and Surgeons of Glasgow. To view his report go to the following link

REPORT: GATUNDU-KENYA CAMP 2022   

                                                                            

1. TECHNICAL REPORT:

a.           DATES AND LOGISTICS DEVELOPED: 25th November – 4th December. 

It was carried out in collaboration with Hernia International Foundation, Prof. Andrew Kingsnorth made it possible for us to do it on very short notice.

It was prepared in a month and a half, made possible by the hospital director, Dr. Jesse Ngugi, who responded quickly to all questions and with the help of the secretary Lizz Beth, we submitted all the documentation to obtain the temporary permits (passports, diplomas, diplomas translated by a sworn translator, certificate of suitability and CV in English). She also helped us to book the hotel and the hospital provided an all-terrain vehicle with driver (Samuel Macharia) for transport from the airport and daily from the hotel to the hospital.

All volunteers collected consumables (surgical gowns, drapes and surgical fields, sutures, mesh, bladder catheters, sterile and operating gloves, anaesthetic material). The 12 de Octubre University Hospital donated anaesthetic medication worth around €500.

The air tickets were taken through Angelis (freelance of Halcon Viajes) with the company Egyptair, which allowed the transport of 2 bags of 23 kg per person + cabin baggage. We carried a total of 400 kg of material including 2 diathermy generators.

b.          ADULT PATIENTS:

H- supraumbilical+ epigastric +diastasis rectus : 8. ( fascia plication, reinforced suture, prefascial mesh).

H umbilical: 3

H epigastric / supraumbilical. 4

H. inguinal 13, 4 bilateral (T. Lichtenstein, T Wantz (1)

Incisional H 4 (T. Rives Stoppa, T Stoppa)

Lipomas 3

Sebaceous cyst 1

Hydroceles 4

c.           PAEDIATRIC PATIENTS:

Undescended testicles: 30

Inguinal hernia 8

Umbilical hernia 6

Hydrocele: 2

Phimosis 1

Total procedures: 87

Total patients 84 patients (47 boys)

d.          COMPLICATIONS: We had no complications during our stay and in the follow-up done by Dr. Chacha.

2. CAMPAIGN REPORT

a.           THE PLACE 

Kenya, located in East Africa, has a population of 51,393,010 people. Its capital Nairobi has a population of 3,130,000 and its currency is the Kenyan shilling (1 KES = 0.01 Euro). It is a multi-party republic. The majority of the population is Christian, with 35% Protestant and 30% Catholic, 30% Muslim and 5% Animist, and the official languages are Swahili and English as well as numerous tribal languages.

Kenya’s GDP per capita, an indicator of its standard of living, was €1,449 (Spain $28,156), and it ranks 152nd out of 192 countries, and the Human Development Index or HDI, which measures a country’s progress and the standard of living of its people, ranks 142nd, indicating that its people have a very low standard of living.

 Gatundu is a small town of about 20,000 people located in Kiambu County with a population of 1,600,000 and is situated about an hour’s drive from Nairobi. It is the birthplace of Kenya’s first president, Jomo Kenyatta, who has a luxurious hilltop residence overlooking Gatundu. In contrast, the town’s infrastructure is very poor, with most of the houses and shops located on both sides of the main road; The shops are distinguished by signs hanging over their doors advertising their businesses, there are numerous fruit and vegetable stalls, churches and schools of different orders and faiths, and on the unpaved side streets, the doors of the houses remain open. The population lives on a dollar a day. Rice, vegetables and other farm produce are the staple food.

The V Level Gatundu Hospital is a hospital funded and built in 2013 by China at a cost of 11 million dollars and was inaugurated in 2016.  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.

It has 5 floors; on the ground floor there are emergency, admission and outpatient services, two hospitalisation floors with several wards with eight beds each, where the operated patients were accommodated. A gynaecology and obstetrics area on the first floor and on the third floor the surgical area with two operating theatres called “Theatres 3 & 4”, which are underutilised, and in which we carry out our operations.  On the 3rd day, another operating table was installed in operating theatre 3, so that we had 2 tables for adults and one for children in the other operating theatre.

The operating theatres are spacious and relatively new, but lacking a lot of equipment; the lighting is good and stable, with no need to use the headlights. There are two well-functioning ventilators and a Valleylab diathermy generator in Theatre 3, which works well; in Theatre 4 we installed an diathermy generator console owned by our Foundation.

The AER room is very basic; this is where patients were monitored after surgery and watched over by a nurse from the Hospital.

There is a relaxation room for the staff, which we used as an office for writing reports, and also as a dining room, since we were served lunch here every day, which included stewed meat, rice, pinto beans and vegetables, as well as coffee and mineral water.

The surgical area also has a storeroom in which we stored all the material contributed to the campaign (face masks, ventimask, bladder and nasogastric tubes, disposable surgical drapes and gowns, new pyjamas, bandages, electric scalpels and plates, surgical gloves, masks, antiseptics for hand washing, meshesm sutures,etc.. We found numerous untidy boxes with material from previous campaigns such as sutures, dressings, general anaesthetics such as halothane, antibiotics, needles and abocaths, needles for spinal anaesthesia, endotracheal tubes, laryngeal masks, face masks, vents, skin staplers and staple removers, etc. To this material we must add the material left by our team at the end of the campaign. Dr Chacha, the current surgeon at the hospital, said he would organise all the material so that it could be used.

b.          THE TEAM was composed of 10 volunteers

                                     Team leader: Teresa Butrón

General surgeons: Teresa Butrón, J Ignacio Tello, S Fdez Arias.

Neurosurgeon: Alina Costache.

Paediatric surgeon Alejandro Unda.

Anaesthetists: Fernando Asensio, Adolfo Ramos Luengo.

Paediatric Intensivist: Emilia Tallo.

Nurses: Elvira Vallejo Sánchez. M J Fornier.

c.           LOCAL STAFF:

Hospital surgeon: Dr. Clifford Chacha Mwite.

Other surgeons from nearby hospitals were on hand for the campaign:

General surgery: Dr Winfred Kimani.

Paediatric surgeons: Robert Mugo, Vivien Cheboiwo. 

Anaesthesiologists from the hospital: Justus Murago, Ruth Muiruri, Eric Karuri, Isaac Karaba.

Nurses: Kennedy Weru, Ruth Waithaka, Lucia Nguru, Claire Njeri, David Chege, Marycyne Chesori.

We have also had medical and nursing students who have helped us, showing great interest in learning about our work.

d.          EQUIPMENT: There is quite a lot of material in big boxes which we made sets for hernias, etc. to optimise it. Many Crile forceps are in poor condition. We used the consumables we brought with us although on the last 2 days we used sterile cloth gowns. The electric scalpel generator was useful as we were able to operate on 3 operating tables.

e.           ANAESTHESIA: Adult patients were anaesthetised by the volunteer anaesthesiologists, mostly with regional anaesthesia, and in the case of incisional H., with general anaesthesia, always with the material and medication that we carry. Children were anaesthetised by local anaesthesiologists.

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

g.           OUR DAILY LIFE: We left Madrid airport on Friday 25th November with the Egyptair airline with a stopover in Cairo, which was delayed and this meant that in Cairo we had to rush to catch the flight to Nairobi. We arrived at 3:00 on the 26th and 5 packages of material were lost in Cairo, including a generator and another with medication. Thanks to the efforts of Dr. Chacha and Dr. Ngugi, they arrived at the hospital on the third day. At the airport we exchanged money, which was absolutely necessary to have the local currency, the Kenyan shilling, to pay for small items such as drinks, food, souvenirs, etc. We passed through customs without any problems on presentation of the letter from the campaign.  We were picked up by Samuel and transferred to the Maxland Hotel https://maxlandhotel.co.ke/ which is half an hour’s drive from Nairobi and about 20 minutes from Gatundu Hospital. It 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 supermarket where you can buy everything you need. The price of the hotel including breakfast and dinner was about 40 dollars a day. At midday we went to the hospital and were welcomed by the nurse in charge of sterilisation; we visited the different parts of the surgical area and the nurses cleaned, ordered and classified the medical-surgical material as well as organising and equipping the two operating theatres, the rest we went with Dr. Chacha to see the patients ready to operate on Sunday. From Sunday 27th to Friday 2nd we carried out 6 surgery sessions from 8h -19h or some days later, in addition we visited the operated patients in the morning and in the afternoon we saw the patients who would be operated on the following day. We were always accompanied by Dr. Chacha who assisted in several operations and sometimes we helped him, as did Dr. Kimani; Dr. Unda was also assisted by the paediatric surgeons who came for the campaign. Dr Tallo (paediatric intensivist) made it possible for many children to be operated on because she supported Dr Unda, the paediatric surgeon, by seeing the children, following the postoperative period and writing in the medical records. On Friday afternoon we finished early and packed up the generators, took photos with all the staff and said goodbye, the hospital director, Dr. Jesse Ngugi told us that for the next campaign more patients would be recruited, after the pandemic and with only 1.5 months notice, it had been complex.

On Saturday 3rd, 5 volunteers left for the Masai Mara Park to return to Madrid on the 6th of December, the rest of us went to Nairobi National Park where we saw rhinos, giraffes, etc.  We returned on Sunday 4th December at 4:00 from Jomo Kenyatta Intl airport in Nairobi, to Madrid, we lost 4 bags, with the generators that were recovered a week later. 

It has been a good campaign because we have worked as a team with the local staff and exchanged knowledge – both parties were satisfied.

3.           CONCLUSION

                      Strengths of this place: It has 2 operating theatres, one of which can be fitted with 2 surgical tables, has a respirator and there are staff, a surgeon in the hospital who recruits patients and is interested in sharing knowledge. The director is interested in the continuation of the campaigns and is efficient and quick to respond.  In addition there are anaesthesiologists who put children to sleep.

Objectives for improvement: Greater recruitment of patients. To be able to see them in the consulting room without them being admitted beforehand. Increase the number of patients undergoing outpatient surgery.  To make a kit of instruments for hernias.

4.           BUDGET:

COST PER PARTICIPANT: air ticket 857 €, hotel (bed + half board) 40 $ / day x 8 days = 320 $, Visa: 60 €.  Total per person: 1.237 €.

TOTAL COST OF THE CAMPAIGN: 11.800 €.

REPORT

24 November- 5 December: Korogwe Campaign Tanzania

Korogwe is a town of just over 60,000 inhabitants located in the Tanga region of northwestern Tanzania. Its communications with the main airport of the country, the Julius Nyerere International Airport located in the populous and old capital of the country, Dar Es Salaam, are by land by means of a road irregularly asphalted along almost 300 km and that becomes interminable in the almost 6 hours of journey that it occupies.

The most feasible connections from Spain to Tanzania are via Istanbul and can normally be reached from our country with only one stopover. Korogwe’s pattern of religious profession mirrors that of the country, with 80% of the population divided between Muslims and Catholics and the remaining 20% being Anglicans and Lutherans. The country has a republican government and the situation there, despite Somalia’s proximity to the north, is fairly calm.

Korogwe is home to an important Catholic congregation, the Congregation of the Sisters of Our Lady of the Mountain of Usambara, which was established in 1954 and plays an important role in helping local society, including the coordination of medical care through Dr Avelina Temba, who is also a surgeon and a person who gives 24 hours of her life to help those most in need, with a special emphasis on health.

The physical space where the campaign took place is the Korogwe Town Hospital in Magunga, which was founded in 1952 and is a fairly basic hospital typical of developing African countries.

It has two basic spaces that can be used as a consultation room and a waiting room, as well as a bedding area with separate spaces for men, women, children and postpartum women, and a surgical block with two operating theatres.

Both operating theatres are equipped with an diathermy generator that works properly and only one of them has a general anaesthesia machine that has been valid during the days of the campaign, except for specific moments when there were power outages and it obviously gave way.

Both operating theatres had air-conditioning systems which were switched on intermittently when it was hot and made our work there quite comfortable. Sister Avelina Temba is the person who swims and runs the hospital and is widely respected by all the staff.

Throughout we have had local doctors and two surgeons from the region working closely with us, with special mention for Dr. David Siwiti who has accompanied us as well as Sister Temba every day in and out of the hospital. In the surgical area there are basic changing rooms with a latrine and a third physical space that can be used for emergencies and caesarean sections, as was the case during our stay.

Sister Temba’s prior coordination and preparation for the campaign has been done directly with me via whatsapp and email in the three months prior to the campaign, so that we have been registered and our temporary registration licenses as admitted doctors by the Medical Council of Tanganyika; all surgical material was also registered in a letter of donation to Korogwe Hospital to facilitate the administrative access of everything we have brought.

About 15 minutes drive from the hospital is a small hotel where we have stayed and which is usually the reference point for the teams that carry out the cooperation campaigns. We had booked 4 double rooms for the 8 members of the team and we could say that it is a quite acceptable and comfortable place as the rooms have a king-size bed and a bathroom with toilet and hot water for a shower. With the help of Sister Temba, we had already booked half board with breakfast and dinner, so the price per day per person for half board was 45 Euros (120000 Ugandan shillings) and both breakfast and dinner were quite good, as they were prepared on the spot on request from the hotel menu and included unlimited carbonated drinks and beer in the price. As for the food, we always had lunch in the surgical area and in groups, so as not to interrupt the surgical activity, and we alternated the local food offered free of charge by the hospital with local products (basically cold meats and preserves) that we had included in the luggage we had brought with us.

The mission team consisted of three surgeons (César Ramírez, leader of the campaign, Javier Moreno and Marta Roldón), two anaesthesiologists (Carlos Ávila and Gloria Hernández) and three nurses (Francisco Gómez, María Castro and Verónica Fernández). Except for Gloria, who came from Madrid, all the other members of the team live in Malaga and we met at Malaga airport on the 24th of November 2022 and from there we flew to Istanbul, where we stayed overnight to catch the flight to Dar es Salaam the next day at 19.30 hours, arriving at the airport at 3 am on the 26th of November, where Dr.  David Siwiti was waiting for us with two vans to take us and the transported material, a total of 390 Kg that included a Ligasure donated by Medtronic for the campaign and the usual for its development (sutures, sterile surgical fields, single-use and sterile gloves, gauze and compresses, sterilising solutions, more than 150 sterilised meshes of different sizes, 50 Ligasure terminals and 4 boxes of surgical material for endocrine surgery that are our property and always accompany us). The process of arrival at the airport and going through customs was quite painful, as they kept us waiting for two hours in the early hours of the morning and made us open all the suitcases and packages despite the fact that they were perfectly labelled, numbered and documented with the certified letter from the NGO Cirujanos en Acción.

On the day of arrival, Saturday 26 November, we spent the day evaluating the patients that Sister Temba had previously selected according to the criteria we had agreed on: hernias of all types (including children from the age of 4), hydroceles, soft tissue tumours, goitres and abdominal masses, as well as any adult pathology that might require surgery. On that day we selected 80% of the patients to be operated on and the remaining 20% came on successive days.

There were seven days of surgery in total, starting on 27 November and ending on 3 December, all of them full days except for Saturday 3 December when the activity ended at 5 pm. During these seven days, the routine was quite scheduled: we met in the hotel dining room at 7 am for breakfast and were picked up half an hour later to be taken to the Hospital. At 7.45 am we would start the preparation of the operating theatre and at the same time the ward rounds of the operated patients, in order to coordinate the start of the actual surgical activity at 8.30 am.

Although Sister Temba told us that ideally we should finish the day’s work at 6 pm (as it was time for nightfall and the staff had to leave the Hospital and go to their homes, most of them on foot and sometimes “not short” distances), I explained to her that in order to carry out all the activity we needed to operate later and we finished at an average time, which was 9.30 pm.

As compensation, we have thanked the staff for their collaboration with a donation of 1000 US dollars which we have given to Sister Temba to distribute among the workers who have collaborated with us. We worked every day taking advantage of the space in the two operating theatres, giving preference to the general anaesthesia theatre for the more complex goitres and hernias.

On the afternoon of the 3rd of December, Sister Temba took us to visit her convent and to pray in front of Our Lady of the Mountain, and afterwards she entertained us with an aperitif made by the sisters themselves; for us it was a great experience to share this space of life and prayer with the sisters and it is something we were very grateful for. In the evening of the same day we organised a dinner in our hotel where we invited all the hospital staff who have worked with us and we shared a very pleasant farewell. It is interesting to note that it is always a good idea to bring your own surgical instruments as the process of washing and sterilising the material is sometimes not very operative and can be a handicap for a high pace of work.

The total number of patients who underwent surgery was 102, and 133 surgical procedures were performed on them, distributed as follows:

1.-Twenty-four cervical endocrine surgeries (including 13 total and 11 partial thyroidectomies) with no major complications, all patients being discharged within 36 hours after surgery. No cases of hypocalcaemia were recorded in the mid-term follow-up, with only 3 patients presenting immediate dysphonia, and in one case a reoperation was required due to bleeding through the surgical wound in a patient who had undergone surgery for a giant endothoracic goitre with a large retrosternal component.

2.-Sixty-three patients underwent surgery for hernial pathology, divided into 43 inguinal hernias (including 5 that were reproduced and 9 of them bilateral), 16 primary hernias of the linea alba (pure umbilical or epigastric) and 7 eventrations (of which four were large and were treated with associated abdominoplasty). Eleven of these hernia surgeries were performed on children under 12 years of age.

3. -24 patients were operated on for hydrocele of different sizes, 5 of whom were bilateral, and two orchiectomies were performed for testicular tumour pathology and two surgeries for cryptorchidism in boys aged 7 and 9 years. Finally, 3 emergency surgeries were performed, two of them appendectomies for advanced acute appendicitis and one perforation of the hollow viscera with biliary peritonitis due to acute blunt trauma requiring double intestinal resection. An exploratory laparotomy was also performed on a 17-year-old boy with an unresolved abdominal mass that turned out to be an extensive peritoneal carcinomatosis of probable sarcomatous origin that was sent for biopsy.

It is important to mention that thanks to the collaboration of Mr. Santos Velasco, a licensed pharmacist from Malaga, it has been possible to provide Tanzania with LT4 thyroid hormone replacement for almost 2.5 years for the 13 cases of goitre in which total thyroidectomy was performed, as well as 60 boxes of oral calcium in case it was necessary and 100 boxes of Ibuprofen 600 mg which were given to each patient operated on for the home treatment of postoperative pain. It is very important to highlight the high degree of collaboration and good atmosphere that we have had at all times and that we have tried to reciprocate by operating on as many patients as possible and counting on the collaboration of at least one local surgeon (if not two) as a scrub assistant in each surgery. We have taught as much as we could and have offered to assist local surgeons in training, who have performed some less complex procedures. Without a doubt, Dr. and Sister Temba is an example of how to organise a campaign and I hope that we will soon be able to return there to continue helping people in need.

                                                                         Dr. Cesar Ramirez

                                                                        Team leader