Author: akingsnorth

MEMORY OF THE MISSION OF “CIRUJANOS EN ACCIÓN” AND “HERNIA INTERNATIONAL” IN FREETOWN (SIERRA LEONA) ON 15-23 JUNE 2019

(Police Hospital and Connaught Hospital) 

 This has been the first mission that “Cirujanos en acción” (CA) and “Hernia International” (HI) have carried out in Sierra Leona. The initial place for this mission was the Makeni district in the inner country, a zone needing badly surgical help in hernia pathology according to the request of contact with HI at the end of 2018, but due to logistic problems it took place finally in the capital of the country, Freetown, and simultaneously in 2 public hospitals, the “Police Hospital” (PH) and the “Connaught Hospital” (CH).

 The “Cirujanos en Acción” team was formed by 10 persons according to the needs of the initial campaign. Four general surgeons: Cesar Ramirez (Málaga), Teresa Butrón (Madrid), Hermelinda Pardellas (Vigo) and Guadalupe Moreno (Ibiza); a paediatric surgeon, José M. Morán (Badajoz), three anaesthetists, Salvatore Catania (Huesca), Beatriz Fort (Barcelona), and Sandra Casares (Ibiza); and, to complete the team, two nurses, Francisco Gomez (Malaga) and Silvestra Barrena (Madrid).

The previous coordination, after the last moment discarding of Makeni’s destiny, has been very troublesome; in order to organize everything we had the great help of Dr. Biku Ghosh, an Indian surgeon, working in the UK for many years, who usually volunteers with the “Saving Lives” ONG and who had just finished a mission in Freetown. The key contact persons in Sierra Leona have been at PH Dr. Paul Fillie (responsible surgeon) and Dr. Mohammed Jalloh (director in charge), and in the CH Dr. Samba Jalloh (a young “practitioner” of Freetown very much implied in coordination work of humanitarian missions) and Dr. James Boima (surgery chief in that centre and high prestige surgeon and national consideration plus absolute reference, of Sierra Leone).

The starting point of each of the team members were their cities of origin, and we all got together at the Paris airport to begin the flight to Freetown. We arrived to our destination on Saturday 15^th late in the evening, and we were received at the airport by Dr. Paul Fillie. More than 20 pieces were booked with more than 350 Kg of material, and in this occasion I want to underline the Air Europa collaboration as they allowed us to travel with excess luggage without additional cost. The Freetown airport (Lungi International) is very far from the city, in a gulf that makes it necessary to take a “ferry” for about 35-40 minutes to arrive, as otherwise there are almost 4 hours by car; this forces us to arrange the times of arrival and of leaving the country in function of the times of the ferry. On reaching the city and disembarking we got a warm welcome by the PH staff, and besides that we had a bus of the Sierra Leone Police for our displacements in the city.

Our stage was arranged in The Jam Lodge, a fairly central hotel which had been recommended by Dr. Ghosh and which we had booked by “Booking.com” previously. It is a decent hotel, with hot water, a good breakfast and in which the Wifi works not good; the price or the room is about 50 dollars a day for single or double room. We daily gathered at 7 a.m. in the morning to plan the day, and at 8 a.m. the bus came to take us. We had a great help in Suleiman Conteh, a young student of political science, who has experience in helping humanitarian missions and who every day sent us food and drink in the two hospitals; the price of food and drink has been about 3 dollars for person a day, but as in both hospitals we paid for food for the whole staff that worked with us the increment was important (we have paid on an average 150 dollars a day for food). The local money is the “lion”, but in fact everybody works with American dollars and this is what we used. On Friday 21^st June night, after the last word in the operation theatre, Dr. Mohammed Jalloh was kind enough to invite our whole mission staff and operation theatre PH staff to a common dinner which was very much appreciated and valued.

The process of gathering and selecting patients by Dr. Fillie in PH has been really good, so that there were more than 250 patients ready to be examined, the majority with a severe hernia pathology, which we evaluated on Sunday 16^th June along morning and evening; in CH there were hardly 30-35 patients selected, some of them with small hernias, all selected by Dr. Boima. In PH there was only one respirator and two operation theaters; in CH we also had one respirator and two operation theaters (both with respirator, but one of them only for children) and this was the first problem we have met as the flow of PH patients to be operated upon in CH was not the desired one, and the administrative facilities have not been good either. Finally, in CH we were given on the last days a third operation theater so that we could fulfill the expectations we had come with. In the PH there was no facility for sterilization of the material so that everything had to be sent to the CH, and this has always been a problem from the logistic viewpoint. Even so, given that we have some boxes of surgical material of our own for children and adults that we had taken from Spain we have been able to help in this. In the PH only an electric scalpel was working and it was of poor quality, that is why we have been able to operate effectively in only one room; in CH they have two electrical scalpels, but only one was working properly, so that it has been fundamental that we had brought from Spain an electrical scalpel provided by Teleflex. CH is a large hospital with more than 200 beds, while in PH there are no more than 30 beds, and this, given the bad coordination between both centers has also brought logistic problems shifting from one centre to another, and this has created internal tensions, sometime unpleasant. From our part, and given that children could be operated upon only in CH, we have decided to divide the team in 2 working groups, one with an anaesthetist, a lady nurse and two general surgeons for the PH and another with two anaesthetists (one of them specifically for children), two general surgeons for the PH and another with two anaesthetists (one of them specifically for children), two general surgeons, one paediatric surgeon and a male nurse for the CH. I can say that it has not been a good experience, and I do not recommend that in future campaigns we work in two hospitals at the same time, and divide the team members even more in countries where we cannot communicate by phone between us because there is neither an accessible phone neither an accessible phone line nor wifi for “whatsapp” communication between hospitals.

On Monday 17 June, which was the first day to begin operations, we have not been able to begin till the afternoon because we have spent the whole morning in the Sierra Leone Medical Council in Freetown; even when all the requested titles had been sent by mail, and the inscription forms had been properly filled in the Medical Council, we have had to go through a personal interview in order to confirm our ability. In that way we have had only 4 and a half days of work, which we have made good use of as far as we were allowed. In PH we had no time limit to work, still in CH we were first told that at 7 p.m. the health workers were leaving and so we could not operate from that time on. This time limitation in CH was extended in the last days with the hint that we could work from that time. This time limitation in CH was enlarged on the last days with the suggestion of giving some help in the shape of economic help for the operation theater staff, as it is apparently assumed habitually in this hospital and which has looked very strange to us.

On the whole we have been able to operate upon 126 patients of which 96 have been adults and 30 children; till the time of leaving, and reporting our direct communication with Dr. Fillie today there have been no mayor complications. The number of surgical procedures carried out has been 144, as in some patients 2 and 3 procedures had been carried out simultaneously (19 hidroceles and umbilical hernias).

It is very important to stress that 70% of the inguinal hernias were H3 or H4 or more invalidating, as we have selected for treatment those that seemed more complex and more invalidating and required more time. On the last day of the mission we operated upon a giant goiter in a 12 year old girl with compressive complication which could not bear decubitum who was discharged the next day without any disphony or symptoms of hipocalcemia.

In spite of all the organizing problems that have troubled us, we can say that the campaign objective has been achieved, and from the view point of the number of patients operated upon the mission has been a success. The Police Hospital is a center where in the future new campaigns will be had because the interest of leaders and surgeons to collaborate with our foundations is maximal and the predisposition is absolute. It would be very interesting to be able to solve the problem of the sterilization of the material (they have no autoclave) and to dispose of another electric scalpel in order to make 100% use of the second operation theater they have. After 2 months I am keeping a periodical relation with Dr. Fillie and I believe it is worthwhile to work in this country habitually.

Dr. Cesar Ramirez

Trainee’s Report – Omar Nasher

Location: Gatundu Level 5 Hospital, Kenya – Africa

Period: 18/05/2019 – 24/05/2019

Team members: Magdi Hanafy (Surgeon – Team Leader), Iain Muir (Surgeon), Omar Nasher (Surgeon), Gudrun Graf (Anaesthetist), John Pickering (Operating Department Manager), Vicki Clark (Nurse), Sue Dale (Nurse)

Since before entering medical school, I always had the dream to participate in a charity medical mission as I believed it would have been a uniquely rewarding experience.  Hernia International gave the opportunity to join the UK Team on the mission to Gatundu in Kenya and I was very grateful for that.

Prior departure, I had several email correspondences, phone calls and a meeting with John Pickering who, having been on numerous missions himself, was able to share his wealth of knowledge and mentally prepare me for what was going to be an amazing life experience. After a long direct flight from London, we arrived at Nairobi International Airport late at night where we were greeted by Cyrus, our exceptional driver/guide in Kenya, who drove us to the hotel.

There we received a smiley welcome by the hotel staff who were able to provide us with warm food despite our late night arrival. The following day after an early breakfast and a 45min adventurous drive through a spectacular countryside of fertile lands and coffee plants, we reached Gatundu Hospital. Upon arrival, we unloaded the jeep of all the boxes containing our equipment which included gowns, gloves, suture materials, instruments, medications and teddy bears for the children.

 After having been greeted by the hospital team we started working. Johns, Vicki and Sue unpacked all the equipment, created surgical trays and tidied up the two operating theatre so that they then became perfectly functioning and organised.          I, Magdi, Iain went to assess the patients (adults and children) on the surgical wards to make sure that the proposed surgery was clinically indicated and we then created our first elective operating list for the following day. Gudrun did a pre-operative assessment of the patients and along with Sue made sure that all anaesthetic machines, equipment as well as medications were ready and safe to be used.

 During the whole week we operated on multiple patients with different pathologies ranging from various types of hernia to undescended testis and hydrocele. All patients stayed in hospital one night after surgery to make sure that they were well post-operatively before going back home which in some cases was quite far away. Every day we reviewed the patients operated the previous day, perform the planned surgeries and then assessed new patients for the following day.

 I had a great pleasure and enjoyment in interacting with the brilliant local doctors, physician associates and nurses who were always accommodating any request we had and demonstrated a great level of enthusiasm as well as willingness to learn despite the limited available resources. One day I was also asked to deal with a 38w newborn with exomphalos (not antenatally diagnosed) and faced the challenge of needing cling film which the Neonatal Unit did not have. Fortunately a member of staff was able to get it near the hospital so that we could initiate the immediate management plan for the baby before transferring him to a tertiary centre in Nairobi.

    The parents and patients were incredibly appreciative for what we did and they really made me feel truly grateful to be in the healthcare profession.

   One day I was given an informal tour of the hospital by one of the interns and visited different areas such as the medical wards, emergency room, radiology, maternity, etc. Wherever I went, people wre always smiling and welcoming me to make me feel as if I was at home.

 Furthermore, I delivered a Paediatric Surgery teaching session which I thought it was going to be only for the surgical doctors but it then turned out to be a session for every staff member including the medical director. The session was well received and found helpful despite my initial apprehension.

My birthday happened to be during the mission period and I must say it was one of the most memorable ones. The mission itself and the team I was with definitely made it a very special day for me.

 This charity mission was a fantastic life experience during which I learned how to best utilise the limited available resources to look after patients and allowed me to reinforce my teamworking skills as I interacted with people belonging to a totally different healthcare system.

 I would definitely recommend this experience to any healthcare professional and I am already looking forward to the next mission!

Omar Nasher

SpR in Paediatric Surgery

Hernia International Volunteer

Bewal (Pakistan) Hernia Camp 2019 Report

Steve Lindley

The week leading up going away is normally the time when excitement kicks in, but on this occasion, re-tension of indo-pak relations and the fact that my passport (bearing a previous Indian visa) was sat in the reject pile at the consulate, meant that I was rather anxious.The few days before I was set to leave, my concerns had evaporated. We arrived in Pakistan and convened at the impressive Bewal International Hospital to meet the team.

The team consisted of hospital co-founder Atiq; an ex-pat Pakistani who works in Birmingham, UK as a vascular and general surgeon, his brother; Khaleeq a maxillofacial surgeon who also works in Birmingham and is the hospital’s co-founder, was on hand to assist and arrange much of the logistics to the mission; Richard, a general surgeon from Tasmania, Australia and myself, an enthusiastic General Surgical registrar from the UK. Our anaesthetists comprised of Sahjaad and Zehrin, (UK Consultant Anaesthetists) who tirelessly kept the list running with unwaveringly effective spinal anaesthesia.

 Atiq, Steve, Sahjaad, Richard, outside Bewal International Hospital

Healthcare in Pakistan can be poor, with limited access to good quality services, particularly in rural areas. Most treatment is not free of charge, and so healthcare inequality is significant and the burden of simple treatable pathology vast. The hospital was built in 2010 with money raised in the UK to support a secondary care facility for Bewal, a small town of 300,000 people, 50 miles south of Islamabad. In the months prior to our arrival, we advertised the hernia camp, and patients presented from the surrounding area, were seen and worked up by the hosptials’ resident medical officers in preparation for our arrival.

We set aside 4 days for our 3 surgeons to work into the evening and through the repair of 76 patients with 81 hernias. Hernias included epigastric, paraumbilical, inguinal, femoral, paediatric (inguinal) and one or two recurrent hernias. Almost all of the cases were performed under spinal anaesthesia, apart from the epigastric and paediatric hernias whom had general anaesthesia. To add to the variety, as we were leaving after a long day of operating, we were met at the entrance with a young patient with a bleeding AV fistula. Duty bound, we took the girl to theatre, explored her wound and salvaged her newly formed vascular access. Everyone left with an eve n warmer feeling than the previous days had given us, although significant more tired!

Steve Operating with the hospital’s OPD

Khaleeq assisting Sahjaad perform a spinal anesthetic

The hospital staff who worked with us all week were tirelessly supportive. The scrub team showed unbelievable levels of dedication and hard work: cleaning theatres, sterilising equipment, recovering and discharging patients, time and time again. Without their support, we could not have repaired one, let alone efficiently repaired all 81 hernias. We were also lucky to be visited by several local surgical residents who scrubbed-in and lent a hand.

 The team at the end of the day, still with plenty of food remaining!

The visiting team were hosted like royalty in a new, beautiful, family house across the other side of the town from thehospital. We were spoilt and never left hungry with an abundance of authentic Pakistani cuisine, laid on my an excellent inhouse chef, and visited frequently by friends and family, keeping us going during the working day.Atiq and Khaleeq were kind enough to show the visiting team around Bewal and onto Islamabad. We were welcomed into the local secondary school to observe ‘presentation day’, and were invited to give speeches. We were also received by the local MP for and treated to even more impressive food. Islamabad is a striking new settlement overlooked by the rolling Margalla hills. We spent lunchtime on the last day admiring the views, before rounding off the trip by visiting Rawal lake, the Pakistan monument and Faisal Mosque; the fourth largest mosque in the world.

 A view of Islamabad from the Margalla Hills

Atiq giving a speech to the local school.

Sahjaad, Richard, Atiq and Khaleeq at the Faisal Mosque in Islamabad

 This hernia international mission has proven itself again to be a thoroughly successful endeavour, with a tally of 374 hernias repaired since 2014. The team in Bewal, along with Atiq and Khaleeq have the wheels well-oiled to ensure that many of the local residents have a chance at receiving free, life-changing, safe surgery. From my perspective, this opportunity has been incredible, combining the hugely rewarding experience of contributing to the teams’ achievement of fixing 81 hernias with a thoroughly memorable and privileged tour of Pakistan, the likes of which is not afforded to the average tourist.

REPORT UGANDA Campaign 2019 (16/22 -3-19)

HOLY INNOCENT HEALTH CENTRE, KAMUTUR. Bukedea

Spanish Team, Hernia International.

 Team leader: Enrique Navarrete

Team:

Surgeons: Enrique Navarrete, Pilar Concejo, Cristina Gonçalves, Kiko Marsal

Anaesthetist: Mar Felipe, Meritxell Ojer

Nurses: Emma Dueñas, Isabel Rodriguez, Mayte Huertas

Once more we returned to the Holy Innocent Health Centre; After our mission jointly with Surgeons in Action, in December 2017, our Team organizes with Hernia International a week of cooperation in this “Rural -Based Hospital” founded in 2014 by Moses Aisia and located in the rural village of Kamutur, Bukedea Region in Uganda.

On the 2017 trip, we arrived at the centre in the early hours of the morning after a very long journey, so this time we wanted to spend the night in a hotel near Entebbe airport, and start the last 270 km lap on Sunday. However, Moses preferred the group to continue the trip once passport and customs had been cleared.At 2:30 p.m., we started with our well-travelled van to the HIHC and arrived, with no incidents, around 12pm at hospital, similar to the 2017 trip, very late and very tired. We stopped to eat chicken legs and fried bananas.

For my colleagues it was the first visit to the centre, and for me the second visit to Kamutur.The distribution of the group was different from the previous visit, with part of the Team staying in one of the huts and the rest in rooms in one of the pavilions at the centre. On Sunday 16.3.19 a 6. Am the team began the day at sunrise, going to get water at the well in order to have an “African shower” (shower cube). The well is manual and supplies water to the community.

After breakfast, we started the day organizing the operating theatre in the new pavilion that Moses had built, and which was to be the place where we would spend most of the day during that week. Likewise, the four surgeons began the pre-operative visit of more than 50 patients who came to be examined and assessed or surgery. That same Sunday, Moses had decided that we should start, and after lunch we started the task at the operating theatre finishing the day after 8 pm in the evening. Tired and contented we enjoyed the first dinner at the HIHC.

From Sunday March 16 until Friday at 12 o’clock had operated on a total of 80 patients, mostly with inguinal hernias, with more than 110 procedures.

Prior to the work in the operating theatre, two of the surgeons had visited the outpatient clinic and the other two with the help of one of the nurses had visited the patients who had been operated on the day before to evaluate the postoperative procedure and discharge from hospital.Most of the patients stayed the night and left on the day after they were operated; on only tree patients needed more days of admission, for wound care and intravenous medication. A child with a serious recurrent testicle problem and two adults, one with a large ventral hernia and a another that needed amputation of the first toe for an infectious process with osteomyelitis.

On Thursday night, Moses prepared a “surprise party” with music, buffet and could drinks (it was not usual to have could water or beverages the rest of the week), All the collaborators during that week participated in this gathering including the cooks that were in charge of preparing our meals every days and those of the rest of the staff.

On Friday we programmed the operating room until noon and then started our trip to Entebbe, where we had booked a hotel near the International Airport on Friday, to start our return home on Saturday morning.  The whole group is very pleased with the work we did at HIHC during that mission. We left a lot of surgical material like sutures, meshes, pain-killers, and antibiotics at the Centre for the future missions to use.

Kiko Marsal

Surgeon

REPORT OF TANZANIA CAMPAIGN

23 February-3 March 2019

   Leader team: Eduardo Perea

General surgeons: Manuel Bustos Jiménez , Eduardo Perea del Pozo, Abdul Razak Munchef , Ana Sennet Boza (R5).

Anesthetists: Inmaculada Benítez Linero, Guiomar Fernández Castellano.

Nurses: María del Mar Martínez Gómez, Inés Sánchez Rey

We have found a center very different from last year and in my personal experience also different from the previous campaigns. We have worked in the two centers where Sister Avelina works, being very well received and welcomed at all times.

– We have been quoted by 20 children who have not operated because they do not have anesthetic tools or a pediatric surgeon to ensure an experienced technique.
– The operated goiters (5) have gone without complications and we have all been able to perform a hemithyroidectomy to avoid substitution treatment.

– the major pathology is the hydrocele with a lower percentage of hernias
– Sister Avelina operates daily in the center, therefore the patients recruited were less and with less advanced pathology (large number of hernias M1 and L1 of the class EHS)
– The hospital consists of operating room infirmary, therefore with a nurse who came with us it would have been enough.

On the other hand, the group has worked at the rate you already know, operating 8 to 14 patients a day with a hematoma as the only complication. We have learned from previous campaigns and I believe that having experienced staff has avoided problems and we have improved over last year. It is not up to me to assess my work as the leader of this mission, but the performance of the group in general has been outstanding.

The economic  effort has been somewhat higher, the lodging was not included as in Benin, the tickets and transportation has been more expensive and we have not been able to count on the help of Surgeons in Action or other external aid.

Another issue, however minor, has been media coverage. The mission has been supported by the Virgen del Rocío Hospital and the activity has been published on the networks of the same and those of the Association through Bea with whom he spoke daily.

We have many things to improve, Teresa and Andrew, but overall we are very happy with the people we have been able to help. Hopefully we can see each other soon, meet and prepare new projects together as well as outline the mission of the coming year.

Thanks for the opportunity to collaborate with you. Thanks to you.

EDUARDO DEL POZO

2019 REPORT LIBERIA

MEMORY OF THE MISSION HELD BY “CIRUJANOS EN ACCIÓN” FROM 26/01/2019 TO 02/02/2019 IN THE ESTHER AND JERELINE MEDICAL CENTER OF GANTA CITY (LIBERIA)

This is the second mission I have directed in Ganta City (Liberia) in less than a year and it started at the same moment we came out from there in April 2010 after the first successful one.

We left out many patients without operation, we were very well treated and besides we were left with the thorn that we could not operate women in Liberia with a pathology that is endemic there, the gigantic goiter. From the beginning it was a formidable challenge. The expedition was finally made up by 7 members: Cesar Ramirez (surgeon and team coordinator), Oscar Cano (surgeon), Marta Jimenez (lady surgeon), José Miguel Moran (paedriatic surgeon), Sonia Trabanco (anaesthetist) and Paco Gomez (infirmarian). We started each from his or her city on 26 January (Málaga, Santander, Badajoz, Barcelona, Gran Canaria and Madrid) and we met at the Casablanca airport to take the Air Maroc flight of 23 hours towards Monrovia. After 4 hours flight in a commercial plane with a horrible heat, we arrived at Monrovia at 2.25 a.m. where the Medical Director of the Esther and Jereline Medical Center and alma mater of the local mission, my friend Dr. Peter George, and the main authorities of that center were waiting for us; the Monrovia airport has not changed at all in 9 months, it is as miserable and lacking in security and luggage control, with only one customs gate which works with great leisure. In this campaign we have again had trouble with our luggage (15 bags of 25 Kg each from Málaga including a generator for the electric scalpel and a Ligasure lent, respectively, by Teleflex and Medtronic) and the help received by the from the earth staff in the Málaga airport has been miserable without any understanding of what we were doing and having to pay almost 500 euros for excess luggage to be able to take everything. It is intolerable that they tell you that you have a limit because the plain is small, and then, when you pay, the limit has ceased to exist. 

The way from Monrovia to Ganta City takes almost 3 hours and a half on a rudimentary byroad, and we were on 3 miserable lorries that Dr. George rents for us during all our stay in Liberia. Our place in Ganta City has again been Jackie´s Guest House, the hostal-pension in which we had individual rooms at the price of 50 euros each including breakfast: it is the best in the city and we have hot water, aircondition and one meal of the type “tex-mex”, more than acceptable, which we get for breakfast and super “in situ” and is taken to the E&J Medical Centre at the noon meal time.

There is absolutely nothing to see in Ganta City and no possibility of excursions to places of tourist interest, and so our days were very intense and much repeated. Every morning we met at 7.30 a.m. for breakfast, and half an hour later they took us to the Medical Centre.

The first day there was a large amount of patients waiting for us, about 400 persons who had been recruited the previous days by Dr. George and his E&J-MC, children and adults, and particularly a great amount of cases (almost women) of giant deforming goiter. I had promised them that if they managed to get a working respirator for goiter surgery, we would daily operate tiroidectomies in one of the operating theatres.

Every day one of the surgeons and the pediatric surgeon had at our disposal a small room for consults where we saw the patients, explored them and selected them for surgery. We have not asked for a single preoperatory and patients (children and adults) have been operated upon after clinical evaluation.

The E&J-MC is something similar to what in Spain could be a small ambulatory in which there are two operation theaters with very basic sterility conditions and they arranged two small patients rooms to use as third and fourth operation theaters, so that during a good part of each day we were busy simultaneously in four operation rooms; we were given only one electric scalpel and it was used for children, so that thyroids have been operated upon with Ligasure, and in the two operation theaters in which we operated hernias there were no lights in the ceiling and no electric scalpel, so that we had to operate with the frontal Photophore and in the dark with cold scalpel, ligature and dissecting scissors.

They have practically no material since in the medical centre they only had cesareans, although they are beginning to do some urgent surgery in urgent cases like acute appendicitis. We have taken with us 3 complete sets of surgical material to operate hernias and one for pediatric surgery which we have gifted to the EandJ-MC after the end of the mission; similarly we have used in full the more than 400 Kg of surgical material we had brought since they hardly have any gloves, gauzes, compresses, antiseptics, sterile gowns, sterile camps or apposites (in fact, since our coming they have used our material for their surgical needs). Similarly we had taken with us and donated more than 200 boxes of omeprazole, paracetramole and analgesics for them to use in Ganta City.

During the mission we operated upon a total of 186 patients (45 children and 141 adults) in which we carried out 268 surgical processes; in this way in 74 patients (almost 40%) we carried out 2 or 3 surgical procedures. We were surprised at the great amount of patients with inguinal hernia who had umbilical hernias of at least 1.5-2 cm, and even more as their largest part they were young patients, thin and with apparently good mussels. We have used 80 mosquito nets donated by Hernia International and about 100 nets of low molecular weight which had been donated by BBraun; even so there were more than needed. One of the aspects more remarkable in this mission is that we operated upon 35 total tiroidectomies with giant goiter, and only in one case has a reoperation been needed for disnea in relation with paresia/paralysis immediately recurring, so that the patient could leave without problems after the traqueostomy. We have not had any striking postoperatory hipocalcemia, and we had brought 18000 LT4 tablets which we left with Dr. George so that they can give alternative treatment to patients operated upon in the next year and a half. The patients remained for a night (the hospital some common rooms of 3-4 patients and then a large common ward for men and another for women where at least 20 patients could be accommodated in each) and we examine them at the beginning of each day so that they could be admitted and no problem remains. A patient operated upon for an epigastrical hernia showed a sharp neurological during the operation, had a heart-lung stop and died during the operation. 3 patients have shown minor postoperatory scrotal hematomas which have not needed any special care. Dr. George explicitly asked us to carry out two urgent operations for an ileal perforation and an obstetric hysterectomy for a postpartum atony with massive bleeding, both with a favorable postoperatorion.

The medical and administrative authorities of the E&J Medical Center have given us all possible facilities. We have received, as in the prior occasion, all kind of help and they have tried to make us as comfortable as possible. On the day we came just as in the day we departed they greeted us with local songs and prayers from the local people, and as a sign of thanksgiving they gave us cloths with tribal motives which we’ll keep with much love. They have urged us to come back as soon as possible as there is much need, abd for us it has surely been an unforgettable mission.

NOTE: We thank the Teleflex, Medtronic and BBraun for their contribution to the campaign.

Fr. Cesar Ramirez

REPORT of BANGLADESH CAMPAIGN,   December  2018

On December 1^st at 5:00am we, the 7 members of the team, met in the Madrid airport: Arturo Cruz, Pablo Lozano, José Miguel Morán, Pilar Murga, M José Fornier, Almudena García and Teresa Butrón. We plastified the bags and posed for the photo before the check in. In Barcelona the two other members, Ingrid Tapiolas and Nuria Ridaura, did the same. We all met in Doha, and flew together till Dakar, capital of Bangladesh, we collected our luggage and went to the national terminal where we had again a checking and we had to explain that we carried our surgical instruments plus a diathermic machine. The certificate about our participation in a humanitarian campaign was very useful. Finally on December 2 we landed in Chittagong, went through customs without problem and met Nasreen Baqui, Director and owner of the hospital, and a cousin of her.

We went to the hospital situated in the outskirts of the city, a 4 floor building which is chiefly used for the rehabilitation of handicapped persons: it is low and has some beds, the first section is for consults, in the second there are 2 operation theaters and 2 presurgery rooms, and the third has about 12 beds for hospitalization. The main surgery room has a ceiling lamp with one arm, and other standing up, plus 2 pre-surgical tables, and a third one with a room with about 12 beds. The main surgical room had a ceiling lamp with one arm and another standing up. Besides are added 2 surgical tables, a respirator with ECG which we found on the last day and O2 canister plus 3 scalpel generators. The gas they use is halothane.

 In the next room we placed 2 stretchers and precarious lamps which had to be made up for with forehead lights. The other two rooms are used as pre and postsurgical. We divided ourselves this way: Lady nurses placed all the material with the help of Pilar, our anesthetist nurse, who was very much in demand. The rest of us went to see patients in three rooms with the help of volunteers: medicine students of 3, 4, and 5 year, hospital doctors supervised by Dr. Sayad Boksha (Physician at Chattagram Mas-O-Shishu Hospital Medical College, Bangladesh), in charge of the campaign and responsible for it, who was of great help during the whole campaign helped by…

We finished the day with a common meeting to organize team work for the next days, and we drew the surgical plan for the next days and the shift to the Well Park Residence hotel at 29 minutes from the hospital. The first day we met with the volunteers to examine the instrumental and to organize the sterilization in hernia kits. The whole instrumental was in a container. The have a vertical autoclave.

We started operating 14 patients on 2-3 tables (16 procedures) which we combined with the usual consults with the help of voluntaries who translated from Bengali to English, and we finished the day organizing the groups for greater efficiency and preparing the instruments kit for best waiting times between interventions. The next days everything was more fluid, we distributed work and so some examined patients while others began operating, and one examined patients till we could begin with another in another operation theater.  Thus in some moments we operated upon 4 patients at a time. We stopped on Friday as Fridays are feast (like our Sundays) and we had some excursions with the volunteers in the river.

The next 4 days we continued operating with a good rhythm attending to 138 patients, 42 of them children, with a total of 155 procedures. We did have morbidity on the last day: a hematoma that did not require revision and a urinary retention that required catheter, reintervention of a child of 18 months for hematoma that acquired a bradycardia and he was translated to a hospital. He recovered satisfactorily.

OTHER ACTIVITIES: The excursion in the river, with lunch, supper with volunteers in several restaurants to enjoy Bangladeshi food. The last day there was a farewell party in Nasreen’s house, the volunteers brought some dished we all enjoyed, diplomas were given, also thanksgiving speeches and many photographs. The campaign ended with good feelings for all.

POINTS TO KEEP IN MIND:

–         The organization was complex. Nashreen answers more whatsapp, and only occasionally emails. Although at the end everything went well.

–         Preparation of instruments: They had sets of hernias but all together in a bottle without any separation. It would be convenient to put them together: 4 camp clothespin, 2 separators, 4 Crile forceps, 2 dissection forceps, one scalpel, and 1 needle-holding. Thus they could be sterilized and they would allow for an efficient change of patient.

–         The respirator has an ECG monitor which appeared on the last day. Halothane gas which we do not use.

–         It is a rehabilitation hospital with operation theaters little used, and it has few dressing gowns.

It has a vertical autoclave with a 1-2 hour cycle.

FARAFENNI GENERAL HOSPITAL

REPORT ON HERNIA INfERNATIONAL MISSION (SLOVEVENIA

& UK TEAM) TO THE GAMBIA

12th – 16th November 2018

Compiled By

Farafenni General Hospital Management Farafenni

North Bank Region The Gambia

20th November 2018
BACKGROUND

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 the November 2018 Mission began in May 2018 with a show of interest contained in an email addressed to Dr Andrew Kingsnorth coordinator for Hernia International from the November 2018 team leader Dr. Tomaz Benedik. The team includes; 3 General Surgeons and a Nurse from the United Kingdom and 1 Surgeons. 3 Anesthetists. 2 Nurses and a Meidical student from Slovenia making up a 11 member team.

OBJECTIVES

The objective of the November 2018 mission were:

1.     To offer surgical services mainly hernia but not limited to hernia alone but patients needing surgical care including children.

         2.     To reduce the backlog of patients on waiting list for surgery at Farafenni and other facilities in                   the Gambia.

PREPARATION

Clearance for the mission was obtained from the Office of the Director of Health Services. Ministry of Health & Social Welfare dated 2nct February 2018 and the necessary formalitirs for temporal registration with the Medical & Dental Concil of the Gambia and the Nurses & Midwives Council of the Gambia. The Hospital Management established a local support team including 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 using the local radio and influential community members.

3. Logistics, Identifying and mobilizing the required resources needed for the mission and these includes; medical supplies. drugs and personnel.

 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 and Catering Unit.

SUPPORT FROM MANAGEMENT

To achieve a successful camp. Management ensured that:

1.     The visiting team’s movement was well coordinated with support from the office of the Director of Health Services by providing transportation from the Airport – Hotel and to Farafenni and back to the Coast after the completion of the mission.

2.     The visiting Doctors and Nurses were cleared through the Ministry of Health and the Councils.

3.     Drugs and supplies needed for the camp were made available by the visiting Hernia team and the Hospital.

4.     Staff identified (local team) were available at all time (SAM – 9PM daily) during the course of the surgery.

5.     Food and water was available to avoid interruption of services by providing lunch for the local staff while a hospital cook prepared meals for the visiting team.

OlITCOME

The November 2018 International Hernia Mission operated on 48 patients with 49 conditions with 1 person being operated on for 2 surgical conditions. Of the total cases performed, hernia represents 69.4%; Lipoma 2%; hydrocele 6.1%; and Keloid & Csyst 22.4%. Of the total patients operated on 42 (87.5%) were males and 6 (12.5%) were females. Gambians represents 97.9% of patients and non-Gambians accounted for 2%. Children under the age 5 represents 6.3% of all patients operated on.

SEX	NATIONALITY	CONDITIONS	AGE DISTRIBUTION
M	F	Garn	Non-Garn	Hernia	Lipoma	Hydrocele	Keloid& Cyst	< Syrs	> Syrs
42	6	47	1	34	1	3	11	3	45
87.5%	12.5%	97.9%	2%	69.4%	2%	6.1%	22.4%	6.3%	93.7%

Table above shows summary statistics of the November 2018 International Hernia Mission

 CONCLUSION

The Mission was a success despite the drop in the number of cases registered from 51 in March 2018 to 48 in November 2018. However, given that from October 2016 – March 2018, Hernia missions to this hospital have operated on a cumulative number of one hundred and eightyfive

(185) patients mainly hernia, registering 48 for this mission is a significant milestone and thus and indication that hernia cases have drastically reduced in our communities. I must also acknowledged the continuous transfer of skills and knowledge between the visiting team and our local team.

SUMMARY OF HERNIA INI’ERNATIONAL MISSIONS Oct 2016 – Nov 2018

Dates	Mission	Team Leader	No of Patients
22nct _ 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
Total	233

The Hospital Management would like to register appreciation to the Slovenian and the British 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 Ministry of Health through the Diretor of Health Services (Dr. Mamady Cham) who was with us all through the process for the technical support and encouragement.

 20th November 2018The Mission was a success despite the drop in the number of cases registered from 51 in March 2018 to 48 in November 2018. However, given that from October 2016 – March 2018, Hernia missions to this hospital have operated on a cumulative number of one hundred and eightyfive (185) patients mainly hernia, registering 48 for this mission is a significant milestone and thus and indication that hernia cases have drastically reduced in our communities. I must also acknowledged the continuous transfer of skills and knowledge between the visiting team and our local team. 

SUMMARY OF HERNIA INI’ERNATIONAL MISSIONS Oct 2016 – Nov 2018

Dates	Mission	Team Leader	No of Patients
22nct _ 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
Total	233

The Hospital Management would like to register appreciation to the Slovenian and the British team for an excellent job , to Dr. Andrew 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 Ministry of Health through the Diretor of Health Services (Dr. Mamady Cham) who was with us all through the process for the technical support and encouragement…

20th November 2018

Report of Liberia Campaign November 2018

INTRODUCTION

The Liberia Campaign was proposed at the end of 2017 by the Cirujanos en Acción Foundation and without any doubt it has been a challenge and a great effort during the previous months, as we had to overcome difficulties in the recruitment of voluntaries, logistic problems as obtaining a large amount of medical and surgical material necessary for our work as the Ganta Hospital lacks all necessary means. The initial budget was very high with the visas, flights, life insurance, lodging and food for the whole team, the voluntaries themselves, the Cirujanos en Acción foundation and the donation of the Fundación Navarra “MuchosPocos” made up by workers and the Direction of the engineering firm M. Torres, a great example of social corporative responsibility. Transportation and the compulsory medical registration compulsory in Liberia were taken up by the Ganta Hospital. 

Liberia is a country in Africa’s west with a 4,5 million inhabitants; its capital, Monrovia, has 1’15 million inhabitants; 84% live under the international poverty threshold (less than 1,25$ per day), and it occupies the tenth place in the poorest countries on earth, with an annual rent per capita of 683 $. The greater majority of its population is Christian (85’5%), and English is the official language, although 16 other languages are spoken. Its legal course coins are the Liberian dollar (1 LRD = 100 cents) and the American dollar, only banknotes. 5% of its population is made up from 2003, although its social and economical by “americo-liberians” or “congos”, descendants of liberated old slaves for the United States, and 95% are Africans from diverse ethnic groups.

Their recent history included two civil wars (1989-2003) with the result of 200.000 dead and 1 million refugees. At present there is peace from 2003, although its social and economical recovery was threatened by the largest epidemics of Ebola (2014-2015), in which more than 4.500 persons died, 300 of whom were doctors.

Ganta City is a place in the Nimbacounty, 5 hours from Monrovia, the largest and more populated of Liberia. The largest majority of its people live in miserable dwellings. The access to Gantha is by a road, recently constructed by a Chinese firm, and it takes 5 hours from the airport.

VOLUNTEERS

This has been the fourth Campaign in Ganta City, after the one organized by a Hernia International team in July 2017 by a Hernia International team, and two more later by the teams of Dr. David Fernández Luengas in September 2017 and Dr. Cesar Ramirez in April 2018, both from the Surgeons in Action Foundation. This is a humanitarian service with great medical needs and with the organization and collaboration of local people.

We seven volunteers belonged to the Fundación Cirujanos en Acción, and we come from México DF, Madrid, Segovia and Navarra:

·        General Surgeons

o   Dr. Manuel Cires Bezanilla, Estella Hospital, Navarra (Team Leader)

o   Dr. Sandra del Barrrio Anaya, General Hospital of Segovia

o   Dr. Estefanía Villalobos Rubalcaba, Medical Center ABC, Mexico DF

·        Paediatric Surgeons:

o   Dr. Lola Delgado Muñoz, 12 de Octubre University Hospital, Madrid

o   Dr. Jesús Redondo Sedano, 12 de Octubre University Hospital, Madrid

·        Anesthetists:

o   Dr. Fabiola Ortega Ponce, Medical Center ABC, México DF

o   Dr. Inmaculada Lahoz Jimeno, 12 de Octubre University Hospital, Madrid.

In collaboration with the “E&J Medical Center”, which helped in the surgical, hospital and consultation areas, I want to underline its capacity for work and collaboration. It has only three specialist doctors, Dr. Peter George, medical doctor and specialist in Ginecology and Obstetrics, who helped our stay, even if we hardly met him during our Campaign, De. Abenago, anaesthetist, and Dr. Jonas, General Surgeon, helped by Jhonson, anaesthetist technician and four nurses and helpers, Ruth, Othelo and Leon, as well as nurses and helpers in consultation and hospital work.

We carried 300kg of medical-surgical material in 12 large parcels, each prepared by volunteers in their hospitals; and controls at the Madrid-Barajas airport were made easy by the kind staff of the KLM; in the Monrovia Airport we were helped by the customs officials and the collaboration of the staff hired by Ganta Hospital staff for shifting our luggage and for going to Ganta in two vehicles with the kindness of its driver Junior.

The campaign lasted from 2^nd to 10^th November 2018. On Friday 2^nd we started from Madrid for Monrovia via Amsterdam in the KLM airline, and we then were taken to Ganta city in a van; on Saturday 3^rd we were given a warm welcome by the patients and staff of the Hospital in pure Godspel stile; we visited the different facilities of the Hospital and two work groups were established, one for the evaluation of the selected patients, and another to put in order and to classify all themedico-surgical material as well as the organizing and preparation of the four surgical rooms.

On Sunday 4^th and till Thursday 8^th we carried out five intensive surgical sessions from 8^th to 19^th, together with the daily visit to patients already upon and the evaluation and selection of new patients. Finally on 8^th Friday we carried out our last visit, dismissed all the patients already operated upon, and attended the touching farewell of the hospital staff and patients. Then came our travelling back to Monrovia and arriving on Saturday 10^th in Madrid.

Apart from the intense activity in the hospital which took up a great part of our time, we met in the Jackies Guest House, a simple hotel but with good cleanness and safety. It has a wifi net an a supermarket. We met there with people from other international organizations. Still, its high prize (50 shilings per room daily) apart from the breakfast and supper price rises heavily the campaign budget. Perhaps another cheaper place should be sought.

E&J Medical Center

It has a basic Laboratory, pharmacy, rooms for adults and paedriatics, urgency room, delivery room and two operation theaters. It has very limited means, and it makes up its deficiencies with the abundant material we brought with us like gauze, compressed, surgical gloves, exploration globes, dressing, sterile gowns, anaesthetics polietilen mesh (supplied by Hernia International Foundation) and antiseptics, suture instruments, electrical scalpel and its slab among other things.

It is necessary to mention that without this material it would be impossible to carry out a campaign in Ganta or in any other humanitarian place; if we consider the large number of interventions carried out we can see the large amount of material needed. We could perhaps think whether it would be better to buy the necessary material in the place of work, thus avoiding the difficulties of its transportation, the customs control, and ever growing difficulty of obtaining such things in our hospitals.

SURGICAL AREA

The surgical activity took place in four rooms, three for adult surgery and one for paediatric surgery.

Two rooms belong to the surgical aria of the Hospital: there is question of two basic operation rooms which an unusable room, as there is no oxygen neither anaesthetical gases. They do have two rooms in the surgical area of the Hospital, there is question of two basic operation theaters which have a not usable anaesthetics material as there is neither oxygen nor anaesthetical gases. They do have concentrators of oxygen and basic monitorization systems (blood pressure, heart frecuency and O2 saturation). They have their own electrical scalpel generator and operation theater tables and proper lights: although electric power is relatively stable,it is indispensable to have light source on the forehead to help. The paediatric and general Surgery worked in this area.

The other two surgical rooms were put up in two small rooms with very elementary means and surgical instruments; two electric scalpel generators belonging to the Surgeons in Action Foundation and insufficient head light depending always on our front lamps.

There are several batches of surgical instruments in acceptable conditions. We brought surgical instruments for adults as it is absolutely necessary if we want to work on a high number of patients.

Sterilization of material is carried out in an elementary autoclave. We used disposable surgical cloths as they hardly have any gowns or surgical cloths.

ACTIVITY

Number of procedures:

210 interventions during the campaign (more than 40 interventions per day).

80 interventions in child surgery

·        61 M, 19 F

·        51 inguinal hernias

·        24 umbilical hernias

·        5 others: circuncitions, hydrocele, haemangioma

·        More frequent technique: intracanalicular

·        General anaesthesia: Ketamine

130 interventions in adults surgery

o   M 92; F 38

o   95 inguinal hernias (70 M; 25 F)

o   19 umbilical hernia ,

o   11 epigastric hernias

o   5 Others: femoral hernias, angioma, apendicitis, suprapubic catheterization, retirada de malla por rechazo

o    More frequent technique:

Hernioplastic of  Lichtenstein.

o   Epidural anaesthesia

BUDGET:

The Ganta City campaign has a budget higher in comparison with other places, due to the high cost of the VISA, airfligth ticket, lodgin and maintenance.

In the budget we have not taken into account the cost of the surgical material, contributed by the volunteers.

                 TOTAL COST OF THE CAMPAIGN (VISA+AIR TICKET+HOTEL+MAINTENANCE):          11.000€

COST PER VOLUNTEER                                                                                                         1500 €

 Dr. Manuel Cires

 Leader of Ganta City Campaign

Surgeons in Action Foundation

GATUNDU, KENYA – NOVEMBER 2018 REPORT

The town of Gatundu, population around 20,000, is situated in the central highlands in Kiambu county. This was the 8^th Hernia International mission to Gatundu Hospital and the 4^th to take place in the Chinese funded and built hospital extension which was commissioned in April 2016. The mission took place between Monday 19^th and Saturday 24^th November 2018.

An International Team

Fernando Di Santiago Urquilo               General Surgeon Spain

Jane McCue                                               General Surgeon UK

Leo Mitteregger                                        General Surgeon Austria (including Children)

Tim Walker                                                 Anaesthetist UK

Kay Wandless                                            Theatre Sister UK

Leo is a seasoned veteran of Hernia International trips (HI). Fernando and I met Leo on our first time with HI at Farafenni in 2017 and decided to work together again. Fortunately, we were able to persuade my UK Anaesthetic colleague Tim to accompany us and felt the team was complete when Kay Wandless also decided to join us. 

Preparations

It was only about eight weeks before we started that the mission was actually confirmed. Once this occurred communication with the Hospital Superintendent, Dr Simon Gitau was always prompt and helpful. He was happy to provide an official letter of invitation to help smooth any approach to the authorities.

Our team set about compiling a list of supplies to take with us.  These included: sutures, diathermy accessories, spinal needles, surgical instruments, wound dressings, antiseptic products, gloves, masks, gauze, headlamps and 2 portable monitor/pulse oximeters. 20 sterilised meshes were provided by HI and a large quantity of unsterilized mesh with instructions for sterilisation to take place at Gatundu Hospital. Leo organised a fundraising event in Austria and consequently purchased a large supply of quality surgical instruments. I visited a healthcare company in the UK and they were kind enough to donate a range of infection prevention products. All other supplies were provided by the individual team members, or with permission, from their own employers.

On previous missions we have taken medication with us but having read of the difficulty encountered by a previous team at Nairobi airport and knowing of the Kenyan government clampdown on counterfeit goods I was keen to obtain permission before we travelled. Disappointingly, repeated attempts to gain approval with the Kenya Embassy in the UK, the Pharmacy and Poisons Board in Nairobi and even the British Embassy in Kenya were unsuccessful. Fortunately obtaining our e-visas was much more efficient.

Sadly, and to the disappointment of everyone , just two days before our departure Kay fell down stairs and sustained a fracture which meant that she was unable to accompany us. Some last minute rearrangements did enable us to take the supplies she had gathered with us.

Our Journey

Tim and I flew direct from London to Nairobi on British Airways and met Leo who had travelled on Kenya Airways via Paris.  We all used our full 46kg baggage allowance (plus hand luggage) but encountered no real difficulties at any of the airports except that one of Leo’s cases (the one with his clothes in!) was delayed by 24 hours. Cyrus who was our driver for the week, provided by the hospital, was waiting for us with his jeep.

Fernando was due to arrive the following morning and I was a little concernedwhen after waiting some hours he had yet to appear and was uncontactable. The thought of losing two team members in two days was concerning. What had actually happened is that the flight arrived early and on emerging from the terminal with the words Hernia International emblazoned on his case an enterprising local woman announced to him that she was his driver and was going to take him to his hotel! 

The Morning Commute

Each morning at 7.30 our trusty driver Cyrus arrived to transport us to the hospital which was about 25 minutes away. The journey itself was a real highlight as we drove up through fertile farmland and beautiful lush rainforest. It also enabled us to see the conditions in many of the villages we passed through which was a contrast to much of Nairobi. We were stopped at a police roadblock one morning but when the Inspector realised our business he saluted us!

The Surgical Facilities

At first glance the facilities look far superior to those in many hospitals where HI operates but the Chinese left without any handover to the Kenyan staff. Not yet open for two years the building is already showing signs of age and there are many systems that have either never functioned or have broken cannot be maintained by the staff. We unpacked our supplies on the Monday morning in the room we had been allocated. Stupidly, I had left the key to my own case at home but ultimately I managed to break into it and remove all the supplies.   We used two wards, one for the men and the other for both women and children . Patients were admitted to the ward the night before the procedure as many had travelled from a distance. 

Both operating theatres were spacious. Reading through past HI reports you can see that things have improved in Gatundu theatres in the past two years. There was a constant supply of electricity, both diathermy machines were working and the operating lights were sufficiently good to operate without headlamps even though only one out of two lights were functional in each theatre. Anaesthetically it was more challenging as most piped gases were not working.The recovery facilities were basic. It was essentially a room across the corridor from the theatres where you could plug in a portable monitor but without suction and frequently unattended by staff.

Daily Routine

We rapidly settled into a daily routine arriving at the hospital around 8am to complete the assessment and marking of the pre-operative patients, to review the previous days post-operative patients and then start operating between 9-9.30am. We operated all day and before leaving the hospital checked the patients we had operated on and started the assessment on the next day’s patients. Most pre-operative assessment were carried out by Tim and Jane.The day in theatre was briefly interrupted for chai and arrowroot around 11am and then lunch around 1.30pm. Lunch was delicious and usually beef stew or ginger chicken with rice, chapattis, coleslaw with bananas to finish. 

On Friday, our last day of operating we arrived in the hospital to find out that the entire operating suite was locked and the single access card locked inside. A lengthy delay ensued and it was only thanks to Tim’s ingenuity that we were able to access a computer with operating instructions largely in Chinese to programme a new card!

The Staff

The staff were great and a pleasure to work with. All had volunteered to participate in the mission on days when they were not scheduled to be working. They were uniformly friendly and willing to work hard. 

Ruth led a team of non-medical anaesthetists and each day whilst Tim was busy in one theatre the anaesthetics in the other theatre, spinal or general, were capably administered by one of the team.Weru was the nurse in charge of the paediatric theatre and David the adult theatre. They and their teams rapidly adapted to working with us.  We were fortunate to have two medical interns, Fionah and Roy and a physician assistant assigned to us for the week. All were bright and enthusiastic and it was good to work with and teach them. The two ward sisters were experienced and there was some continuity throughout the week as one attended the paediatric rounds and the other, Mary, accompanied me on the adult rounds. 

Case Mix

The cases had been screened and selected by the local junior doctors. Regrettably around four patients with hiatus hernia had been scheduled for a Nissan’s procedure. None of the team felt this was appropriate given the facilities and so these patients were cancelled. Another three patients were cancelled – two boys with undescended testes who need further scanning as there was no palpable testis in the groin and one adult patient who had a significant thrombocytopaenia. All the remaining patients who had been recruited were operated on. Most patients spoke English which made consenting easier than in some other HI locations.  In total 55 surgical procedures were performed on 48 patients. All bar two of the paediatric procedures were performed by Leo whilst Fernando and I shared the adult cases. 

Surgical Procedures
Adult	Child
Inguinal hernioplasty (of which 1 recurrent)	11	Umbilical herniorrhaphy	16
Incisional hernioplasty	4	Orchidopexy	9
Epigastric hernioplasty	4	Inguinal herniotomy	3
Para/Umbilical hernioplasty	3
Femoral hernioplasty	1
Jaboulay procedure (hydrocele)	3
Excision of giant lipoma	1
Total	27		28

 The case mix varied somewhat from other missions in that there were more obese patients and a higher proportion of incisional hernias, one of which was huge and required the suturing together of several meshes. One histopathology specimen was processed by a colleague of Fernando in Spain, as the patient was unable to afford for this for this be done in Kenya. Luckily, considering the excised specimen contained some suspicious elements, the report was benign.

There were no returns to theatre and all patients were discharged promptly at the expected time. The final patient review took place on the morning of Saturday 24^th November and no short-term complications had been detected by this time.

During the week we were also asked to see two neonatal patients. One baby had gastroschisis and after implementing the initial advice we gave the baby was transferred to the Children’s hospital in Nairobi for definitive treatment. The other baby who appeared to have a congenital syndrome which would present anaesthetic difficulties along with an inguinal hernia was also for referral to the same hospital.

Education

As we were a small team running two theatres our educational effort was not delivered formally but during our clinical activity and focussed on the following areas:

·        Upskilling the staff about pre-operative preparation

·        Establishing the WHO checklist in theatre for every case

·        Updating the non-medical anaesthetic staff·        Teaching basic surgical skills to the junior doctors

 Issues

·        There needs to be clarity of expectation over case mix which should be confirmed ahead of each mission.

·        Whilst there was a large volume of supplies left from two previous hernia camps which may have been useful it was kept is a state of complete disorganisation and at risk of expiry before use. If we had been at full complement in our team we could have made progress on this area.  

·        Unfortunately, attempts to sterilise the mesh at Gatundu were unsuccessful probably due to a lack of calibration of the autoclaves which rendered the temperature control unreliable and alternative arrangements will need to continue. 

·        There appears to have been no handover process from the Chinese contractors to the Kenya staff. As a result there are systems in the hospital that have never worked and there seems to be no effective maintenance programme.

Accommodation

We stayed at Bubbles Hotel between Thika and Gatundu about an hour’s drive from Nairobi. There are eight recently built en-suite rooms situated in lovely gardens and surrounded by coffee plantations. There is a bar, restaurant and swimming pool and they took security seriously. All the food is cooked freshly which meant that whilst it was of a good quality it did take a while to arrive. We got around this problem by ordering off the dinner menu at breakfast time and then saying what time we wanted to eat that evening.  The staff were incredibly friendly and really wanted us to have a good time during our stay, so much so that on our last night there they treated us to an African BBQ feast. We sat out late, warmed by a brazier, eating far too much and drinking African “wine” a very palatable, but potent, mix of alcoholic fruit juice and honey. We looked forward to getting “home” in the evening (and the cold Tusker that was waiting for us). The hotel is good value and we would strongly recommend that future teams stay here.

On Saturday 24^th we departed for Nairobi with a short stop at Thika waterfall on route. Nairobi is a vibrant, and in parts, affluent city. The Nairobi National park was well worth a visit – even in the rain! Those who were able to stay a little longer travelled to Lake Naivasha for one night. What we saw of Kenya really was beautiful.

Summary

It is well worth continuing the link with Gatundu Hospital. The arrangements worked well, the staff were very willing, friendly and hard-working and the patients extremely grateful.  We were sad to say goodbye. This is a good place for someone embarking on their first trip with Hernia International.