This first campaign of “Cirujanos en Acción”in Engineer was offered us by Hernia International and was organized in a record time of two months. In it took part experienced volunteers like José Miguel Morán Penco, paediatric surgeon in Clideba, Badajoz, the nurses PepaFornier Coronado from the Matero-infantil Hospital Clideba, Badajoz, ConcepciónVilchez Rodrigo La Fe University hospital from Valencia and Manuela Dorado Alvarez from Rio Hortega Hospital of Valladolid.
As new members came the general surgeons of the University Hospital of Plana Vila Real (Castellón), José M Guallar Rovira and Vicente Pellicer Castell, the anaethetists Santiago Fernández Gacía of the University General Hospital of Castellón and Álvaro Becker Cárdenas of the Sagrat Cor Hospital of Barcelona, Valeria Solari, paediatric surgeon of the Sozialmedizinisches Zentrum Ost (Viene, Austria) and Antonio M Satorras Fioretti, general surgeon of the Public Hospital of Mariña, Lugo, whose hospital gave most of the medication we used.
We started on the night of December Friday6 from the Madrid airport in a flight Ethiopian Airlines with a stop at Addis Ababa, arriving at Nairobi on the morning of Saturday 7and were received by Peter Karanja, our local coordinator, who had to solve in customs at the last moment the paying of charges for importing materials and medicines.
After a travel of several hours by bus, delayed by the need of buying clothes for two members whose luggage had been stolen in Madrid or did not reach the airport, we reached the hospital at night and were received by the director of the center, Dr Junius Ntwageh.
On Sunday, after arranging the material we had brought with us, we began selecting cases. After the treatment given in the local media there chiefly came paediatric patients who were examined by us for the final selection.
HOSPITAL
Engineer is a rural place in the Nyandarua County, two hours from Nairobi and a few kilometers South of the equator, close to the natural reserve of Aberdares. Given its altitude and the fact that it coincided with the rainy season, the presence of mosquitos was minimal, and we were told that there were no malaria cases in the whole zone.
The Engineer County Hospital is a public centre made up by several buildings of one or two stages. In one on them was the surgical area in which we had a large operation theater where we placed two tables, and a close room with four beds, two of them monitoriced for the immediate postoperatory.
We had two respirators that worked with Halotano, Isoflurano (supplied by the hospital as we could not get it in Spain) and nitrose oxide, as well as just one electro scalpel terminal to which were added the two we had with us. More problematic was to get tubulaters for the lactants, though they were got form another hospital.
We also had a small place where we could carry out minor surgery interventions with local anaesthetics, and a resting place where we eat what the hospital itself sent us.
The hospital has several surgical instrumental sets which, even irregular, allow the carrying out simple surgeries like hernias or tumors of soft constitution in adult patients. For paedriatic patients we used sets we ourselves had brought.
Although the hospital does have an autoclave there has been some difficulty to sterilise the instruments quickly; many white coats and cloths were disposable and supplied by us. We also used our own gauzes the usual gauze as the usual sterilization was in containers and it took too much time.
In the center there is also a radiology and ultrasound service and we asked for some studies, as well as a laboratory that carries out a hematological study and routine hematological test of VIH in all surgical patients. It besides offers assistance in toco-ginecology, maternity and infections, and it has a pharmacy that took care of the remaining medicines at the end of the campaign.
The patients were hospitalized in several rooms of the mother-child pavilion with nurses in charge, where several rooms of four or six beds were occupied one night at list.
The collaboration of the center staff was remarkable – with one more day or work on feast days – to be able to work on a greater number of patients, particularly those of nurses Beatriz and Erasmus and Rachel, the lady superviser of the operation theater with the preparation of sterilization of material. Also, the help of Shadrak and Daniel in consultations and when having to move.
ACTIVITIES
We suddenly realized that we had not received the necessary permission from the Health Ministry that would grant us to carry out assistential activities. Even when we insisted again and again the situation continued the whole afternoon and the morning of Monday, during which we received the visit of the Ministry for Health of the County. It was only in the afternoon when the license was signed and we finally could begin the campaign.
Besides, Thursday 12 was Jamhuri Day or Independence Day, a national feast that in which, in spite of our insistence we could only work in the morning (while we used the afternoon to visit Lake Naivasha with its hippopotamuses) and Saturday 15 at noon we finished up, so that we lost two full days for administration problems.
Working in two – and at times three – operation theaters we treated 80 patients with a total of 96 procedures. The majority were pedriatic (42 children and 38 adults) with ages between 3 months and 86 years, and predominantly men (61 men for 19 women).
The anaesthetics given have been general (43), regional (19) and local, with sedation (6) or without it (12).
In paediatric patients we carried out 27 orquidopexies for not descended testicles, 14 inguinal herniotomies, 5 umblicals, 6 circuncisions, and it treated a hand retractable burn, exploration of a cervical mass and one urethral dilatation.
In adults we carried out 15 hernioplasties (6 inguinals, 5 umbilicals, 3 epigastric and one femoral), 6hidrocelectomies, exeresis of 17 hurts in soft parts and one orquidopexia. Besides we urgently treated a cesarea and sew up a face wound.
The larger part of patients spent one night in the postoperatory room. No significant complication appeared.
Staying Places
The only hotel with minimal standard for our stay in the neighbourhood was the Musa Garden, with simple rooms and without real Wifi. The price of 50 euros for person and night, breakfast included seemed too much to us. Supper in their dining room with soup, rice and vegetables and meat or fish cost about 7 euros per person and night. After that the terrace was used for relaxing a while.
Meals were taken in the same operation theater in order not to lose time, with a half morning breakfast and lunch with several options (rice, vegetables of various kinds and meat).
As it was the time of the rainy season, we suffered constant humidity, so that we could not dry up our clothes from one day to the next.
On the last night the county Gobernor offered us supper together with the authorities and workers of the hospital thanked us for the work done, gave us several gifts and insisted on our coming for more campaigns and promising to solve all administrative problems.
There was only left now our coming to Spain on Sunday after a visit to the Nairobi National Park In order to prepare a new campaign in a hospital with instalations and staff which allowed us to work properly.
Expenses
FOR EACH VOLUNTARY
Flight tickets… 600 euros
Stay (50 euros night, 8 nights)….400 euros
Suppers (7 euros night, 7 nights)… 42 euros
Price for volunteer… 1.042 euros
TOTAL COST… 10.420 euros
RECOMENDATIONS FOR FUTURE CAMPAIGNS
Election of dates that may not coincide with local festivals (December 12), preferably during the dry season.
Previous confirmation of temporal licences.
Need to take with us at least one diathermy generator.
Need to take all the paediatric instruments and some set for grownups.
The Gatundu campaign of November 2019 was proposed by Surgeons in Action Foundation, and the same as in the rest of the campaigns it has meant a new challenge and effort during the previous months for the creation of a team of volunteers, and above all the logistic aspects as the getting of medical surgical essential for our work, as the Gatundu Hospital does not have the necessary supply. Obviously the difficulty in communication with the responsible people of the Center in order to now the number of volunteers and material resources need for the Campaign.
The economic budget was high with the expenses of the visa, flights, transport, staying and food for the team, the Surgeons in Action Foundation and a donation of the Coro Divertimento de Pamplona in collaboration with the Zuasti Club which organized a concert in order to get funds for this Campaign.
THE PLACE
Kenya, placed at the east of Africa, has a population of 51.303.010 persons. Its capital Nairobi has 3.130.000 inhabitants, and currency is the Kenyan chelin (1KES = 0’01 euros). It is a republic with many parties. The majority of its people are Christian, with 35 % Protestant and 30% Catholic, about 30% Muslim, 5% animists, with Suajili and English, apart from many tribal languages.
The PIB per capita of Kenya, good indicator of the life level, was 1.449 euros (Spain 28.156 dollars), and it is the 152 place in 192 countries,and the index for Human Develoment or IDH, which the United Nation elaborates to measure the progress of a country and the life level of its inhabitants, it is found in the 142 position, which indicates that its inhabitants have a very low life level. Gatundu is a small village in the Kiambu with 1.600.999 inhabitants, and it is placed at an hour by car in Nairobi. The first president o of Kenya, Jomo Kenyatta, was born here, and he has a stylish residence on top of a height over Gatundu, in contrast with the buildings in the city which are very precarious, most of the lodgings are very precarious, the majority of the lodgings and shops are at both sides of the main road; they are buildings of a single story with cheap roofs; the shops are distinguished by posters over their entrances and where they advertise their business, there are plenty of small shops of fruits and vegetables, then churches and schools of different kinds; in the side streets there are many little shops of fruits and vegetables, churches and schools of different creeds; in the side streets without asphalt the doors of the houses remain always open. People live with a dollar a day. Rice, vegetables and other products from the field are their food.
VOLUNTEERS
A team of seven volunteers of the Surgeons in Action Foundation:
2 general surgeons: Dr. Manuel Cires and Dr. José Hernandez
2 paedriatic surgeons: Dr Lola Delgado and Dr. Jesús Redondo
2 anaestetists : Dr Pilar Murga and Dr. Ana Pizarro
1 nurse: Lola García
This campaign was carried out in collaboration with the British ONG Hernia International Foundation.
We brought about 200 kg of medical-surgical material in 12 great parcels with the typical bags of rafia bought in the Chinese shops. All that was collected by the volunteers in the hospitals. The Hospital directors put at our disposal a van with a driver which took us directly from the Hotel to the Hospital, besides of the shifting to the Nairobi airport.
FOOD AND TRANSPORTATION
We were lodged at the Maxand Hotel (https://maxlandhotel.co.ke/ which is half an hour by car from Nairobi and about 20 minutes from the Gatundu hospital. It is a very safe hotel, as it is within a walled up place with entrance access controlled by safety guards. The rooms are individual with bathing room and beds with mosquito net, as also good conditions for cleanness and hygiene. It has wifi which works very well in the rooms as in the hall and dining room. Breakfast is buffet type. There is a commercial center by the side of the hotel with small shops, pizzery and a supermarket where we could buy all we needed. The price of the Hotel with breakfast and supper included is about 60 dollar a day. The pay of the Hotel can be done in dollars or with a credit card.
Next to the Hotel we visited a religios-focolar Center called Mariopolis Center, http://mariapolsispiero.org/mariapolis-center-wim/, which is a very quiet citadel with several buildings of friendly aspect with a friendly aspect offering the possibility of lodging at a much more reachable price about 30 dollars a day in individual lodging of 25 dollars in for sharing a room which perhaps should be valued as lodging in future campaigns in Gatundu. If more information should be needed one can contact the [email protected].
It is absolutely necessary to have local coins, the Kenyan chelin for the payment of small expenses like drinks, meals, remembrances, etc. We recommend the change to be done at the airport itself on arrival, as there are no exchange places in the Gatundu area, and they accept payment in local coins only.
“LEVEL IV GATUNDU HOSPITAL”
It is a hospital financed and built in 2013 by China at an expense of 11 million dollars, and which was inaugurated in 2016. It is an annex to the old Gatundu Hospital made up by several one store pavilions communicated between themselves , with many green zones.
There are 5 levels; in the lower stage there are urgencies, admission and ambulatory services, two hospitalization stages, with several rooms of eight beds each where operated upon patients are lodged. An area of Gynecology and Obstetrics on the second stage, and on the third stage a surgical area which has two operation theaters called “Theaters 3 and 4” which are not sufficiently used and in which we carry out our activities.
They are wide and relatively new, although with very little material. The working of the lights is correct and steady without any need for the front lantern. They are two respirators which work well and one console of electric scalpel Valleylab in Theater 3 which works well. On Theater 4 we installed an electric scalpel which is property of our Foundation.
The REA room is very basic only. In it were monitorised patients after surgery watched upon by a lady doctor of the Hospital.
There is a room for relax for the staff which we used as an office to write down the report as also as dining room as they served there our lunch which was cooked meat, rice and vegetables, besides coffee and mineral water.
The surgical area has also a place where we placed all the material brought for the campaign; we found material from formal campaigns as mosquito nets of different sizes coming from Hernia International: sutures, dressings, general anaesthetics like Halotano, antibiotics, needles and Abocaths, needles for raquideal anaesthetics, endotraqueal tubes, larynx masks, facial masks, ventimask, vesical and nasogastric catheters, surgical and disposable dressing gowns, new pajamas, bandages, electrical stapler, skin stapler,surgical gloves, masks, antiseptics to wash hands, and other surgical instruments in good condition that allowed us to have 8 boxes and were quite usable for the Campaign. To this material has to be added the material left over at the end of the Campaign. We evaluated everything , classifying in order all the material, and we told the one responsible for the operation theater the need to make a list and inform our Foundation as perhaps we would have to take anything with us for a future campaigns.
The sterilization is carried out in autoclave the works with heat.
The operation theatre staff was directed by the chief engineer David Karuga, and we want to stress his friendliness and working power to the point of being quite necessary for our daily work. There were also Medicine students who helped us and showed much interest in knowing our work.
It is a pity we could not get the help of local surgeons, whom we did invite to take part in different surgical sessions, as the formation of personal staff is one of our first activities so that in the future perhaps our help will not be necessary. But we will also surely show our regret not to have been able to be there for the Campaign with the Director of the Centre, Dr. Gitaud, whom I finally could not meet, in spite of kept contact through electronic mail during the months previous to our coming to Kenya. It would have been much more interesting to have been able to speak of logistical questions, as the getting better patients In number as in the type of pathology, just as well as the need to have a list of the material kept in the Hospital, in order to organize future campaigns in the future. Well, it could not be, although I am not less surprised by the lack of interest and the lack of cordiality with my team.
SURGICAL ACTIVITY
Before the beginning of the Campaign a technical writing was sent telling Dr. Gitaud that the voluntaries team could carry out from 20 to 25 surgical interventions a day, giving a total number of 100-125 interventions.
Finally, during the 5 days of the Campaign 86 surgical operations took place. The patients were previously selected by local doctors, and the selection and preparation of the clinical history, was remarkable. We did not take up urgent surgical pathologies.
86 patients were operated upon, almost forty less than expected.
On Friday 1 we started from Madrid and Bilbao at 6:55 h. towards Nairobi via Frankfurt with Lufthansa Airways, arriving at our destination at 21:25 hours. We went to the Maxland Hotel in Juja Citynext to G. It was a journey of more than 14 hours, which went without problems except for a difficulty during the check-in the Madrid-Barajas Airport: there was overbooking that almost left three volunteers stack, but which could be solved finally. In Kenya there was no difficulty, and the local workers were very kind.
On Saturday 2 we went to the Gatundu Hospital, where we were received by the nurse responsible for sterilization, we visited the different surgical areas and we carried out work of cleaning, orderings and classifying medico-surgical material as well as the organizing of two operation places. We could not begin on that day the surgical activities as we had planned, as we had not called any patients. From Sunday 3rd to Thursday 7 we carried out five surgery sessions between 8 and 19 hours , apart from the daily visit of patients already operated upon.
Finally, on Thursday 7th evening we started, some of us on our way to Tanzania and others to lake Naivasha where could see many hippopotamus and water birds in order to proceed in Friday 8 to the Masai Mara National Park, enjoying two rest days; we carried out a safari seeing many wild animals in their habitat, with herds of herbivorous, depredators watching and masais dressed in their traditional dresses asking for dollars for letting themselves be photographed. We went home on Sunday 10th November at 23:10 hours from the Jomo Kenyatta lntl of Nairobi, back to our places in Madrid and Bilbao at 12:35 hours of Monday 11th November. Those intense and unforgettable 11 days were thus left behind.
BUDGET
The cost of the medico-surgical material is not placed in this budget.
Total cost of the Campaign (visa, plane, hotel, maintenance): 7.700 euros
Cost for volunteer 1.100 euros
Signed: Dr. Manuel Cires
Gatundu Campaign responsible 2019Surgeons in Action
Korogwe Hernia International (HI) missions have a history – we were already the 12th HI-team to this town in the Tanga region. It consisted of 9 members: 3 surgeons, 2 anaesthesiologists, 1 radiologist, 1 medical student, 2 nurse anaesthetists (one of them with additional skills in repairing medical devices).
Invitation from Dr. Avelina Temba and Korogwe hospital and the mutual trust within the team from last year was spontaneously leading towards another mission here. Competent anaesthesia team from Feldkirch, Vorarlberg, Austria (Dr. Wirnsperger, Dr. Lienhart, nurses Sarah Bertsch, Daniel Döwa) was a call for a strong surgical part (Mr. Shambhu, Prof. Omejc, Dr. Gorjanc). The majority of the team came together in Triniti Hotel close to Dar es Salaam airport. Shambu came to Momella Village in the north after my 1st Mission there. We travelled to Korogwe from different parts of Tansania. Due to much better roads than in the past we arrived to hospital at the same time after 6-7 hours drive.
Checking patients for surgery was the first task on Sunday evening and we were able to write operating programme for 3 days already, including 2-3 pediatric cases every day. The youngest patient with a big inguinoscrotal hernia was just over 1 year old., the oldest patient had 82 years.
Already familiar team members of Korogwe general hospital were very motivated and the turnover of the patients was fluent. We were not used to take a lunch break but rather stop earlier in the evening after finishing 5-6 cases per table, finishing the day with surgery in HIV positive patients. Local doctors (dr. Ahmed, dr. Tedi, dr. Heri) assisted and also performed a decent amount of hernia repairs under our assistance in order to get more and more independent in modern hernia surgery.
Parallel operations on 3 tables, including stopping theatre 3 occasionally for cesareans (performed by local doctors), enabled 79 procedures on 65 patients in 5 days.
The presence of an experienced radiologist again turned out to be a very reasonable decision. Dr. Marija Jekovec took this time a portable ultrasound machine with her and performed 95 US-exams, including in OB-GYN and on our surgical patients. Daniel repaired 2 anaesthesia machines, 2 monitors and 1 oxygen concentrator. Consider taking a specialist like him on other missions as well. Having a motivated medical student Franziska Ganster with us turned out to be a very good idea, because she took care of small things that we tended to forget and was also learning by assisting to both surgeons and anaesthesists.
Good work in the hospital was also possible because we were accommodated well in the recently built Korogwe Executive Lodge. Very comfortable rooms and a restaurant with tasty breakfast and dinners enabled us to restart our work fresh and enthusiastic.
Korogwe hospital is definetelly ready to host new hernia missions in the future, according to invitation of director dr. Michael and sister dr. Avelina. They get every year new young GPs and doctors to assist and learn from experts. Anyway, there is a question if they need HI missions as hard as 12 years ago. Definetelly there are hernia patients, that they can manage by themselves. But among them, there are cases every year that present a big challenge even to very experienced hernia specialists.
Among 65 patients (with 79 procedures), we operated on 14 children (21%) and 51 adults (79%). 14 patiens (21%) were female. Sixteen patients (24%) had umbilical hernia>1cm and suture repair (direct closure or Mayo repair) was performed in all children with this diagnosis and underlay or sublay mesh repair in adults. The most frequent diagnosis was inguinal hernia (33 pts, 51%), of course. In inguinals in children, Mitchell-Banks repair with fascial suture was performed; in teenagers and young adults Shouldice procedure and Lichtenstein with LDPE mesh were performed. In a re-recurrent hernia in 1 old patient and in 1 adult with cryptorhidism orchidectomies were performed. In incisional and epigastric hernias (8pts, 12%). Other diagnoses were hydrocaele (13 pts, 20%), where Jabouley`s procedure was performed. Additional procedures as rectus diastasis combined with umbilical hernia were performed in some patients. We drained big incisonals, scrotals and some hydrocaeles with suction, corrugated and/or penrose drains. Our anaesthesia team also helped in CPR of 2 newborns after cesarean sections.
Due to an expert anaesthesia team (many times anaesthesia was performed by locals under their supervision) 20 general anaesthesias with ET-tube or LMA were performed, 44 pts received spinal anaesthesias and 2 procedures were done in local anaesthesia. All pediatric cases received additional caudal blocks for postoperative analgesia.
We felt privileged for having no complications which we contribute to not overcrowded programme. We also took enough time for every single procedure, without any hurrying. Last by not least, sister Avelinas prayers were accompanying us always during the whole fulfilling week.
Team Members:
Prof. Dr. Mirko Omejc – consultant surgeon, Ljubljana, Slovenia
Mr. Shambu Narayan Nadav – consultant surgeon, Oban, Scottland, UK
Dr. Jurij Gorjanc-consultant surgeon, team leader, Austria; Slovenia
Dr. Michael Wirnsperger-consultant anaesthesiologist, Feldkirch, Austria
Dr. Hannes Lienhart – consultant anaesthesiologist, Feldkirch, Austria
Dr. Marija Jekovec – consultant radiologist, Ljubljana, Slovenia
Sarah Bertsch – anaesthesia nurse, Feldkirch, Austria
Daniel Döwa, anaesthesia nurse, Feldkirch, Austria
Franziska Ganster, medical student, Munich, Germany
Our sponsors:
Kirurgija Bitenc
Splosna bolnisnica / General Hospital Slovenj Gradec
Africa Amini Alama – AAA (www.africaaminialama.com) is a charitable hospital, located on the tableland between Mt. Meru and Mt. Kilimanjaro in Northern Tanzania. The name AAA means “place of trust in the future of Africa” or also “Africa, we believe in you”.
The organization was founded by Christina Wallner und Cornelia Wallner-Frisee just 11 years ago. After Austrian radiologists, like dr. Celedin, made contacts to the organization and donated some devices, we were encouraged to start the cooperation between Hernia International (HI) and AAA. This first “inspective” mission consisted of experienced HI specialists in order to treat as many patients as possible, but also to check the possibility for further cooperation.
Our team consisted of 8 members: surgical consultants Christoph Sträuli and Jurij Gorjanc , surgical resident Lara Maniglio, anesthetist Katharina Wentkowski, gastroenterologist/endoscopist Klemen Mojškerc, anesthetic/theatre nurse Petra Koch, medical device expert Michael Wentkowski, medical device expert assistant Alex Koch.
Good communication between our team and Mag. Dr. Cornelia Wallner-Frisee started almost 1 year ago and the mission was well prepared. All our patients were treated free of charge exclusively on humanitarian basis. The hospital is compared to African standards surprisingly well equipped. They even started to perform basic laparoscopic operations and we also performed 1 laparoscopic appendectomy with very elementary equipment that we intend to improve.
Experienced anaesthesiologist Katharina performed general and spinal anaesthesia to both operating tables while teaching the two local anesthetic nurses. Alan and Fanuel are very experienced in spinal anesthesia already. Training concentrated on safe general anesthesia in children, low flow technique to reduce the use of anesthetic gas and regional plexus techniques. Nurse Petra was of great help in anesthesiology and surgery. In addition she trained the local theatre nurses in hygiene standards. Christoph and me enjoyed performing surgery as well as educating talented Lara and local surgeons Dr. Kombo and Dr. Sebastian. Dr. Kombo is already very independent in various procedures as a young consultant and Dr. Sebastian has indeed a fine feeling for surgery. The majority of patients had hernias and hydrocaeles. Michael and Alex repaired the sterilizer, diathermy machine, CO2 regulator, endoscopy and laparoscopy monitor and many more. In addition they organized a 4-days hands-on workshop to train local engineers in maintenance and repair of medical devices. Excellent endoscopist Klemen brought the endoscopy in the hospital to a higher level, also performing some polypectomies.
Our team did not meet before but as Dr. Wallner-Frisee stated, we worked together as if we have known each other for a long time. We started surgery at 8.30 in the morning, had a lunch break in the hospital restaurant and then proceeded with surgery and recruiting new patients on the ward till sunset.
Good work in the hospital was also possible because we were accommodated very well in the Lodges Nature Homes and Hillside Retreat. There is basic accommodation available on the hospital campus as well, but it was already occupied by other volunteers. Thursday afternoon we visited a Massai boma in the evening. On Saturday (after finishing work) the whole team walked and drove through the nearby Arusha National Park.
Other diagnoses (appendicitis, foreign body)………2 Pts (6%)
In children the inguinal hernias were repaired with Mitchell Banks technique, with or without fascia closure, according to age, respectivelly. Suture repair was used in children with umbilical hernias. In teenagers, Shouldice technique was instructed and local surgeons loved to learn this approved meshless technique. In incisionals, epigastric and umbilical hernias in adults, sublay repairs were performed with LDPE and PP-mesh. Surgery was performed in spinal anaesthesia (20 Pts) and general anaesthesia (12 Pts).
Additional work:
Gastroscopies…………………………………….……..10 Pts
Colonoscopies…………………………………………….3 Pts
OPD…………………………………………..daily up to 30 Pts
Repaired machines and devices:
Autoclave for theatre…………………………………………1
Diathermy machine……………………………………………2
Laundry machine………………………………………………1
Refractometer/Optimetry……………………………………..1
CO2 monitor……………………………………………………..1
Anaesthesia gas monitor……………………………………..1
Endosopic camera color adjustment……………………….1
Perfusomat………………………………………………………1
Electromyography and stimulator device………………….1
Invasive plexus stimulator…………………………………….1
Colorimetric blood analyzer…………………………………..1
General training for local engineers (electricians, car mechanics, carpenters)
Topics: Types and composition of medical devices (diagnostic, surgical, therapeutic, invasive versus non-invasive). Electrical and biohazard safety measures, electrical characteristics, general main power concept and safety checks, typical maintainance tasks, systematic disassembly and assembly devices, testing procedures and strategies to detect typical failures.
Our team:
Christoph Sträuli – consultant surgeon, Switzerland
Jurij Gorjanc – consultant surgeon, Austria (team leader)
Report of Hernia International Mission to Ganta City
November 19- 25, 2019
The team consisted of the following:
Peter Bystricky, surgeon (Czech Republic)
Stepan Matoska, surgeon (Czech Republic)
Paulina Mysliwsky, anesthesiologist (Poland)
Denis Blasquez, pediatric surgeon (France)
Ajaiya Mull, anesthesiologist (Germany)
Iain Muir paediatric surgeon (Scotland)
Bill Cosgrove, pediatrician (United States)
Scott Leckman, surgeon (United States)- Team Leader
We were hosted by Peter George, general surgeon and Chief Medical Officer at the Esther and Jereline Koung Medical Center. We all stayed at Jackie’s Guest House and ate all of meals at the restaurant there. We skipped lunch each day as we were so busy and the heat seemed to suppress one’s appetite.
We operated for six days in four operating rooms. The two rooms with adequate air conditioning had no running water. In the one room that had an anesthesia machine, we did the pediatric cases. The final room had no A/C.
Sterility was challenging. There was one small autoclave heated with charcoal. Power would occasional be lost, but a back up generator (brought from Dr. George’s home for missions) would usually kick in. There was one occasion in which there was no access to water for a few hours.
Items we were glad we brought were: Gloves, suture, headlights, spinal bupivacaine, ketamine, spinal needles, LMA’s and other anesthesia equipment.
In the six days, we did 161 procedures in 133 patients. Most were inguinal hernias, including some recurrent hernias. The vast majority of inguinal hernias were scrotal and were difficult to repair especially since electrocautery was not available. There were 14 umbilical hernias, 14 hydroceles, three femoral hernias and some ventral hernia repairs. We were able to help train at least one young Liberian doctor in hernia repair. After nearly four weeks, there is one known complication, a post-operative hematoma which required evacuation.
Bill Cosgrove, our pediatrician, had probably the most impactful experience. He trained nurses and midwives in neonatal resuscitation who in turn trained others under his supervision. There was at least one birth he attended with the help of Paulina, in which the baby would not have survived had he and Paulina not been there. Now there more than fifty medical personnel he trained. One can only guess what impact this will have.
We are grateful for our excellent host, Dr. George. He is very committed to the people of Liberia and works under very challenging circumstances. We are also grateful for the enthusiastic help of the anesthesia staff and scrub techs who were always eager to assist us.
The Hernia International Organization a multi – European Humanitarian group started partnership with Farafenni General Hospital in 2007 marking the beginning of the organization’s first Hernia Camp in the Gambia.
Preparations for this year’s Mission began in June 2019 with a show of interest contained in an email addressed to Dr Andrew Kingsnorth coordinator for Hernia International 2019 team leader Dr. Meyer Jurgen. The team includes; 2 General Surgeons, 2 Resident Doctors, 1Anaestheologist, 1 Anaesthetist Nurse Technician and 1 Surgical Nurse making up a 7 member team.
OBJECTIVES
The objectives of the 2019 mission were;
To offer surgical services mainly hernia but not limited to hernia alone but patients needing surgical care including children.
To expedite access to surgery to patients on waiting list at Farafenni General Hospita and other facilities in the Gambia.
To provide opportunity for surgery to people with hernia in communities who have limited knowledge on the condition through sensitization using mass media.
PREPARATION
Clearance for the mission was sought from the Office of the Permanent Secretary, Ministry of Health dated 26th August 2019 and the necessary formalitirs for temporal registration with the Medical & Dental Concil of the Gambia and the Nurses & Midwives Council of the Gambia contained in a letter addressed to the Director of Health services dated 25th September 2019. The Hospital Management established a local support team including a Surgeon; a Medical Officer; Anesthetist Technician; Theatre Nurses; General Nurses and other support staff to work with the mission. From the success registered in the previous Hernia Misssions, the local team were encouraged to work with the visting team resulting in the establishment of 3 key sub teams.
1. Clinical: assigned with the responsibility of screening and booking (including contact details) of all hernias and related cases seen at the clinic.
2. Communication: responsible for sensitizing the general public including health facilities through Regional Health Teams; National Broadcasting Radio; Community Radios across the country and influential community members.
3. Logistics: Identifying and mobilizing the required resources needed for the mission and these includes; medical supplies, drugs, personnel and transporatation to ferry visiting taem.
The units that were fully involved in the preparation process included Administration; Nursing Department; Operating theatre; Laboratory; Laundry; Drug Revolving Fund Unit; Security; Generator Unit, Maintenance unit and Catering Unit.
SUPPORT FROM MANAGEMENT
To achieve a successful camp, Management ensured that;
The visiting team’s movement was well coordinated with support from the office of the Director of Planningand Information by providing transportation from the Airport – Hotel and to Farafenni and back to the Coast after the completion of the mission.
Drugs and supplies needed for the camp were made available by the visiting Hernia team and the Hospital.
Staff identified (local team) were available at all time (8AM – 8PM daily) during the course of the surgery.
Food and water were available to avoid interruption of services by providing lunch for the local staff while a hospital cook prepared meals for the visiting team.
OUTCOME
The 2019 International Hernia Mission operated on 71 patients with 76 conditions meaning more than one person being operated on for more than 1 surgical condition. Of the total cases performed, hernia represents 80.2%; hydrocele 13.1%; lipoma 5.2% and Keloid & Csyst 1.3%.
Of the total patients operated on 66 (92.9%) were males and 5 (7.0%) were females. Gambians represents 84.5% of patients and non-Gambians accounted for 15.5%. Children under the age 5 represents 12.6% of all patients operated on.
SEX
NATIONALITY
CONDITIONS
AGE DISTRIBUTION
M
F
Gam
Non-Gam
Hernia
Lipoma
Hydrocele
Keloid& Cyst
< 5yrs
> 5yrs
66
5
60
11
61
4
10
1
9
62
92.9%
7.0%
84.5%
15.5%
80.2%
5.2%
13.1%
1.3%
12.6%
87.3%
Table above shows summary statistics of the 2019 International Hernia Mission
Table above shows summary statistics of the 2019 Hernia International Mission
CONCLUSION
The Mission was a success as there is an increase in the number of cases registered from 51 in March 2018 and 48 in November 2018 to 76 in 2019. It is important to note there is a documented evidence that from October 2016 – November 2018, Hernia missions to this hospital have operated on a cumulative number of one hundred and eightyfive (233) patients mainly hernia, registering 71 patients for this mission is a significant milestone in our efforts to provide more people access to surgery. I must again repeat and acknowledged the continuous transfer of skills and knowledge between the visiting team and our local team.
SUMMARY OF HERNIA INTERNATIONAL MISSIONS Oct 2016 – Nov 2019
Dates
Mission
Team Leader
No of Patients
22nd – 29th Oct 2016
Slovenian Mission
Dr. Jurij Gorjanic
56
20th – 25th Nov 2017
International Mission
Dr Leo Mitteregger
78
12th – 16th Mar 2018
International Mission
Dr. Antonio Satorras
51
12th – 16th Nov 2018
International Mission
Dr, Tomaz Benedik
48
29th Oct – 2nd Nov 2019
German Mission
Dr. Meryer Jurgen
71
Total
304
The Hospital Management would like to register appreciation to the German team for an excellent job, to Dr. Adrew Kingsnorth for his leadership role in coordinating missions. The local staff must be commended for their dedication and commitment. Equally important, we express gratitude to the Director of Planning and Information Ministry of Health and by extension to Mr. Sang OJ Mendy Transport focal person for the Ministry for providing transportation for the team..
KAMUTUR SURGICAL CAMPAIGN. BUKEDEA DISTRICT. UGANDA. SEPTEMBER 20th-30th 2019
SURGEONS IN ACTION FOUNDATION
1.TECHNICAL REPORT:
a. DATE AND LOGISTICS:
A team of 12 people: 4 general surgeons, 1 pediatric surgeon, 3 anesthesiologists, 1 radiologist, two surgical nurses and a professional photographer.18 packages with a total of about 400kg ofsurgical equipment and medicines.
Departure from Madrid on Friday 20/9 at night and arrival in Madrid on Monday 30/9 in the morning. This time we traveled with Ethiopian Airlines. A success, because the journey, with stopover in Addis Ababba, is shorter, and also allows us to carry 2 23kg packages per person. Saturday 21/9: A long bus journey, which we already know from other campaigns, heavy due to long distance and what it means to travel on the road through Africa: traffic jams, pavement in bad condition, dirt tracks.., until reaching Kamutur, a village in a rural setting in the Bukedea district.
Sunday 21 to Friday 27/9: Surgical interventions, from 8:00h to 20h, in 3 simultaneous operating rooms. b. ADULT PATIENTS:
68 procedures have been operated on in 62 adults.
More complex procedures have been performed than in previous campaigns, thanks to improvements made in the new surgical ward. To highlight some procedures: -19 inguinal hernioplasties, with PLP meshes provided by the volunteers. -1 infraumbilical laparotomy for removal of right ovarian cystic mass, previously diagnosed by ultrasound by our radiologist. -1 xyphopubic laparotomy for massive splenectomy.
-8 hemitiroidectomies by unilateral giant goiters.
-1 total thyroidectomy per giant bilateral goiter. -3 large submandibular pleomorphic adenomas. -1 large left inguinal tumor with extension to the thigh, about 20cm, Schwannoma said by pathology report. -1 large incisional hernia, with retromuscular PLP mesh (Rives) -The rest of procedures have included umbilical hernias, anal pathology, soft-tissue
tumors (some of them very large) and removal of complex keloid scars.
c. PEDIATRIC PATIENTS:
35 procedures have been operated on in 25 paediatric patients, from 1 to 16 years of age. As most noteworthy: -7 inguinal hernias-4 hydroceles -1 retrorectal teratoma. -1 patient of 16th with multiple neurofibromas in left face, of great complexity, who had been abandoned in the hospital. -1 distal hypospadias. -All other procedures include umbilical hernias, cures and soft-tissue tumors.
We have had to reject some paediatric patients, because of high complexity, such as a large facial tumor, stoma closures or tonsil surgery. It should be noted that, due to the location of the hospital in a rural environment, away from any urban core of a certain entity, the recruitment of patients is quite complicated. Firstly, because of the campaign’s publicity difficulties (advertinsingsare placed on local radio stations and phone messages are sent) and secondly because of the patient’s difficulties in getting to the hospital. This is especially sensitive for paediatric patients. Total procedures: 103
Total patients: 87c. COMPLICATIONS: So far as to leave Kamutur on Saturday 28/9 in the early morning, it is worth highlighting only two re-interventions by post-surgical hematomas, one in total thyroidectomy, which was successfully resolved, and another after removal of a pleomorphal adenoma submandibular, equally resolved with drainage. We haven’t had any phonatory complications in any thyroidectomy. The patient who had splenectomy was pending post-splenectomy vaccination,and has evolved successfully following our departure. The pediatric patient with face neurofibromas has successfully evolved with healing of the surgical wound, keeping important palpebral oedema that evolves more slowly (one of the removed neurofibromas was in retroorbital location). The rest of the patients have had no complications. We have received reports of Pathological Anatomy from Mbale Hospital, of the cases we consider most necessary. For subsequent campaigns, always assessing the difficulties and cost of this, let it be known that this study can be carried out in the samples deemed appropriate.
2. CAMPAIGN REPORT a. THE PLACE: Uganda is an East African country, bordering Kenya, South Sudan, Congo, Rwanda and Tanzania. It is an independent country, belonging to the Commonwealth, since 1962. He has had a very convulsive recent past, and currently maintains a relative socio- political calm, with presidential regime led by Museweni, who has ruled since 1986. It is divided into 111 districts and a capital city, Kampala. More than 80% of the population is Christian. Each woman has an average of more than 6 children. Life expectancy is estimated to be around 52 years. The Bukedea district, where Kamutur is located, is a district with about 120. 000 hab, in a rural environment, and with 80% of itspopulation below the poverty line.
The Holy Innocents Health Center (HIHC) has improved a lot since our last visit. It currently has care for gestation and delivery, hospitalization area, laboratory with basic diagnostic tests, and a surgical pavilion already completed, and a new surgical hospitalization building connected to the surgical pavilion, in a very advanced phase of construction, with a ward for women and another for men. Regarding the surgical pavilion, it is a building that has 3 operating rooms, whose current endowment is: -1 operating room with electro-surgery generator, an anesthesia tower and a monitor. -1 operating room with an electro-surgery generator, a monitor and an oxygen concentrator. -1 operating room without electro-scalpel. All three operating rooms have a new and very functional operating table. There are legs. Each has ceiling light and a floor lamp, although it is advisable to bring front spotlights. There is no running water yet available, although it appears that the external pipeline from Mbale will be completed in the coming months. In addition to operating rooms, the pavilion has toilets for men and women, a post- anesthetic recovery room, a cleaning room, an instrument and sterilization room, a warehouse, a staff room and a waiting area for patients. It has a system of solar panels and rechargeable batteries to support electric power. Unfortunately, it is still not enough to meet the needs of the pavilion when it is operating at full capacity more than two days, because the rate of charge of the batteries is lower than the consumption rate, so it is necessary, to this day, to complement the energy input with a diesel generator. This situation is likely to change with improvements that are pending, one is the increase in battery capacity, and the other is the arrival of power supply that is planned for theend of this year.
The hospital center is clean and tidy. A more than acceptable asepsis-antisepsis circuit is maintained, using a pressure autoclave using a gas-heated pot (there is an autoclave, which consumes too much electrical energy and cannot be used at the moment) and organizing the instrument in small kits, aided by all the single-use sterilized material we carry with us. We have collaborated with 3 very efficient and willing local nurses, to which we appreciate their great capacity and willingness to work. With regard to the admission process, two aspects should be highlighted: -The admission process in the hospital includes the payment of between 10,000 and 50,000 Ugandan shillings, which is equivalent to a maximum of 12 euros, and the completion of a small medical history by local doctors, usually in the days before our arrival. -The medical team of the campaign consulted in the consultation area all the selected patients, to decide the indication and order of surgery. It should be noted that any surgical intervention in Mbale Hospital, especially in the case of more complex patients such as thyroidectomies, can account for between several hundred thousand and several million Ugandan shillings. Apart from some cases where the indication of surgicalintervention by the surgeons responsible is not accepted.
b. THE TEAM On September 20, Friday night, we left Madrid a team of 12 people: -Carlos de la Torre Ramos, pediatricsurgeon, -Sebastián Fernández Arias, general surgeon, -Ana Gay Fernández, general surgeon, -Julio Calvete Chornet, general surgeon, -Beatriz Revuelta Alonso, anesthesiologist, -Miguel Angel Pereira Loureiro, anesthesiologist, -Astrid Alvarez Fernández, anaesthetologist in training (R4) -Nieves Alegre Bernal, radiologist, -Nuria Agulló Marin, nurse, -Gustavo Sánchez Bravo, nurse, -Sergio Sánchez Agulló, photographer,
-David Fernández Luengas, general surgeon. This campaign has been carried out by a team from the Surgeons in Action Foundation. Together with the medical team, on this occasion a professional photographer has participated in the campaign, with the aim of collecting audiovisual material to make a documentary montage about this place, its reality, its needs, and the task that the Fundación Action takes place here. c. LOCAL STAFF There are currently two doctors at the hospital. For our work, we have had 2 nurses in the operating room (Esther and Rose), who did circulating work together with our nurses, and cleaning and sterilization. In addition, we work with hospital nurses, who assist all hospitalized patients 24 hours a day, and two wardens who take care of patient transport and other tasks. It is right to acknowledge to all of them the enormous effort made and the joy with which they have shared the work with us. We were very pleased to note upon our arrival the cleanliness of the facilities, which we were able to check how it was maintained day after day by the cleaning team. We have also collaborated with local doctors (Viktor and Kenneth), who have helped us with the prior selection of patients, and have participated in surgical interventions. During the last day in Kamutur, there was a great celebration, on the occasion of the official opening of the surgical pavilion. More than 100 people attended, with the presence of Ugandan Senate authorities, representatives of the Ministry of Health, and the Bishop of Mbale. A mass was officiated and the pavilion was officially opened. The authorities present were able to check the enormous effort made to equip the hospital with the necessary means to perform surgical interventions safely.
d. THE EQUIPMENT In addition to the surgical ward, it is worth noting: -Surgical instruments, there is a basic reserve of instruments in the hospital, but we have carried instrumentals to make about 6 basic kits, which have allowed us to work fluently, relying on constant cleaning and sterilization in the autoclave by local nurses. -Regarding consumable material and operating room clothing, the needs are enormous.We have used much of the material we have worn, among gauze, compresses, gloves, dressings, disposable sterile cloths, disposable sterile gowns, anesthetic medication iv, iv antibiotics for prophylaxis, mosquito meshes and antiseptic solutions for surgical wash, among other things. Without this material, posing such a campaign to this place is impossible. The next teams must be very aware of the need to provide all this material, although it is true that, thanks to the material left over from previous campaigns, material is gradually stored in the pavilion (current inventory of the warehouse is attached). -Regarding the work of our radiologist, she has been able to use a simple ultrasound, acquired by the hospital, which has a single low frequency convex probe for abdominal cavity examination, and does not have Doppler. With it she has carried out two different tasks: 1.- Diagnostic studies to the patients we have required. 2.- Basic training plan in the use of the ultrasound for doctors and local midwives, for use in basic diagnostic studies and for gestation control. -Another task that we have done during the campaign is the training of local staff in basic cardiopulmonary resuscitation maneuvers, with a CPR mannequin donated by the company Ambú, and which we have left there so that in future campaigns you can continue to use it for training.
e. ANESTESIA, ASEPSIA AND QUIRURGIC MATERIAL
1. Anesthesia: The hospital has an anesthesia machine and an oxygen concentrator. The anesthesia machine functions as an oxygen concentrator, i.e. it collects ambient air and concentrates it to get Fi02 of approximately 80-90%. It could be connected to an oxygen bullet or a wall oxygen delivery system, but the pavilion lacks these systems. Yes there are a couple of oxygen bullets, but the connections are not compatible and their use would leave the hospital without them, so the bullets were nearby to use only in case of urgency. The respirator has an internal battery that lasts about 30 minutes, to take into account in case of failure with generators or solar panels. The oxygen concentrator continues to function perfectly, so we were able to perform general anesthesia in two of the operating rooms simultaneously. In the third operating room, most surgeries were performed under local anesthesia and many with locorregional anesthesia, without incidents. In this campaign, thyroid surgery was done for the first time, with everything surrounding these types of interventions. In addition to the laryngoscopes, we had fasteners and we carried airtraq of different sizes. We used them in a timely manner, but all the orotracheal intubations were successful, without any incident. Although if such interventions are to continue, we must be prepared for possible difficulties.
In addition to all the medication usually carried in these campaigns, the Hospital was insisted on the provision of halothane (there is only one halothane vaporizer, it is not possible to use another type of gases), to be able to perform the maximum number of surgeries with the lowest cost in inductors, and some kind of muscle relaxant. In previous campaigns there was no fridge to store the medication. Now there is a fridge in the surgical pavilion, and we got succinylcholine and cisatracurium in Kampala, albeit at a very high price. Halothane is almost impossible to obtain in European countries, and in Uganda they can take care of buying it. The relaxants should take them, so in future campaigns it would be possible to carry what each anaesthetist considers, well protected in cold during the trip, since there they can be stored without problem. With regard to the material they have in their warehouse, there is a significant surplus in face masks, guedel, spinal needles of different sizes, local anesthetics (hiperbara and and isobara bupivacaine), electrodes, nasal oxygen masks. All other medications and fungibles need to be provided in each mission. Important mention of any drug we anticipate needing in thyroid surgeries. For this campaign we have carried calcium gluconate iv, calcium+calcitriol oral, levothyrosine, as well as material for eventual realization of tracheostomies. Surgery was performed in adults (abdominal wall, thyroid, skin tumors…) and in children (abdominal wall, urological, sacrocoxygeal, facial tumor…) without any incidenceof any kind. 2. Asepsis: Basically, they have a “sterilization” room where they store the packages with the sterile material, and where a “express pot” autoclave is placed on gas fire, with pressure meter. The system itself is rudimentary, but effective for getting the material sterilized. I recommend the following teams to carry sterilization bags and witnesses, very useful there. Surgical clothing is very scarce, with very few cotton gowns and re-sterilizable cloths. We use a lot of disposable cloths that we carry from Spain, as well as disposable robes. We have been particularly concerned that all our adult patients with indication of antibiotic prophylaxis receive a dose of cephazoline 2gr iv or similar in anesthetic induction, which we have taken. In the hospital there is a pharmacy with some medications, but in general, it is advisable to take all the medicines that are deemed to be used. 3. With regard to surgical equipment, we carried a lot of material that is essential that other missions also carry, from gauze and compresses to sterile gloves, drains, dressings, steri-streaps, sutures, elastic bandages, etc… The surgical instruments there are useful, although generally somewhat rudimentary. We have preferably used our own instrumental divided into small kits. f. OUR LIFE IN KAMUTUR The alarm clock rings at 7:00am. It’s time to get up, grab a big bucket and approach the hospital well, in the middle of the central square to fill it with water. There’s enough hustle at that time, and you always find some kid in the well that gladly applies to the pot’s crank to get the bucket filled. Then there is going through the kitchens to add enough hot water, for tastes, and approach our “shower”: a stay with walls of approx. 1.5m high, outdoors, where we could perfect the technique of the bucket shower. The mornings are fresh, about 20 degrees max. The rest of the day during this time of year is warm, up to 30 degrees, and with relatively frequent rain showers. As far as the bathroom is concerned, we have improved from last year. It is no longer necessary to go to the latrine “communal”, because we have a bathroom in the area of the bedrooms and two others in the surgical pavilion. As there is no running water, it is necessary to pour a good bucket of water for flushing the toilet. All meals were made on the covered terrace, with a menu basically the same every day, clean, cooked there, and enough to feed, without great difficulties. Our life in this place is very simple. We have always felt very well treated and very accompanied. Apart from hospital life, which occupied much of the day, our social life was limited to conversations around the table. Especially in the evenings, when, after dinner, we enjoyed one (or two) wonderful bottles (75cl) of Nile beer, with an entertaining conversation. Regarding the rooms, we have lived in relatively cozy cabins, two for the 6boys, another for the 4 girls, and a room for Nuria and for me. They are quite basic, with the beds as only furniture, but clean and comfortable enough to spend a week.We paid around $70 each for the room and food, for the whole week. Communication with the outside world can only be done through the Ugandan telephone network, via SMS or calls at an international rate. Our trip back to Entebbe we did it in two days of car of about 4.5h each day, taking the time to rest on Saturday in a hotel in Jinja, where we could enjoy a boat ride on Lake Victoria, visiting the famous source of the river Nile.
3. CONCLUSION: In short, we consider that this campaign has been a success, both for the number and complexity of patients that we have been able to operate, with little complications, and for the satisfaction of the team for the great treatment received by the authorities and local staff. This year, thanks to the functioning of the pavilion, we have been able to perform, for the first time in Kamutur, surgical interventions of greater complexity, with general anesthesia, such as thyroidectomies and abdominal surgery. Strengths of this place: – Moses Aisia, true hospital engine. Its ability to launch, from nothing, this center, is amazing. – The hospital itself, a true center of hope for this place, with a much-needed population, mired in poverty. – The treatment we have received and the willingness of the staff to work with us. – The works carried out, with the surgical pavilion already functioning, and the new hospitalization ward in the very advanced phase of construction. Improvement objectives: – Improve the process of recruiting patients for campaigns. This is a goal that should be considered paramount, to make the most of campaigns. Among the measures that can be implemented, there are two that would probably be very profitable: -Get a means of transport that would collect patients in nearby villages in the days leading up to the campaign. -Make a visit to Kamutur Elementary School, which has 681 students censed today, to perform a medical checkfor surgical pathology, which is likely to be going unnoticed to their parents. – Ensure complete energy independence in the surgical pavilion. – Medical material: Today, any campaign must have the need, already explained, to carry with all necessary medical material. Our recommendation is maintained to supply the hospital with this material, by the management of the center. – Complete the channelling of running water and electricity, by the Ugandan government. – Complete the start-up of the blood bank, currently in the manning phase, according to the rules of the control protocol required by the Mbale Blood Bank.
4. BUDGET: For informational purposes, and without going into excessive detail, it must be said that the campaign in Kamutur is more affordable for the surgical team than other locations. This is due to two fundamental reasons. One, the cost of the plane ticket, not especially expensive. Another, the costs of accommodation and maintenance, which have been almost non-existent (70$ for the entire stay of 6 days), in addition to road transport, about 450 dollars round trip all the equipment. The budget has not accounted for the cost of all the material we have contributed, in total about 400kg. COST PER PARTICIPANT: Approx. 900€ TOTAL COST OF THE CAMPAIGN: Approx. 10,800€, paid for by the volunteers and with partial funding thanks to the Spanish Surgical Association grant of 3500€.
Fdo.: David Fernández Luengas Responsible for the campaign Surgeons in Action
5-10 August 2019 The Brazilian mission took place in Belo Horizonte ( 1,5 million people), capital of the State of Mina Gerais, one of the wealthiest states in Brazil. It was organised by Gustavo Soares and Christiano Claus and well prepared with the participation of 12 local surgeons and one overseas surgeon (myself).
Operations were done free of charge place on 4 sites : University Hospital, a large up to date place were all type of surgery can be performed, Sao Francisco Hospital : a non for profit organisation which let us use their facilities, Santa Monica Hospital in Divinopolis a private hospital which opened free of charge a theatre room for several patients every day, sessions also took place at Ouro Preto Hospital, the previous state capital city. In the 2 largest hospital we had 4/5 theatre rooms for us all day long. There is a lot of controls and security at each hospital entrance which makes it a bit difficult to enter the hospital if you are not accompanied by one of the locals.
Theatres are usually well equipped, theatre lights are good, instruments quality depends on the hospital, the scrub nurse is usually an (unpaid) surgical registrar in his first year of training who is always very keen on closing all wounds and craving to do more surgery. One senior registrar was excellent at laparoscopic inguinal hernia repair. There is a good balance between male and female trainees which is promising as all senior surgeons were male. Communication was a bit of an issue as few people speak English, it is worth wile to speak some Portuguese if only to make sure you operate on the correct patient, correct side and could ask for assistance when needed. Check lists are not performed before and after surgery. Rooms are very well cleaned after each operation by a team of 2 cleaners. Anaesthetist perform usually a spinal anaesthesia and are good at it, nurses are well trained and efficient. No child to operate on. There is nothing to bring as meshes and sutures are provided by the local pharmaceutical companies. Of note, everything is kept in a safe room where an attendant only releases the products on demand from the theatre room for a given patient and this is recorded to avoid stealing which seems to be a serious issue even in the private hospital!
There was a good balance of hernia types, inguinal, mid lines, para stomal, large incisional hernias and numerous umbilical of all sizes and shapes, some patients seemed to have been waiting for more than a year before they could access surgery. The Brazilian surgeons are keen and good at performing laparoscopic repair of these and are not using too much single use equipment. Mesh usage was the routine for most hernias. 250 repairs were performed over the week, follow up is organised by the juniors, we had private and public surgeons coming every day from various other hospitals.
Accommodation was in a good hotel in the town centre although with the local traffic it always takes time to go to and return from the hospitals, early morning start at 06H30, return when the job is finished. Pleasant evenings in restaurants and bars with the Brazilian teams, we had 2 sponsored meals on Monday and Thursday night. One interesting teaching session Friday afternoon with a packed amphitheatre. Ambiance is Brazilian, work hard and have fun after.
This hernia mission in Brazil is great, never boring, be careful however, this is a hard working week with no moment to relax. Have your vaccinations including yellow fever up to date.
VENTANILLA – International Humanitarian Hernia Mission. June 2019.
Ventanilla, Callao. Perú.
On the 8th of June 2019 a mission of the project Hernia International arrived into Lima Perú. The mission intended to visit for two weeks the Ventanilla District General Hospital. Ventanilla District is a densely populated community located at two hours drive from the city of Lima and belongs to the Province of El Callao. The population of Ventanilla is about 300.000 inhabitants.
Volunteers of the Ventanilla Mission June 2019: The mission was composed of nine volunteers; five consultant surgeons, two consultant anaesthetists, and two theatre nurses.
– Rafael Chavez – Surgeon, UK
– Dominic Robert – Surgeon, Australia
– MaAngeles Torrico – Surgeon, Spain
– Celia Moreno – Surgeon, Spain
– Claudia Tinoco, Surgeon, Spain
– Eugenio Briz – Anaesthetist, Spain
– Vicente Cuquerella – Anaesthetist, Spain
– Mara Garcia – Scrub Nurse, Spain
– Natalia Rodriguez- Scrub Nurse, Spain
There was a very enthusiastic involvement of all staff in the hospital, including the Medical Director, Surgeons, anaesthetists, nurses, and all support staff. The local surgical team was led by Dr Ronald Medina and Dr Luis Bernaola, Consultant Surgeons.
Ventanilla Hospital is a Level II District General Hospital and has approximately 100 beds and 5 operating theatres. It is staffed with 6 anaesthethists and 17 professional scrub nurses. The Department of Surgery carries out conventional hernia surgery, biliary surgery, both laparoscopic and open; ano-rectal surgery and peripheral tumours.
Theatres:
The hospital has five operating theatres, clustered in a single surgical area. Four of those theatres were made available to the campaign, leaving one to cover their own emergency work in general surgery and Obs & Gynae.Of the four available theatres, two were standard, purpose-built theatres and the other two were small military, field-operating theatres that are coupled to the main building in a semi-permanent fashion.
Patient Population:
Patients were recruited at a national level. All recruited patients were assessed in advance and offered detailed information, consented and given instructions regarding preparation for surgery, including personal hygiene. As a result all patients that attended looked relaxed, well groomed and comfortable.All patients were clerked and admitted to the ward by the local interns and then transferred to the surgical area were they were re-examined by the surgeon, marked accordingly and had an opportunity to have a further conversation with the operating surgeon.
Anaesthetics were mostly spinal, a number of cases had their operations under local anaesthetics and all paediatric patients and those with large incisional hernias had general anaesthetics. The anaesthetic team were extremely keen and helpful.
The surgical trainees participated actively in all the surgeries.
Results
Surgery:
Number of procedures: 169
Inguinal: 57
Crural: 9
Incisional: 9
Umbilical: 76
Epigastric: 17
Spiegel: 1
Complications:
Follow up information is still pending. I shall report on that as soon as it is available.
Discussion of results
Observations, procedures and knowledge transfer throughout this mission
– Sterility in theatre – The operating theatres were kept in pristine clean conditions. The hospital staff kept excellent asepsia and antisepsia measures throughout the whole visit. The nursing staff were instrumental in keeping an impeccable theatre discipline and technique.
– Scrubbing: No brushes were available for scrubbing, only clorhexidine foam was utilised.
– Antiseptic preparation of the operative field: Only clorhexidine soap was utilised to prepare the operating area. A film of soap was normally left before draping and commencing the operation.
– Patient dignity
The local team were very pleasantly impressed by our uniform approach to patient’s dignity. They self-criticised the fact that they were less concerned with regards to keeping the surgical patients decently covered throughout the whole process, including examination, transferring to operating table, anaesthetics, surgery and postoperative management. The local team considered this an important learning point to take on board.
– Marking the operation side and site
The local team saw with interest our routine practice of marking the side of the operation at the time of preoperative examination and consent. They expect to adopt this safety technique.
– Preoperative morning briefing:
The local team normally undertakes a morning ward round to review the patients scheduled for surgery on the day, and for final pre-op indications.There were no morning briefings in the operating theatres during the campaign. Perhaps this should be implemented in subsequent missions
– WHO checklist Pre and postop:
The surgical team undertook the WHO checklist before and after each surgery. This is common practise in Ventanilla Hospital and the visiting volunteers kept this routine.
Communications
There were no visible telephone landlines in the clinical areas, however, communications were very effective thanks to the local team, which successfully ran the whole campaign on a Whatsapp platform.
Discussion with lectures from local professionals and from the visiting volunteers.
Opportunity for networking:
This mission was an opportunity for networking with our colleagues from Peru. As a result, we have been invited to conferences and congresses; at least two local doctors have shown interest in visiting our centres for training.
Case discussion Whatsapp group:
The local team has developed an international group, based on Whatsapp, for discussion of clinical cases of interest. This platform has remained very active.
Promoting presentation of results:
These report and results have been made in collaboration with the ventanilla team and we have suggested to the surgical residents that they may find material here for a presentation in a local or regional surgical conference.
Mary Jane Reed, MD, FACS, FCCM Team Leader June 24-July 5, 2019
Summary: Mongolia and Hernia International have had a long standing relationship and this was the 10th year working in collaboration with the excellent surgeons in both Ulaanbaatar and Moron.
Dr Naraa was our Mongolian host and was instrumental in making our HI mission successful.
Enkee was our in country coordinator who was a wonder in organization and relations. Our teams worked in Hospital 2 in the capital of Mongolia, Ulaanbaatar and in Moron Hospital in Moron, Khovsgol providence. The teams evaluated and operated on 45 adult patients with inguinal, umbilical, post-operative ventral hernias, phimosis and cryptoorchism in Ulaanbaatar over 4 days. In Moron, the team did half pediatric hernias. Including adult inguinal and ventral hernias total of 24 cases were done in four days. The HI hernia team were co surgeons on all of the cases with young attendings or senior residents at Hospital 2 in Ulaanbaatar and regional surgeons in Moron. The Hernia International team consisted of three surgeons all experienced in global surgery.
Biku Ghosh, a senior British surgeon with extensive experience in all aspects of general surgery including pediatrics and breast cancer. Dr Ghosh donates his time extensively to global surgery projects including HI. Dr Mary Ann Hopkins is new to HI but not to global health. She is a fellowship trained laparoscopist and advanced hernia expert who also is the Director of Global Initiatives of New York University Medical Center. She brought her expertise to teach repair of large complex ventral hernias. I rounded the team out as the second US surgeon. Although not my first global surgical mission leadership, it was my first time with HI. I am a acute care surgeon and critical care surgeon with advanced laparoscopy and bariatric surgery background.
June 24-28, 2019-Hospital #2 Ulaanbaatar. The team brought 100 pieces of mesh in various sizes, suture and dressings. No mosquito netting was used in this mission. Although the majority of operations were inguinal hernias, a third of the cases included large post-operative ventral hernias.
A few bilateral hernias were performed laparoscopically.
Lectures on hernias and other general surgery topics were delivered by the HI volunteers.Ulaanbaatar is a busy and vibrant city.
Our hosts assured that we experienced some of the sites.
June 28, 2019-Dr Naraa and a Hospital #2 team of residents escorted the HI team to Moron by ground. This is a long trip via road but full of incredible sites.
July 1-July 5, 2019– HI-Mongolian team operated at the Moron hospital. Here, the HI team operated with regional surgeons. Half of the patients were pediatric hernias with the adult cases equally divided with inguinal and post-operative ventral hernias.
And we very much enjoyed getting to know our hosts.
