Author: akingsnorth

REPORT OF THE ULLONGUE- MOZAMBIQUE CAMPAIGN

DATE  19-12-2022

1. TECHNICAL REPORT:

       a.     DATES AND LOGISTICS DEPLOYED:

ULLONGUE CAMPAIGN 28-10-2022 TO 6-11-2022

       b.    ADULT PATIENTS:

NUMBER  OF  PATIENTS: 96

NUMBER OF  PROCEDURES: 105

DIAGNOSES:

INGUINAL HERNIA = 18

UMBILICAL HERNIA = 4

EPIGASTRIC  HERNIA = 3

FEMORAL HERNIA = 1

HYDROCELA = 8

TUMOURS OF SOFT PARTS (cysts and lipomas) = 50

GANGLIOMA = 7

CHELOID = 4

ANAL FISTULA = 2

HAEMORRHOIDS = 2

TOE AMPUTATION = 1

BREAST TUMOUR = 1

TESTE TUMOUR = 1

ABDOMINAL MASS = 1

INTESTINAL OCCLUSION DUE TO COLONIC VOLVULUS = 1

uterine rupture (assistantship) = 1

            c. PAEDIATRIC PATIENTS:

                          NUMBER OF PATIENTS: 30

                          NUMBER OF PROCEDURES: 33

                         DIAGNOSES

                          Right costal tumour (Teratoma) = 1

                          Amputation of right arm + wound dressings face + wound dressings EII = 1

                          Cervical tumour = 1

                          Malar tumour = 1

                          Vulvar synechiae = 1

                          Frontal exostosis = 1

                         Fistula due to osteomyelitis EIE = 2

                         Ganglion = 1

                         Baker’s cyst IBD = 1

                         Inguinal hernia = 6

                         Umbilical hernia = 10

                         Hydrocele = 1

                          oft tissue lump = 6

• COMPLICATIONS: WE HAVE NOT HAD ANY COMPLICATIONS, we have been in contact with colleagues in the area and the patients we have left in hospital, no complications.

2. CAMPAIGN REPORT

1.  THE PLACE

The rural hospital of Ullongue was already known to us, as this is the third campaign we have carried out there (all before Covid). The equipment of the surgical area has only improved in that we had oxygen and that the anaesthesia machine worked but only in one room.

We operated in 2 operating theaters:   the paediatric in the operating theatre and in the other ward we placed 2 tables that are stretchers, and separated them with a screen.

The hospital ward is opposite and unlike other times there is now a hospital doctor who monitors the patients and gives us support.

Recruitment this time was zero, there was no recruitment at all, and we found that we had to do it on arrival, which is why we didn’t operate much. The paediatricians on the first day went to the orphanages to recruit and we visited there in the mission and in the hospital. This was because the contacts  we had there, are now gone

• THE TEAM (members of the group)

   Dr Lola Delgado paediatric surgeon

   Dr Jesús Redondo: paediatric surgeon

   Dr Pilar Murga : anaesthetist

   Dr Isabel Moreno : anaesthetist

   Dr Quique colas : adult surgeon

   Dr José Manuel Hernández : adult surgeon

   Dr Sandra del Barrio: Adult Surgeon

   Dr Lucia Catot : Adult Surgeon (leader team)

   Dr Helena Sarmento : Internist

   Mª Jesus Nieto : Nurse

   Lola Mora : Nurse

   Father Vitor Lamosa- interpreter

   Irene Manzanares: Photographer

• THE LOCAL STAFF: everything has changed

The medical director Dr Maria

A hospitalist

Dr  Olga Sheron who does emergencies

Real Gilberto, who is a surgical technician who does the caesarean sections.

Mr. Julius who does everything, cleans, sterilises, and helps us with everything.

• THE EQUIPMENT :

The paediatricians were well equipped, they brought material and 1 dyathermy generator.

The adults brought 2 dyathermy generators and surgical material. They left us some material but not much.

As for consumables, we brought everything, as there is nothing there.

• ANAESTHESIA

In the case of paediatric surgeries, all of them were performed under general anaesthesia.

In the case of adults, regional anaesthesia, as there is no oxygen or trolley in the room suitable for these surgeries.

                        f.    ASEPSIA AND SURGICAL MATERIALS – They have to sterilise and package.

                        g.   OUR LIFE IN:

We get up around 5.45 am, before breakfast we already have to see people who come from the villages and are waiting for us, the visits always have to be with someone who understands their language (Father Vitor Lamosa).

We have breakfast at the mission and then we go to the rural hospital of Ullongue, about 20 minutes away by car (this year some Portuguese friends of Father Vitor left us a minibus with driver for our day to day). And in this minibus we also take the patients visited in the mission who require surgery.

Arrival at the hospital,

– Group 1 visits the patients who had been operated on the previous day.

– Group 2 goes for a consultation

– Group 3 goes to the surgical area with the list of patients scheduled for surgery.

We have lunch around 13.30h which is prepared for us at the mission.

We continue operating until the end of the programme, while we are operating patients are arriving from villages or emergency consultations, and patients are being examined. 

Examples:

– A patient we saw occluded and who underwent urgent surgery with a diagnosis of occlusion due to sigmoid volvulus.

– 5-year-old child with traumatic amputation of the right arm with multiple contusions, requiring amputation.

– Patient with multiple injuries from a catana who was transferred to the provincial hospital (we had to pay for the petrol for the ambulance).

– Traumatic uterine ruptures, before going to the centre, from the villages if the patient does not go into labour they use the root of a tree for dilatation.

Return to the mission, with the minibus, we and the operated patients that we have brought on the way, who will go home, or stay that night at the mission.

In the campaigns here in Ullongue, every day is a surprise.

And everything flows like that, if there are no inconveniences such as the power going out and the generator not working, the oxygen running out, and thousands of other anecdotes.

Arrival at the mission, shower and dinner prepared for us.

            3.         CONCLUSION

Strengths of this place: the place itself, the need they have because if we don’t go,   nobody goes.

Objectives for improvement:

   Recruitment, the difficult thing is that, if there is no one there, it is ifficult to         recruit because the villages are far away. Now it seems that the same people will      be there  next year and they will be able to help us.

            4.         BUDGET: (small breakdown of costs)

COST PER PARTICIPANT: air ticket 1388.38€ + donation in the mission where we sleep (100 pp).

The air tickets were more expensive than usual as the airlines and flights have changed and now we are going via Luanda.

 Signed: Lucia Catot

Team leader

Surgeons in Action

1. TECHNICAL REPORT:

a. DATES AND LOGISTICS USED:

Campaign conducted from 3 to 13 November 2022.

b. ADULT PATIENTS: Inguinal, umbilical, ventral hernias, goitres, lipomas and sebaceous cysts,

c. PEDIATRIC PATIENTS: Joint campaign with another paediatric campaign in Banjul (Gambia) where all children seen in consultation are referred.

Total procedures: 105 procedures

Total patients: 90 patients

d. COMPLICATIONS (at 7 days PO):

2 urinary retentions, 1 cervical seroma.                       

 2. REPORT OF THE CAMPAIGN

a. THE LOCATION

The General Hospital of Farafenni is a centre created in 1999 with the government’s commitment to be the centre of reference in the east of the country Gambia, with health resources centred in the capital (Banjul).  It is a large, well-equipped and well-organised centre, consisting of 250 beds with a current occupancy of 175 due to the possibility of human resources.

Farafenni is a small inland town situated in a strategic location near the only bridge located across the Gambia River. It is therefore a place of passage not only for local trade, but also to allow the crossing from one part of Senegal to the other. The population to which it provides services is indifferently from both countries. The languages spoken by the the population are mainly Wolof and Mandinka. The hospital is divided into an initial office and emergency care area, and a nearby laboratory and testing building, from where different walkways go to surgical patients, maternity, children’s, internal medicine and dentistry, all of which are on two floors.

in the operating theatres, there is a clean circuit with two large operating theatres, one for maternity and the other for general surgery. Each operating theatre is equipped with a basic respirator with halothane capacity and a diathermy generator. The operating theatres are equipped with split air-conditioning which allows comfortable working hours despite the high temperatures outside. The obstetric equipment could not be used for our campaign, due to the large number of caesarean sections.

The operating theatre can be structured in such a way that 3 tables and two operating theatres can be placed inside in a spacious and functional way with space for entering patients on a stretcher

 b. THE TEAM (members of the group)

Specifically, the team is made up of the following specialists

General Surgeons: Eduardo Perea, Manuel Bustos Jiménez, Isaías Alarcón del Agua,

Abdul Razzak Muchref Al Dandal, Carlos Javier García Sánchez (the trainee);

Anaesthesiologists: Guiomar Fernández Castellano, Jessica Gallego Solana;

Nurses:  María del Mar Martínez Gómez and Daniel Luis Nadales Muñoz

c. LOCAL STAFF

Hospital with a large team of staff available in addition to the extra staff hired for the impact of patients recruited for the campaign. Those involved in the campaign have been: – 6 Cuban doctors working there, one of whom is a surgeon and allows for helping as assistants as well as follow-up of patients who have undergone surgery.

– 3 security personnel who are with you at all times in the outpatients room and in the hospital and translate Wolof and Mandinka.

– 4-6 ward assistants/nurses who monitor patients in the postoperative period and take the IV before surgery.

– 2-7 operating theatre staff with various functions: from cleaning to orderlies. One nurse with basic anaesthesia skills and 2 nurses who can circulate or handle instrument. Presence in the operating theatre varies according to the time of day.

d. THE EQUIPMENT

The operating theatre consists of 3 tables of which only 1 is a surgical table in itself. A diathermy generator that only accepts one terminal. Various sutures from leftovers from previous campaigns. No meshes. Two monitors with pulse oximeter and BP cuff.

e. ANAESTHESIA Operating theatre equipped with an anaesthesia respirator with manual ventilation and possibility of using halothane and isoflurane.

Oxygen cylinder (possibility of up to 4 or 5).

Physiological saline solution and Abocath.

Cabinet with some ampoules of noradrenaline, bupivacaine with dextrose and adrenaline.

2 monitors.

f. ASEPSIS AND SURGICAL SUPPLIES

Basic surgical set boxes consisting of sufficient but deteriorated instruments. One laparotomy box with additional material that was not used during the campaign.

The gowns and drapes are sterilised in the same way in an autoclave. Depending on the target number of interventions, it is recommended to add more gowns and drapes, sometimes there is not enough time to sterilise. It woule be better if another diathermy generator could be provided.

g. ACCESSIBILITY FOR THE POPULATION

Due to relative poverty of the local population the cost of hospital admission is very low and accessible, 40 euro cents per admission for the Gambian population and 80 euro cents for the Senegalese population. Imaging and laboratory tests are charged separately and are not excessively expensive.

h. OUR LIFE IN FARAFENNI

Day 1: Arrival in Banjul in the early morning. The proximity of the country and the many combinations allows flexibility of schedules, but most flights arrive very late in the capital. In our case, due to the Vueling strike, our tickets from Barcelona were cancelled only 72 hours in advance and it was necessary to buy new flights from Valencia, delaying the start of the campaign by one day.

With Air Maroc it is possible to carry two pieces of luggage per person of 23 kg each. Our problem was the transport of all the material from Seville to Valencia in 2 vans that we rented without prior notice, increasing the budget of the campaign. On arrival we were kindly picked up at the airport and taken to sleep a few hours in a nearby hotel, the Woodpecker. Room for up to 6 people at a good price.

Day 2: Transport in two cars from Banjul to Farafenni by the southern road to avoid the ferry.

4 hour drive with good road conditions. Arrival at the Wallyman hotel, very close to the hospital and pleasant with a garden with access to air-conditioned single rooms. Nearby mosque with prayer at 5 a.m. as anecdotal information. We moved to the hospital on foot (15 minutes), a safe and closed area, but poorly lit. We recommend headlamps.

A warm welcome at the hospital and a consultation to prepare the next day’s operation  schedule by the surgeons. Anaesthetists and nurses unpack and prepare the operating theatre, checking the ventilator and the oxygen available for the large number of goitres.

Day 3-8: Incessant OR activity to try to compensate days lost due to the plane strike. Very large consultation with many patients coming from very far away, taking a ward round before starting the operations and numerous surgeries until 7 pm. Very good local staff collaboration for the development of impeccable activity.

Due to the strategic location of the centre and the effect in local media publicity, 189 patients have been seen in consultation. As an extra contribution to our activity, we have carried out satisfaction surveys with all patients and we have collected the geographical dispersion of the patients attended as well as the environment and the hours from origin.

Day 9: Return to Banjul one day before the flight to sleep in Banjul the night before, one of the cars breaks down on the way back, delaying arrival at the hotel until early morning.

Day 10: We take advantage of the morning to visit a local market and eat fish in a tourist restaurant. Departure in the afternoon to the international airport to return to Spain.

3. CONCLUSION

Strengths of this place:

– Strategic location with a large population in need

– Presence of a Cuban community with which it is easy to communicate and patient follow-up.

– Great collaboration of the local hospital for patient recruitment and to assist in consultation, ward and operating theatre.

– A large number of Spanish foundations and NGOs working in Banjul, which can be of help in accessing the population in need.

Objectives for improvement:

– It is recommended to bring a urologist, there are a large number of urinary disorders.

– Endocrine surgeon recommended, although hernias are our target, the area is endemic for goitres and Graves’ disease.

– Bring another source of energy (diathermy generator or Ligasure for goitres).

– Hospital that admits large multidisciplinary team.

4. BUDGET: (small breakdown of costs)

COST PER PARTICIPANT:

– Return flights with material check-in 650€.

– Hotels 250€.

– Food 50€.

– Transport and others 450€.

– Total €1500 per participant

TOTAL COST OF THE CAMPAIGN: approximately 13.500 €.

Eduardo Perea del Pozo

Team leader of the Farafenni 2022 campaign Surgeons in Action

Austrian-Slovenian-Australian-Liechtenstein Team Mission

Ngarenairobi, Nov 7th-11th 2022

Ngarenairobi is an administrative ward in Siha District of Kilimanjaro Region in Tanzania. The ward covers an area of 172 km² (66 sq mi), and has an average elevation of 2,111 m (6,926 ft). According to the 2012 census, the ward has a total population of 9,431.
The Ngarenairobi Health Centre (NHC) belongs to the Congregation of Spiritus Sancti Fathers. The NHC was host for Hernia International (HI) mission for the first time in history. The reason for the mission was dr. Ally Kombo, skillful and ambitious young surgical consultant, who was inspired by HI-charisma after hosting our 2019 mission in Momella village. He made the contacts with the hospital owners, especially fathers Damian and superior father Calistus.

The travel from our homes to NHC took us about 24 hours. Some of us summited Mt. Meru Mountain (4566m) in the days after arrival.

Summit of Mt. Meru (4566m)

After that, the team met on Sunday prior to the mission at the Provincial house of the Congregation and from there and back we were transported to the NHC daily (about 30 min). Our team consisted of 9 members: 3 surgeons, 1 anaesthesiologist, 1
radiologist, 1 scrub nurse, 1 nurse anaesthetist, 1 future student and 1 photographer.
Additionally, at least 5 local surgical consultants/residents and anaesthesia consultant/residents and nurses came from many parts of Tanzania, even islands Zanzibar and Mafia to learn. We imported 220 kg of equipment and drugs in 11 bags. This year there were no difficulties at the customs due to previous communication with the TMDA from our medical hosts.

Our team – dr. Kombo (in the middle) has become independent in hernia surgery

Checking patients for surgery was the first task on sunday evening and monday morning. As NHC is a village, a bit away from civilization, patients came every single day after they were informed via posters, local radio and social media. Every single day, there were just enough patients for 1 day, not too many, not too few.
The turnover of the patients was fluent. We were not used to take a lunch break, biscuits, soft drinks, coffee and delicious cashew nuts / ground nuts were sufficient for most of us between operations. Besides goiter and hernia surgery and small operations for other indications, assisting to local doctors and nurses was high on our priority list. We took time to do this as education and teaching is important on our missions. Local doctors, especially dr. Kombo, became independent and self-confident in hernia surgery.
Parallel operations on 2 and sometimes 3 tables, enabled 51 procedures on 46 patients in 4 days.

Preoperative check-in

Good work in the hospital was also possible because we were accommodated well (breakfast and dinner) in the Provincial House of the Congregation of The Community of Priests (in the Opus Spiritus Sancti). First, there was a plan to stay in a dormitory closer to the hospital, but after some talks it was evident that proper meals could not have been organized there. NHC might host new hernia missions in the near future, as there is readiness from the side of the organizers.

Thyroid surgery – big goiters are still endemic in Africa

Among 46 patients (with 51 procedures), we operated on 8 children (28%) and 33 adults (72%). 20 patients (43%) were female. The most frequent operations were hernia repairs (10 inguinals, 10 umbilicals and epigastrics), followed by Jaboulay`s procedure for hydrocaele operation. In inguinals in children, Mitchell-Banks repair was performed and Lichtenstein repair with LDPE mesh was performed in the vast majority of patients with inguinal hernia. The youngest patient was 2 years old. Thanks to the excellent anaesthesia team and Ligasure device (which we brought with us) we performed 3 subtotal goiter resections in big benign goiters and cancelled two more due to not optimized preoperative medication. They should be operated on during the next missions. There were 5 orchidopexies due to undescended testicle in children and 1 circumcision in a boy with symptomatic phimosis. Other diagnoses/operations were operations for benign breast lesions and other smaller excisions.

Preoperative ultrasound examination

Maria performed 52 ultrasound examinations with her portable US. This was of great help
pre-operativelly in goiters and other diagnoses (hernias/hydrocaeles) as well as postoperatively to discern haemathomas from normal tissue swelling.
In OT 1 (good lights, we brought diathermy and left it there), mainly general anaesthesia was
performed, while procedures in OT2 (week lights, diathermy) were in spinal and local anaesthesia. In OT 3 (which was improvised due to the strong surgical team from the recovery room), we used head lamps.

Teaching good surgery/anaesthesiology was high on our priority list

Scrub nurse Manuela was capable of preparing tables and material in 3 OTs – which was only possible because she managed to teach and motivate local scrub nurses to help and be active. It is also a good idea to have a (future) student on such a missions – Timotej was helpful in every situation. Nik as professional photographer helped him many times when he was not busy filming and taking great photos. He was even able to repair the electronics of the table in OT 3.

We felt privileged for having no complications (minor or major) which we contribute to a not
overcrowded programme. Again, we took enough time for every single procedure, without hurrying. A normal working day started at 8 am and ended at 6.30 -7 pm. Good working and a friend- building atmosphere was a result of mission preparation several months before (great thanks to dr. Ally Kombo, dr. Thomas Kosiano, father Damian and others). The prayers of the priests of the hosting order supported us additionally throughout the mission.

Team Members:

Dr. Dominique Robert – consultant surgeon, Colac, Australia
Dr. Marija Jekovec – consultant radiologist, Ljubljana Medical Centre, Slovenia
Manuela Logan, scrub nurse, Liechtenstein
Prof. Mirko Omejc, MD, PhD – consultant surgeon, Ljubljana Medical Centre, Slovenia
Dr. Michael Wirnsperger – consultant anaesthesiologist, Krankenhaus Zams, Austria
Wolfgang Walser – anaesthesia nurse, Feldkirch, Austria
Timotej Gorjanc – future student
Nik Gradišnik – professional photographer

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

Our sponsors:

Krankenhaus der Elisabethinen Klagenfurt

Medical Center Gorjanc

Implantoloski institut / Implant Institute

Krankenhaus St. Vinzenz Zams

LKH Feldkirch

Spital Grabs

Kirurgija Bitenc

University Medical Centre Ljubljana

Local children with members of the Team

POLICE HOSPITAL CAMPAIGN REPORT – 3-13 MARCH – FREETOWN, SIERRA LEONE

1. TECHNICAL REPORT:

DATES AND LOGISTICS DEVELOPED: The first date planned was 2-12 December 2021, entailing the purchase of air tickets from the Royal Air Maroc company, but due to the Covid pandemic and the closure of flights by Morocco it was delayed to 20-30 January, with the extension of the air closure it was delayed again to 3-13 March, the date on which it was finally carried out. This meant a change of anaesthesiologists because those who had signed up at the beginning did not obtain permission. It also meant an exponential increase in emails and whatsapp between the director of the hospital Dr. Mohamed Jalloh and myself as coordinator of the campaign, as well as between me and the volunteers. It was also necessary to update the VISAs and delay the interview with the Medical Council to obtain the relevant permits.

ADULT PATIENTS: A total of 85 patients between 17 and 75 years were operated.

Right inguinal hernias 32, left inguinal hernias 19, bilateral hernias 4.  (Lichtenstein and Rives technique).

Femoral hernia 1

Umbilical/epigastric hernia 2

Hydroceles 7

Cryptorchidism 2

Lipomas 18

Ectopic breast 1

Knee bursitis 1

Epigastric tumour 1

          Total procedures: 94

          Total patients 85

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), ventilator (not working), O2 concentrator and scalpel generator (not working), and a smaller one with a surgical table, a photophore, diathermy generator (not working), a small area for surgical washing, a room for material on the upper floor, and 2 other rooms on the ground floor with a table for consultation and another one that was set up for eating. It has 4 hospitalisation rooms, 2 on the ground floor with 8-10 beds each for men and women, with beds with mosquito nets and a control table for the nurses, where the patients stayed after the operation. In the room on the upper floor, the patients were prepared for the operation and brought down to the operating theatre with their IVs in place. Several consultation rooms of different sizes where we evaluated the patients who had been previously recruited.

THE TEAM of volunteers was made up of

– General surgeons: Teresa Butrón (coordinator), FJavier Grau Talens, Cristina Alejandre.

– Anaesthetists: Irene Macía, Lidia Álvarez.

– Nurses: MJ Fornier Coronado, Ana Nombela.

LOCAL STAFF.

Director of the hospital: Dr. Mohamed Jalloh, he provided us with the invitation letter for the campaign and the permissions from the Medical Council after sending him the documentation. 

Hospital administrator Mr. Koroma, he accompanied us to the airport on arrival and departure and was always ready to help us. 

 Doctors: Dr Munu (only stayed for the first 2 days), Dr Samba Jalloh (acted as coordinator and helped with patient recruitment and other coordination, although he was not a member of the police, but he filled in for Dr Paul Fillie in 2019, picked us up from the airport and accompanied us to the Medical Council office, he is a member and facilitated the permits).

Surgical technician: Mr. Kelly Jalloh who was in the operating theatre with me and assisted in all the operations. 

Anaesthetist: Dr. Matilde who was with the anaesthetists for much of the time.

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

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

EQUIPMENT (surgical instruments, supplies): There are enough instruments to make several hernia kits. There is a lack of suitable retractors. There is no autoclave and this meant that sometimes there was a lack of STERILE instrument kits to continue with more interventions, but this has improved over the last few days with the help of the local staff and nurses who have optimised the kits by adjusting them to the pathology in which they would be used.

ANAESTHESIA regional and local anaesthesia with sedation was performed, only one patient with an epigastric tumour had to be put to sleep because of pain that did not subside with local anaesthesia and sedation. All the material was carried by the volunteers, as anaesthetic material is scarce or lacking in the hospital.

ASEPSIA AND SURGICAL MATERIALS the hospital does not have an autoclave and all the instruments are washed and prepared in packages that are taken to another hospital every night to be sterilised. For this reason there were only about 10 kits and this prevented us from operating on a larger number of patients each day. This was solved by remaking the kits and adjusting them to the material that was necessary for each procedure.

OUR LIFE: We arrived in Freetown on the 4th at 2:00 am, we had left Madrid the day before; Roberto, Faustino Santisteban’s nephew, took some of the material with him.  At Freetown airport we had a PCR test and that delayed our departure, there was no ferry at that time. We were picked up by Dr. Samba Jalloh and Mr. Koroma and we all travelled in a police van to our hotel, The Jam Lodge. After a shower and a light meal, we were taken to the hospital where all the equipment had been brought. The nurses tidied up and the anaesthetists and surgeons set about seeing patients and preparing surgical schedules for the following days. Our daily routine from 5-11 March was breakfast at the hotel at 7:00. Transfer to the hospital where we changed and the anaesthetists and nurses prepared the operating theatre and the surgeons visited the patients who had remained from the previous day.

Javier and Cristina started to operate in the large operating theatre, they had no diathermy generator, so they operated without it, and with a professional photophore that Javier had, and in the small operating theatre I operated helped by Kelly Jalloh, surgical technician, with a photophore that was there and when it broke down, with another photophore of Javier Grau’s.

We ate in an adjoining room, food brought by a lady from there, based on pasta, fish or chicken, spices and a piece of fruit. Between operations, we would evaluate more patients in order to continue preparing the surgical schedules for the following days.

Activities after finishing sometimes late, focused on dinner at the hotel 4 nights and another day at a local restaurant. Two nights we dined at beachside restaurants with a nice view and tasted local culinary specialities. On Saturday the 12th we visited the remaining patients, checked a wound in the operating theatre and collected all the material: we packed the scalpel generator and some of the anaesthetic material that was not going to be used there. We said goodbye to all the staff and Dr. Samba Jalloh, Mr. Koroma and the supervisor Mr. Unisa, accompanied us to a resort at the foot of a beach with lots of light and clear water, there we ate and finally we went to a craft market to do some shopping and then to the ferry to get to the airport. We waited for the PCR result that we had done the day before and were able to board the ferry. Everything was over with the objectives achieved.

3. CONCLUSION

                      Strengths of this site: 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: Equipment of the operating theatres: improve the lighting, fix the 2 diathermy generators that do not work, fix the respirator if you want to operate goitres.  An autoclave is required for sterilisation of material as it was sterilised outside. Adjust the kits to the pathology to be operated on so that there is a greater number and more patients can be operated on in one 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 835 € + Hotel single 450 €, double 350 € + meals and ferry airport: 100 € + PCR (2) 120 € + VISA 80 € = 1585- 1485 €.

TOTAL COST OF THE CAMPAIGN: 7 volunteers: 10.600 €.

+ cost of medical supplies.

                                                 Teresa Butrón

                                                 Team Leader

                                 Surgeons in Action/ Hernia International

TANZANIA    2 0 2 2

Hernia International Foundation

Slovenian-Austrian-Swiss (Liechtenstein) Team Mission

Malya, Tanzania March 20^th-26^th 2022

Click here to view video

Malya Village with its Health Center (MHC) was host for a Hernia International (HI) mission for the first time in its history. The reason for the mission was Dr James Marco, a skilful and ambitious surgical resident, who was inspired by HI-charisma after visiting the village of Momella during our 2019 mission.

The week-end travel from our homes to Malya HC took us 32 hours and even 42 hours for some of us.  Three consecutive flights from Vienna (Zürich) to Doha, Kilimanjaro (Arusha) and an internal flight to Lake Victoria (Mwanza) were followed by an almost 3-hour jeep ride from Mwanza to MHC. Unfortunately we had to fly without our experienced anaesthetist Dr. Michael Wirnsperger, who was Covid-19 positive some days before departure.

Our team consisted of 5 members:  2 surgeons, 1 radiologist, 1 scrub nurse and  1 nurse anaesthetist. Additionally, surgical consultant Dr. Avelina Temba, Rev. sister of our Lady of Usambara from Korogwe joined us for two days and her presence enabled us to import medical equipment without notable delay. It should be emphasized that every HI-team travelling to Tanzania in the future should apply for importation of ALL medical devices and drugs at the TMDA website online at least 3 months before the mission to avoid serious bureaucractic issues at the airport.  We imported 205 kg of equipment and drugs in 12 bags. No additional fee for excess luggage was payed at the Zürich airport thanks to Manuelas’ negotiation skills and her past Red Cross connections.

Checking patients for surgery was the first task on Sunday evening and Monday morning. As MHC is a village, far away from civilization, patients came every single day after they were informed via posters, local radio and social media. Every single day, there were just enough patients for 1 day, not too many, not too few. The youngest patient was 1 month old, the oldest had 90 years.

The turnover of the patients was fluent. We were not used to taking a lunch break, but biscuits, water and delicious cashew nuts were sufficient between operations. Besides performing operations on hernias (numerous recurrent and scrotal), assisting the local doctors and nurses was high on our priority list. We took time to do this as education and teaching might be of at least as much importance as performing the operation itself. Local doctors (Dr Temba, Dr James Marco and Dr Mchemba) became more independent and self-confident under our supervision.

Parallel operations on 2 tables, including suspending hernia operations to give precedence for Cesarean sections (performed by local doctors), enabled 46 procedures on 38 patients in 4,5 days.

Dr Rems (experienced consultant, past chief surgeon and hospital director) and I were happy to see grateful patients and improved surgical technique of local surgeons. Wolfgang, a skilled nurse anaesthetist from Feldkirch, Austria was completely souverain in performing general anaesthesia in patients of all ages and built a trustful team with the anaesthesia staff at Malya HC (medical officers William and Mathias). For our scrub nurse Manuela from Lichtenstein, this was the 4^th international mission, after serving in Cameroon and on Red Cross combat missions to Syria and Bangladesh several ears before. Once again, the presence of an experienced radiologist turned out to be a reasonable decision. Marija performed 41 US-exams, including in OB-GYN and on our surgical patients pre- and sometimes postoperatively. Due to the high mean age of patients after inguinal hernia repair under spinal anaesthesia, US check on evenings post operatively was a routine in elderly patients (average age of adult inguinal hernia patients was 58 years). Due to untreated benign prostatic hypertrophy in some of these patients, unrecognized urine retention post spinal anaesthesia might be an  underestimated but serious issue in commonly forbearing and compliant patients. In these cases we performed urinary catheterization and gave adviced on further management.  

Good work in the hospital was also possible because we were accommodated well in the christian MMCT Guest House (bed, breakfast and dinner). Malya HC might not be able host additional hernia missions in the near future, as Dr James Marco is moving to the Ngudu District Hospital, 33 km away. But a visit of the surgical chief of staff Dr Misana from that hospital  brought us a new invitation. They have great need and abundancy of patients. Mesh surgery is not performed in that remote part of Africa at all, compared to hospitals and health centers of our last missions (Korogwe, Arusha).

Among 38 patients (with 46 procedures), we operated on 5 children (13%) and 33 adults (87%). 7 patiens (18%) were female. The most frequent diagnosis was inguinal hernia (29 pts, 76%), followed by Jabouley`s procedure for hydrocaele (8 pts, 21%). In inguinal hernias in children, Mitchell-Banks repair and in teenagers and young adults a 4-layer Shouldice procedure was performed;  Lichtenstein repair with LDPE mesh was performed in theevast majority of patients with inguinal hernia. In incisional ventral hernias, the sublay procedure was the method of choice. We performed 1 orchidectomy in a patient with a giant hydrocaele and testicular atrophy. Other diagnoses/operations were for acute appendicitis, mastitis in a newborn (extremely rare according to published data), abscesses, undescended testicle, benign breast lesions and skin tumors. We placed suction, corrugated or Penrose drains after almost all operations on big incisional and scrotal hernias, and some hydrocaeles. Our anaesthesia team also helped in Cesarean section.

In OT 1 (good lights, we brought diathermy), mainly general anaesthesia was performed, while procedures in OT2 (no surgical lights, without diathermy) we used spinal and local anaesthesia.

We felt privileged for having no complications (minor or major) which we attribute to a not overcrowded programme. Again, we took enough time for every single procedure, without any hurrying. Good working and a friendship-building atmosphere was a result of mission preparation several months before, not to mention sister Avelinas attitude and prayers throughout the mission as an additional factor.

Team Members:

Dr Miran Rems – consultant surgeon, Jesenice, Slovenia

Dr Jurij Gorjanc – consultant surgeon, team leader, Austria & Slovenia

Dr Marija Jekovec – consultant radiologist, Ljubljana, Slovenia

Manuela Logan – scrub nurse, Grabs, Switzerland & Lichtenstein

Wolfgang Walser – anaesthesia nurse, Feldkirch, Austria

Our sponsors:

Medical Center Gorjanc

Implantoloski institut / Implant Institute

Hospital of St. John of God St. Veit/Glan

Krankenhaus St. Vinzenz Zams

LKH Feldkirch

Spital Grabs

Kirurgija Bitenc University Medical Centre Ljubljana

The first joint mission of the Surgeons in Action and Hernia International Foundations following the Covid-19 pandemic has been carried out in Bopolu City, a small Liberian inland town of 3200 inhabitants located in Gbarpolu County, home to approximately 90,000 people. It is the first campaign to be conducted in this destination, and the reason is that this is where Dr. Peter George is now working.

Peter George has been the collaborating doctor of our two foundations for many years and is now the head and medical director of Jallahlone Hospital, the reference health centre for the whole county. This is my third campaign in Liberia that I have coordinated with him, and he has always shown great organisational skills and leadership in his country.

The preparation of the campaign has been very complicated since it was suspended on two occasions as a result of the spread of the Covid pandemic and the restrictions on entry to Liberia even for people from countries with a high vaccination rate and the possibility of carrying out routine diagnostic tests for active infection such as PCR or antigenic tests. On two previous occasions in 2020 and 2021, the campaign was postponed when everything was organised and the plane tickets had been bought, which is why it has meant a great financial, moral and resilience effort on the part of the team members.The team members were three surgeons (César Ramírez, Pablo Muriel and Sarai Ayllón), two anaesthetists (Sandra Casares and Beatriz Fort) and three nurses (Francisco Gómez, Rebeca Sanabria and Julia Cáceres), and we all received authorisation from Dr. Peter George from the Medical and Dental Council of Liberia to practice since our professional documentation was sent electronically. The initial expedition included a fourth surgeon, Marta Roldón from Málaga, who was unable to travel due to a positive PCR test the day before departure.

The departure of all the team members was on Thursday 20th January in the afternoon and we met in the evening in Madrid; Pablo and Beatriz left from Barcelona, Sandra was in Madrid and the rest of the team members from Malaga. The trip was made with Air France (Air Marocq has stopped operating flights to Liberia in the pandemic) and started in the early hours of Friday 21st with the Madrid – Paris flight at 6 a.m. and from Paris we left on Friday 21st at 12.25 p.m. to arrive in Monrovia at Roberts International Airport at 8.25 p.m. on a direct flight. As part of the security protocols we followed in order to get to Liberia, all team members travelled with a certificate of having received three doses of messenger RNA vaccine and a certificate of a negative PCR test carried out at least 48 hours before departure to Paris. Each team member was required to pay $150 for diagnostic tests for active infection on arrival in Monrovia and on departure, and these tests were carried out by airport health staff on arrival and by the laboratory manager at Jallahlone Hospital in Bopolu three days before our departure from Liberia, both of which were rapid antigen tests.Once we had passed the Covid health checkpoint at the airport, Dr. Peter George was waiting for us at the baggage claim (as he always does) to facilitate the logistics of transporting the 23 pieces (over 500 kg) of equipment we had brought, for which we had to pay an excess of 1200 Euros at the airport in Madrid. Since it was after 10 p.m. on the 21st upon our arrival, that night we slept at The Blue Lagoon in Monrovia, an acceptable hotel with a swimming pool available and which is a frequent place for the Liberian middle class. On the morning of the 22nd we left Monrovia for Bopolu, a drive of almost 5 hours to complete a little over 90 km on a road that is terribly bad, full of potholes, rocks and that becomes unbearable at times. We arrived in Bopolu City at 3 o’clock in the afternoon and were welcomed with a big party by the women’s association of the city. There is an important feeling of protection of the role of women and they are looking for a situation of equality that does not yet exist in Liberia, a country where the structure is still very patriarchal. After a warm presentation at the hospital by the health and administrative authorities, we unpacked all the material and placed it in the hospital facilities and then went to our place of residence to take possession of the rooms and carry our suitcases.

Jallahlone Hospital is a medical-surgical centre with the typical structure of small Liberian hospitals located outside the capital, in the style of the one we knew in Ganta City (E&J Medical Center).

It has an operating theatre equipped with a ventilator in which interventions can be performed under general anaesthesia; the usual activity of this operating theatre outside the campaigns are caesarean sections but also herniorrhaphy (I don’t know how often), hence the large number of reproduced inguinal hernias that have been operated on in this campaign, easily identifiable by the type of incision and because they did not have mesh in place.

There is a hospital ward for men, another for women, another for children and a fourth, a maternity area. The second physical space that we have set up as an operating theatre has been a regular medical care room in which we have placed two stretchers for transferring patients who are somewhat unstable, but which have been used to operate on hernias and major outpatient surgery. In the operating theatres there is only one electric scalpel which works irregularly; we have brought two from Spain and we have given one as a gift to stay there in the Hospital. In the main operating theatre there is no air-conditioning but there is a ceiling light that works acceptably from 10 a.m. onwards, which often goes out and is interrupted; in the other room there is air-conditioning, which makes it more bearable, but there is no light and it is essential for the surgeon and assistant to use headlamps.

There is no wifi network in the hospital or in the whole region, and in order to connect to it we had to buy a router at the airport, which had to be progressively recharged during our stay.The accommodation site was about 300 metres from the hospital and is a building that is not used regularly (there are no visitors or tourists there) and has about 25-30 rooms equipped with a bed (with mosquito netting but with a base of boards that acts as a bed base and usually breaks), a bedside table, a fan and a bathroom that has no electricity or running water (there is a large bucket of about 100 litres from which water is drawn with a ladle to take a shower and clean the toilet for daily needs). The stench is unbearable in the bathroom as the drains run under the shower tray. The food as always in

Liberia is quite acceptable, and Peter makes sure that we always have fresh fruit (pineapple and papaya very tasty), vegetables (especially tomato and cucumber) and a diet based on rice and fried chicken every day. We supplemented each day with cold meats of all kinds, cheese, piquitos and olive oil which gave us a lot of comfort. Every night we had cold beer and carbonated drinks of all kinds in our accommodation, where dinner was brought to us. Similarly, we had a fridge at the Hospital in Dr. George’s office which was always stocked with water and soft drinks to compensate for sweat and exertion losses. Every day we were picked up by two vans at 7 a.m. and taken to a small room 50 metres from the Hospital where we were served breakfast and by 8 a.m. we were at the Hospital every day.

The working day was quite organised and each day we had 20-30 patients there who we saw little by little and filtered to indicate the surgeries for the following day, taking advantage of the time between one surgery finishing and another starting. The working days were interrupted by a 30-45 minute lunch break in Dr. George’s office and then lasted until about 10.30-11pm. Each day early in the morning we would visit the inpatients to assess for postoperative complications and discharge them.

A total of 7 and a half days of work, including from Sunday 23 January at 8 a.m. until Sunday 30 January at 3 p.m., were spent. A total of 152 patients were operated on

185 surgical procedures were performed, which can be grouped as follows: 109 inguinal hernioplasties (15% bilateral and another 15% reproduced); 20 umbilical / epigastric hernioplasties; three large eventrations, two of which were associated with abdominoplasty; nine giant goitres in which five total and four subtotal thyroidectomies were performed;

Tthree splenectomies for giant splenomegalies; ten hydroceles; five cryptorchidectomies; one orchidectomy for neoplastic neoplasia; one orchidectomy for neoplastic neoplasia; and one orchidectomy for testicular neoplasia; one radical hysterectomy and double anexectomy for giant ovarian neoplasia; one radical right nephrectomy for a 25 cm tumour dependent on the right kidney; two cord cysts; 21 minor surgeries under local anaesthesia (lipomas, sebaceous cysts, granulomas and keloids); and one hygienic surgery for the removal of a very advanced acral melanoma.

The only major complication recorded was the need to perform a temporary tracheostomy on a patient with postoperative disnoea due to paresis of both vocal cords (both recurrent nerves had been preserved and there is an imaging record). In all other surgeries we had no major or minor complications recorded. The two surgeons at Jallahlone Hospital (Dr. Dahrly and Dr. Dwanna) actively participated in the vast majority of the surgical procedures as assistants and we tried to explain as much technical knowledge as possible. The cooperation of the nursing staff, anaesthesia assistants and anaesthesia technicians at the hospital was excellent and made us feel very comfortable.

During our stay we were greeted by the major of the county of Gbarpolu and we had an audience with the senator of Bopolu, who thanked us for our presence as this was the first international team they had received and made me realise that Peter George is a very well positioned person in the eyes of the authorities and a reference point for health in the region. I would like to point out that with the sponsorship of the United Arab Emirates, a large hospital is being built in Bopolu, which is well advanced and has all kinds of services, more comfort, more space and more operating theatres. Those responsible for the work, who are Lebanese, have been very kind to us and have invited us to have lunch one day in their facilities.

To sum up, Jallahlone Hospital is a perfectly prepared site for surgical campaigns and Peter George is an influential person, with great influence among his people and great organisational skills. It is to be hoped that many more missions can be held in Bopolu in the future, especially when the new hospital is completed. Overall, it has been a very hard mission from a physical and working conditions point of view, but all members of the team have been very satisfied and satisfied with the work done and the results. The average cost per volunteer was almost 2000 Euros per person, including flights, transport by car in Liberia, food and accommodation.

The death of Dr RR Tongaonkar, renowned rural surgeon and prime protagonist for the use of mosquito net for inguinal hernia repair, occurred tragically on 7^th September due to COVID-19.

Rising from humble origins in rural India, Ravi graduated from the prestigious BJ Medical College, Mumbai with record Merit scores and chose Surgery for his career. He decided to settle in his birthplace of Dondaicha, Maharashtra State, which in the late 1960s was a small town of 17,000 population, 150km from the nearest District hospital. Two buses a day stopped in the town and there was a railway halt on the line to Pune. Local transport was by bullock cart. During the next 50 years, the population tripled and Ravi established a thriving Clinic (some say a “Mayo Clinic”) providing humane and affordable (free for the indigent) care to the community. A chance meeting with a surgeon using mosquito net for hernia repair, inspired Ravi to take up this techniaue and instigate its global promotion, which will be his lasting legacy.

Born on 17^th November 1939, Ravi’s early life was strongly influenced by both his Father, a Freedom Fighter (who on 15^th August 1947 had the honour of bringing down the British Union flag on the Collector’s Office in Dhule, and hoisting India’s tricolour) and Mother (a teacher) who inculcated a selfless sense of duty. Their Mother tongue was Marathi and Ravi was not schooled in English until his arrival at Medical College. After paying for his food and lodgings, he had so little money that he wrote lecture notes on pieces of waste paper he had stitched together. With similar determination to succeed he stood first in every MB BS exam and his postgraduate MS. Shortly after these significant achievements his parents arranged for his marriage to Asha. He later related that their first meeting to discuss their future, took place in a railway canteen. Following the wedding (after which the procession took place in a bullock cart), Ravi declined the offer of the post of lecturer (with an assured path to Professor of Surgery) and decided that he and Asha (at the time a medical house officer) would establish a practice in Dondaicha.

Appropriate accommodation for the clinic was in short supply, but eventually they settled in an old Swedish missionary’s bungalow which had five rooms suitable for development as a medical centre. From Day 1 the practice was hectic and involved a huge burden of medical ailments as well as surgical operations. Work continued until 8 or 9 o’clock at night, six days a week, relentlessly. In his acclaimed book “Making of a Rural Surgeon: An Autobiography” Ravi describes in vivid detail the trials and rewards of these days as he brought the practice into the 21^st century with modern equipment and medical supplies. He and Asha developed radiographic skills, Asha trained in anaesthesia and created a basic diagnostic laboratory. In 1986 Ravi attended a laparoscopic course arranged by the Indian Association of Gynaecological Endoscopists and introduced diagnostic laparoscopy to his practice. He taught himself TransUrethral Resection of the Prostrate on a potato model. His resourcefulness and eagerness to be at the cutting edge of surgery was enormous.

It was in 1986 that at a chance meeting with Dr Brahma Reddy from Kurnool, at a workshop in Hyderabad, Ravi was given the chance to pursue a project which required all his intelligence, tenacity and academic brilliance – the use of mosquito net for inguinal hernia repair. His seminal publication in 2003 in the Indian Journal of Surgery reported over 300 cases meticulously followed with excellent results. Many other publications have followed.

Global recognition occurred in 2009 at the European Hernia Society meeting in Berlin.

The pinnacle of success was receipt of an Innovation Award at the World Innovation Summit on Health in Doha in 2013.

At a recent international conference Ravi is quoted as saying “Since the year 2000 at a modest estimate, till today around 35,000 hernia surgeries were performed across the world using mosquito net mesh”. Hernia International contributes about 2000 of these cases annually.

In recognition of his excellence in Rural Surgery, Ravi has been President of the International Federation of Rural Surgeons and President of the Association of Rural Surgeons of India.

In 2012 I visited Ravi’s hospital in Dondaicha and operated with him. I will remember him as a lively, warm and noble human being whose priority was the well-being of the members of his community.

Andrew Kingsnorth

Director, Hernia International

Team members:

Surgeons:                    Trent Cross (Team leader)            Australia

                                    Mohan Jayasundera                Australia

                                    Hans Moser                            Germany        

                                    Jurgen Meyer                          Germany

                                    Markus Heiss                          Germany

Anaesthetist:   Peter Schuller                         Australia

Hernia International mission to Mongolia May 2015

This mission to Mongolia was a two part mission, with great contrasts in facilities and case mix. In the first week Trent, Hans, Jurgen and I travelled to Bayankhongor airmag, a rural centre around 15 hours drive from Ulaanbaatar. The second week was based at the Second General Hospital in central Ulaanbaatar, where we were joined by Markus who replaced Jurgen. The whole mission was co-ordinated by Enkhee, who not only provided all logistics support, but came with us on our long trip to Bayankhongor airmag, and ably helped us throughout the varied and challenging mission.

Bayankhongor is the administrative capital of the airmag (province), serving a population of 80,000 many of whom are rural herders. Although the distance from Ulaanbataar is around 700km, the journey across the empty steppe took over 15hours, arriving at around 2am.

However, the country side was beautiful in its barrenness, with the winter snows still melting on the grass steppe.

The local Hospital administrator and provincial governor both went to extreme lengths of hospitality to make us feel welcome. Some of the highlights include: a full traditional Mongolian concert performance in the concert hall, performed specially for the Hernia International team; Accommodation provided for us at the local hotel; Visits to the local Natural History Museum which specialised in the regional Gobi Desert flora and fauna; A grand dinner provided by the provincial governor in his private restaurant; and after our last day at the hospital, a huge traditional Mongolian feast in a yurt with the obligatory vodka toasts.

In the hospital we were provided with two operating theatres and divided the cases between the German and Australian teams.

The local surgeons were very keen to learn, and by the end of our week were performing most of the operations with our guidance.

As well as adult hernias, there was a large volume of paediatric cases, including many redo hernia operations and orchidopexies. The incidence of cryptorchidism seemed to be very high, perhaps due to the extreme cold endured over the winter! We were continually amazed at the stoicism and bravery of the local children.

Every lunchtime we were provided by an amazing assortment of different traditional Mongolian fare provided by the hospital kitchens. At the end of the week we were all fluent in the Mongolian and Russian terms for the surgical instruments and other important vocabulary!

After this busy first week, where we were humbled by the hospitality of our local hosts, we headed back to Ulaanbataar. Trent and Jurgen returned early, with Trent and Markus to present at the First Mongolian Congress of laparoscopic and endoscopic surgery. The remaining team members took a detour, visiting the Shargaljuut Sanatorium. This involved a 3 hour drive across the steppe on dirt four wheel drive tracks through pristine rural country side. The emptiness was punctuated by local herders and their yurts. We were lucky enough to visit one, as one of the herdsman was a relative of the driver, and were allowed to ride his horse and sample the traditional fermented cheese. The Sanatorium was definitely an eye opening experience, based around various hot springs which were used to treat an assortment of illnesses.

The second week at the Second General Hospital was a contrast in facilities and cases. The Hospital had been visited by previous operation hernia teams, and were particularly keen to learn more advanced techniques. Several laparoscopic inguinal hernia repairs were performed (both TAP and TEP), a giant parastomal hernia repaired demonstrating the Sugarbaker technique, as well as a wide variety of adult hernias. We were ably led by our team leader throughout this mission, which was definitely full of excitement and action!

Mohan Jayasundera

Report of the mission in Ganta City (Liberia) from 8.-15. Feb. 2020

The team consisted of 3 members: Leo Mitteregger from Austria (general surgeon and team leader), Fernando de Santiago Urquijo from Spain (general surgeon) and Christine Kirchberger from Austria (scrub nurse).

The mission was planned several months ahead. For Christine it was the first visit in Africa. We met at Brussels airport and arrived together at the airport in Monrovia at Friday, Feb 7th in the evening. We were picked up by the medical director of E.&J. Medical Center, Dr. George, and his driver. We did not have any problems with our extensive luggage at the customs. We brought appr. 100kg additional luggage because of many useful medical items. The trip to Ganta took almost 5 hours directly to Jackie’s guest house where we had our lodging and our meals (breakfast and dinner).

Next morning, Saturday, 8th Feb., we had a welcome celebration in the waiting hall of the hospital. Afterwards we checked some patients and selected them for surgery. There were so many patients so that we started in the afternoon right away using two theatres – one for adults, one for children.

Till Feb. 14th we operated 36 children with 42 interventions and 36 adults with 40 interventions. Each child got two soft toys, one before and one after the operation. Twice we had a break because of a Cesarian section done by Dr. George himself.

Every day after finishing work we did a ward run to check the operated patients and examined the patients for the next day.

 At the end of the mission each of us had to pay 670 USD for lodging and meals for 7 days. In addition we were requested to pay 450 USD for transportation (Monrovia – Ganta – Monrovia, guest house – hospital and retour). After a short discussion we paid 300 USD (100 USD each). That’s why we would say that Liberia is rather expensive.

Nevertheless we enjoyed our mission very much and the response of the staff and of course of the patients was great and rewarding.

I think we will come back again to Africa.

Leo Mitteregger

Esther and Jereline Medical Centre, Ganta City, Liberia

November 30^th – December 8^th 2019

This was a four surgeon Hernia International Mission:

John Hobbiss, Colorectal Surgeon, UK

Mahesh Pai, Vascular Surgeon, UK

Emma Sidebotham, Paediatric Surgeon, UK

Thorbjorn Sommer, Bariatric and Colorectal Surgeon, Denmark

John and Thorbjorn had been on previous Hernia International mission, John on the first trip to Ganta City in July 2017, a first trip for Mahesh and Emma. This was Hernia International’s 7^th trip to Ganta City. We arrived together on the evening of Friday November 29^th, on a flight from Brussels, being met pre passport control by Dr George, Chief Medical Officer, Esther and Jereline Koung Medical Centre.

We spent the night in Monrovia and were driven to Ganta City next morning, arriving around midday. After lunch we proceeded to the Medical Centre. Dr George had already triaged and admitted 4 paediatric patients and having unpacked our equipment we got the mission started by operating on these that afternoon.

And that was how the mission progressed so that running four theatres, over the 7 and a bit days of operating we operated on 197 patients (plus complications detailed below and the caesarean section Torbjorn assisted with!) repairing 222 hernias, predominantly inguinal, some femoral, with occasional umbilical hernia repairs and hydrocele surgery.  

This was only possible due to the large number of patients Dr George had attracted to come for assessment and surgery by an excellent radio campaign to get the message out about the mission, even after a previous mission only two weeks before. Furthermore, Dr George saw all the patients in clinic, triaging them and admitting them to the wards, so that we were simply in theatres ready to operate, with only a handful of patients triaged for surgery that we then declined to operate on (e.g. umbilical hernias in infants). Getting started in the mornings sometimes felt slow but once we began, for the three adult theatres, the next patient was sitting on a chair outside the room ready and waiting to be examined and operated on. For the paediatric patients we did a ward round to assess and mark them then they were brought to theatre as soon as the one was sent back to the ward post op.

We had one anaesthetic technician/nurse between the four theatres, Emmanuel from Sunday to Wednesday with Abenego from Thursday to Saturday, and some input from a third nurse anaesthetist, Cyrus, who went from theatre to theatre giving spinals with great efficiency and efficacy, with occasional caudals and supplementary ketamine for the children.

The theatre staff were extremely helpful and many were excellent surgical assistants. Othello in the paediatric theatre was particularly helpful, doing a ward round with me, helping to translate and compiling lists of the patients for the day.

 There was a local surgical trainee, Wanaka, who operated for several days with Thorbjorn who was able to train her well to perform mesh hernia repairs over the course of the mission, an excellent adjunct to the performing of surgeries. In total we lost about two days of operating spread over two of the four theatres for caesarean sections and laparotomies. 

I operated on 50 children and two older teenagers but my adult colleagues humoured me and took me through 3 adult mesh hernia repairs so that I’d feel better prepared to do adult hernias if there were less children on a future mission.

We stayed in Jackie’s Guest House about 2 miles from the hospital, safe, clean air conditioned accommodation with a plentiful supply of hot water and internet access. Jackie’s has a restaurant where we ate most of our meals. It also has a small shop where we purchased drinks and snacks to take for lunch along with nuts and energy bars we had brought from home: this kept us going through the day as there was no true break for lunch and the large size of our other meals meant that we did not need more.

We left Ganta City on Sunday morning. Our flight was not till the evening so we were fortunate to meet and be entertained to lunch at the Boulevard Hotel in Monrovia, by Mr Jeremiah Koung and his associate Mr Ibrahim Hamdan, who had established the Esther and Jereline Medical Centre and donated it to the local community, giving us the opportunity to explain the purpose of our mission with Hernia International and Mr Koung to explain some of his further aspiration for improving healthcare facilities in Nimba County and throughout Liberia.

Complications:

Whilst in Ganta  we also came across complications of hernia operations performed by previous Hernia International missions and cases subsequently operated on by the local team. We operated on four such cases, two of whom had an infarcted testis. It was a stark reminder that the sort of cases that we were operating upon have the potential for serious complications

Equipment:

Esther and Jereline Medical Centre are able to provide very little equipment beyond surgical instruments. UK style disposable drapes and gowns are available for surgeries performed such as caesarean sections but are not allowed to be used for the Hernia International surgeries, to the point that we were expected to provide gloves for the staff assisting us as well as for ourselves. This inevitably requires some compromise in the gowning and draping we would perform in the UK against what is adequate for some degree of asepsis and what is feasible to bring as luggage on the mission.

Essentials:

Gloves – surgeon and assisting theatre staff

Skin Prep solutions

Sutures (we thought that we were going to run out and Dr George obtained more, which we paid for, through the local pharmacy. These were Chinese manufactured, appeared to be finer than the equivalent Ethicon sutures and expensive)

Face masks

Hats

Surgical scrubs

Local anaesthetic

–          bupiuvicaine for spinals (multi use stoppered vials best, even if these would be single use in UK)

–         Lidocaine or bupivacaine for local infiltration/LA procedures.

Drapes

Gowns

John brought many boxes on Co-amoxiclav to be given for at least the mesh hernia repairs for 48 hours post op. We understand from the theatre staff that the patients were charged for them. We had no role in them being given out as these were taken over by Dr George when we unpacked the equipment.

One theatre of the rooms we used had an operating light, head lights were essential in all other rooms. There was sometimes a wait to get the electricity running in the morning but little interruption of the lists once running.

Alcohol for hand prep is also useful. The water ran out by the end of some days.

Expenses:

This is an expensive mission compared to many in Africa. The Liberian economy currently works largely through the US Dollar. Accommodation is Western prices: we paid $60/night in Ganta, plus paying an extra night to secure the accommodation, and $75 in Monrovia. All food is in addition to this, and again at Western prices $20-30/day, we bought snacks for lunch. Transport for the week within Liberia cost $480 for the team.

There is also the expense of equipment to bring that is greater than many Hernia International projects. We paid for 16 vials of bupivacaine, more bottles of skin prep and elastoplast tape in addition to the sutures. Bringing more prep and local anaesthetic would be helpful.

Acknowledgements:

We wish to thank the following organizations for supporting this trip

Dorothy Whitney Elmhirst Trust

BMI Beaumont Hospital, Bolton

Circle Hospital, Bath

Molholm Private Hospital

Teal Laboratory Services Limited