Author: akingsnorth

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. 

Report on Hernia International Mission

to Aligarh, India 2018

 This was the first Hernia International mission to Aligarh, India. We were hosted by local Rotarians. We operated at the RUSA Medical Center in Aligarh. The Rotarian physician owners of the hospital were very generous in their support of the mission.

 The team consisted of the following:

Peter Bystricky, surgeon (Czech Republic), Stepan Matoska, surgeon (Czech Republic), Paulina Mysliwy, anesthesiologist (Poland), Denis Blazquez, surgeon, Teresa Ota, anesthesiologist (United States), Peter Novak, surgeon (United States), Scott Leckman, surgeon (United States)- Team Leader

 Conditions were good. We were given an entire floor at the hospital. There was a pre-op ward, three operating theaters and a post-op ward. Patients were kept overnight with a few exceptions who stayed longer. There was one electrocautery unit for the three operating rooms. Anesthesia for children was ketamine. Local and spinal anesthetics was used for adults.

In the five and one-half days, we operated on 80 adults and 14 children. There were 86 inguinal hernia repairs, 1 recurrent hernia repair, 8 umbilical hernia repairs, 4 incisional hernia repairs, 2 recurrent incisional hernia repairs, one hydrocelectomy, one epigastric hernia repair, one femoral hernia repair and one evacuation of post-op hematoma (complication). So, a total of 105 procedures in 94 patients. At one month, there was one known complication, a wound hematoma, which was treated with evacuation.

 In the evenings, after operating, we were hosted for dinner by local Rotary Clubs at which we were able to socialize with people of Aligarh.

We would like to thank Rotarian Rahul Wadhwa for spearheading the effort. We greatly appreciate the Rotary Clubs of Aligarh City, Royal, Pride, Smart City, Diva, and Rudra for their support in making this a successful endeavor.

Northern Irish Team

Korogwe, Tanzania

November 2018 

November came and so we embarked in our mission to Korogwe , Tanzania, the 11th mission of Hernia International to this wonderful part of the world. Our team was composed of 4 surgeons, 2 anaesthetists and 4 theatre nurses.

Surgeons:

Mr Aleksander Stanek-TEAM LEADER, Consultant General Surgeon, Northern Ireland, UK, with a vast experience in organising and taking part in hernia missions in Sub Saharan Africa.

Mr Gregory Wirth, Urology Surgeon, Switzerland, several times volunteer with Hernia International.

Ms Gergana Racheva, Paediatric Surgeon, England, UK, 1st mission.

Ms Cristina Croitoru, Surgical Registrar, Northern Ireland, UK, my 3rd mission.

Anaesthetists: 

Dr Patrick Stewart, Consultant Paediatric Anaesthetist, Northern Ireland, UK, 2nd mission.

Dr Tilman Yue, Anaesthetist, Switzerlands , 1st Hernia International mission but with previous experience in missions in areas of military conflict.

Theatre nurses:

Hazel Dineen, Tanya Vance and Helen Sheridan from Northern Ireland, UK, 1st mission.

Maelle Achard, Switzerlands , 1st mission.

Our mission began in Dar Es Salaam, biggest city in Tanzania, where we all meet on Saturday 10th of November after flying from different corners of Europe. Or, actually, it began nearly a year ago when we started to prepare, to gather equipment, to obtain registration with the Tanzania’n Medical Council and to arrange all the logistics needed for a successful Hernia International Mission. Our person of contact, was Sister Avelina Tempa, Surgeon and Sister with the Catholic Order of Sisters of Usumbaya, who works in both Korogwe Hospital and St. Joseph Healthcare Centre, part of the Convent, which we had the pleasure to visit in our last day.

We left the hotel in Dar Es Salaam Sunday morning and we traveled for 6 hours (with stops) in an air conditioning bus , arranged by Sister Alina Tempa, to Korogwe, 281 km north-west.

On arrival to Korogwe we headed directly to the hospital where we were greeted by Sister Avelina, the Medical Director of the Hospital and the rest of doctors and administrative staff.We the set on to arrange all the equipment that we brought, see the patients for next few days, prepare the theatres and make the operating lists for the next morning. After dark we returned to the White Parrot Hotel for a cold Tusker Beer and a well deserved rest. The White Parrot Hotel is 30 minutes walk from the hospital, 10 minutes by car or Tuck-Tuck. It is clean, has hot water showers and a a decent food buffet, all for roughly £20 a night. The restaurant is outside so DEET is essential.

The next day most of the team went to The Korogwe District Council to meet the government officials and sign in in the Republic of Tanzania Visitors Book. For Mr Stanek, Dr Stewart and myself this was our 2nd mission to Korogwe.

After being there in May 2017 we desperately wanted to return and try to improve the quality of the service we delivered to the people from Korogwe and Tanga area who came to the hospital for our help. The issues we tried to address this time around were:- Oxygen-as there was a shortage of Oxygen last year we contacted a company that deliver two tanks of oxygen to the hotel in Dar El Salam and we successfully transported it to Korogwe.

–     Repairing one of the anaesthetic machines donated to the hospital by Spanish Rotary club. Unfortunately despite Dr Stewart’s best efforts the machine functioned only for a few hours so he had to use one of the old anaesthetic machines that uses Halothane as the anaesthetic gas.

–     Recovering the patients. As the hospital doesn’t have an official recovery room with the help of our wonderful Theatre nurses and monitoring -pulse oximeters (£10 on ebay) we managed to successfully recover all patients prior to returning them to the ward.

–     Introducing patient safety tools: WHO Surgical safe list, Patient Identifier armband, patient Hernia surgery information leaflet.

–     Delivering teaching to local staff, especially in performing Hernia repair under Local anaesthesia.

 On Monday at 8.00 am our work begun. We had 3 running operating theatres. Two bigger ones with AC for paediatric surgery done under general Anaesthesia and for large Inguino-scrotal hernias and hydroceles done under spinal anaesthesia. The 3rd theatre, slightly smaller, with a functioning fan, was used for Hernia Repairs under local infiltration. This theatre was the emergency theatre so we had to stop in our work and make room for several emergencies: C-sections, appendicectomy, performed by local doctors.

All patients came to theatre with their notes, an identifier (hand written white tape) and the children were accompanied by their parents . During almost all surgeries a WHO surgical list was filled in.All patients received pain relief (blister of Ibuprofen/Paracetamol) and a Hernia Repair Information Leaflet in both English and Swahili.

During 5 days we managed to operate on 62 patient and we performed in total 75 procedures, as some patients had bilateral pathology or a combination between hydrocele and hernia. There were 24 children operated on, all under general anaesthesia and 38 adults, 21 operated under spinal +/- sedation and 17 under local anaesthesia. Except from the halothane anaesthetic gas, most of the anaesthetic drugs were brought over by our two anaesthetist, Dr Stewart and Dr Yue.

Out of the 75 procedures the majority were Inguinal and Umbilical or paraumbilical hernias. There were 8 epigastric hernia repaired and 14 hydrocele repairs. We had one patient return to theatre after an inguinal hernia repair for bleeding, haemostasis was achieved under local anaesthetic and he was discharged several days later.

We also managed to teach the local staff and provide them with the equipment to carry on reforming hernia repair surgery, especially under local anaesthetic, outside of the missions.Our theatre nurses, Tanya, Hazel, Helen and Maelle , provided teaching on preparing the surgical trays, instruments, swabs and needles count at the end of each surgery and postoperative recovery. We also learn some new tricks ourselves .

Our anaesthetic team also helped in 2 Cesarian sections , one for twins, and a below knee amputation for necrotic foot, procedure done under spinal anaesthesia.During our week in Korogwe we were joined by a group of medical students from Denmark who were there for their elective. They joined us in theatres helping with everything they could including assisting in surgery. Medicine proved again to be a common language for us all.

It was an exhausting, hard working week but very rewarding both professional and personal. We all worked as a team, learning from each other and improving each others practice. Performing safe surgery is achievable in any environment by using simple and general applicable tools and that has been our aim during every mission.

As per the local team-no patient was re-admitted due to post operative complications.On the last day we were invited by Sister Avelina to St. Joseph Healthcare Centre, part of the Convent, where our anaesthetic team was consulted in repairing one of their anaesthetic machines. This is a very nice hospital located deep in the Tanga Region Forest and provides different medical services from paediatric and Maternity care to Hernia repair, appendicectomies, lumpectomies and emergency laparotomies.

On our way to the hospital we stopped at a local school where we had the honour to bring a smile on so many faces with the help of the donated toys by our colleagues in our home hospitals and the sports equipment donated by O’Neills company and organised by our team leader, Aleksander Stanek.There were so many children at this school, and even though they very much appreciated our gift, it felt so little.Sister Avelina invited us as well for a lovely lunch at the convent and with the help of the nursing staff at the hospital , who baked a lovely cake, we celebrated the birthday of our paediatric surgeon Gergana.

On Saturday morning we said our goodbyes to Korogwe, and to Dr Wirth who went to Dar Es Salaam, and we all embarked on a trip to Arusha, circa 8 hours north from Korogwe, transport being organised , again, by Sister Avelina. The greater part of the team organised a safari as a perfect ending to a Hernia International Mission in Tanzania.

The 11th Hernia International Mission to Korogwe, was, in my opinion, a great one. An unequaled experience, with a wonderful group of people who put in their time, professionalism, humour and motivation to promote health in a remote part of the world.

As we all got back to our homes and, to quote one of the team members, “enjoyed a glass of tap water”, I can only speak for myself but sure I am not the only one, started to think on our next adventure.

For all the team,

Dr Cristina Croitoru

Report: Makunda, India. November 2018

Dominique Robert, Consultant Surgeon (Head of mission)

Team : Dominique Robert, Rob Bohmer and Jurij Gorjanc

Makunda is in Bazaricherra, Assam, IndiaMakunda hospital is a missionary hospital created 25 years ago by Ann Miriam and Vijay Anand Ismael, in the southern part of Assam, near the border with Bengladesh, from a derelict dispensary to a 150 bed hospital which has now paediatric and adult intensive care, adults wards, a large maternity coping with 5000 deliveries a year and 1500 caesarean sections, 2 theatres and all the necessary equipment to run the hospital as well as a nursing school, nurses and doctors accommodation and a secondary school. Both Ann working as an anaesthetist and outpatient doctor and Vijay as a paediatrician surgeon have put a continuous and tremendous effort to achieve this. Money is coming from donations and a fee for service is charged to each patient.

The 2 theatres have 4 operating tables, air conditioning and sufficient basic equipment. The nurses are extremely proactive and efficient and craving for learning, Rob did a laparoscopic small bowel obstruction and spontaneously had 3 nurses assisting. They are all competent, smiling, easy going and want the job to be done. The lack of a permanent general surgeon is obvious but will be addressed in the coming months. Only 3 tables can be used as the fourth one is dedicated to the gynaecologists who usually perform no less than 5 sections a day.

Usually, new patients are seen directly in theatre, children arrive with their IV line in and are mainly induced with Ketamine, most adults will have a spinal anaesthesia, follow up is organised by the doctors on the wards which is a good option as very few patients speak English and there are many dialects used in Assam. You may be asked to perform an extra non hernia operation but we are guests here and it is not compulsory, small bowel obstruction, fistulas in ano and gastroscopies were added to the lists.

For the next team : 3 surgeons is enough as there are 3 tables, 2 would not be adequate as if one falls ill, the list cannot go on, 4 pointless and the hospital has to deal with plenty of emergencies and hernia patient admissions may be delayed. Bring : gloves, your own theatre outfit, caps and masks, meshes ( make sure they have at least a sterilisation date and/or a use by date written down), sutures, patients are thin so 0 or 00 stiches are sufficient, sub cutaneous skin stitches, 40% of the patients are children and anything you can as it will be used quickly. Never used before diathermy cables with a 3 pins connection are in demand. An anaesthetist would be a bonus as there is only one permanent anaesthetist David who has to deal with the emergency sections.

This part of Ass

am is quite deficient in infra structures, electricity and water supplies, there are a few small shops only in Bazaricherra where you can find only basic products. Accomodation was in Ann’s house, showers are bucket type, a new house is being built for 8 visiting doctors at a time and should be completed next year. This is a very interesting hernia mission to achieve in a poor rural area far away, it takes 4 hours minimum to drive the road from Silchar airport. This is a malaria area and prevention is recommended. There is nothing else to do if you are not in theatre.

Hernia International Mission

Dodi Papase, Ghana, November 2018

This was the first Hernia International mission to Dodi Papase, and we received a very warm welcome from Dziwornu Kunutsor, Specialist General Surgeon, and the staff at the St Mary Theresa Hospital. We were provided with comfortable accommodation on site in one of the staff bungalows, (a short 3 minute walk to the theatres each day) and had the pleasure of Joyce cooking delicious Ghanaian food for all our meals.  

The team had worked together on several previous missions, and there was a good feeling of getting back together and catching up on individual news of the last 12 months. Our multinational team comprised Katharina from Switzerland (Anaesthetist and team leader), Michael from Switzerland (Medical Engineer), Margaret from the UK (Registered Nurse) and Surgeons Christoph from Switzerland and Stefan from Germany.

 We met at Accra airport and stayed overnight in a nearby hotel, and the following morning travelled for 6 hours to Dodi Papase. After about 1 hour of driving the condition of the roads became variable – intermittent sections of about 5 – 10 kms of un-sealed roads and vehicles in both directions weaving chaotically over a terrain of large potholes – some still full of water from recent rains. We were mindful of how much more treacherous the journey would have been in the wet season when we encountered an abandoned overturned lorry carrying huge logs of wood. The concentration and skill of our driver Joshua was nothing more than awesome! At least one of us was clinging to the edge of the seat at times!!

It was impressive how well prepared and organised the St. Mary Theresa Hospital was for the mission. The local IT technician had designed and produced a dynamic poster advertising the mission. This had been displayed on the hospital ambulance, the entrance gate to the hospital and in community clinics. As a consequence, recruitment had been very successful with some patients travelling in even from neighbouring Togo. The theatres had had a major refurbish in 2010 from the sponsorship of the German Govt, Rotary International Foundation, and German Rotary volunteer Doctors and we certainly felt the benefit of working in the 2 theatres that were well equipped with supplies and remarkable clean- in fact, more than what we had experienced on other missions.

Andrew Kingsnorth had provided mosquito mesh and for the first time specifically manufactured packets for medical sterilisation. The individual pieces of mesh were assembled in the packets in advance of the mission and sterilised onsite at the hospital according to the planned surgery lists each day. This process of sterilising the mesh on site (in steam sterilisers) worked well, along with being able to leave a generous supply of assembled mesh in packets for the staff to sterilise as and when required for future hernia surgery.

Depending on other hospital commitments, Dziwornu and 2 GP’s joined the HI team each day for the surgical lists which ran from 8am until 7-8pm. The Ghanaian doctors are working after university and before specialist training for three years as GPs. GP are seeing, treating and admitting patients in the hospital and also performing some surgical procedures as Caesareans, appendicitis or hernia repair. So our teaching was well placed. There was much sharing of ideas, skills and knowledge, and great collaborative team work, and it was fascinating to compare and contrast the prevalence of surgical emergencies between African and Western populations – particularly relating to abdominal surgery. The clinical stories were riveting.

A total of 60 hernia operations were performed which included 8 bilateral hernias. The cohort included 9 children all of who had general anaesthesia. Patients with complex hernias had spinal anaesthesia – Katharina taught the local anaesthetic nurse (Festus, a very motivated young anaesthetic nurse) spinal techniques along with the ‘tricks of the trade’ of many other aspects of anaesthesia. 

At the beginning of the week there were some problems with the generator. A period of 24 hours elapsed without electricity before this was resolved by a great collaborative effort from Michael, our team medical engineer, and the hospital engineers. Meanwhile surgery was continued with the use of head lamps! Michael’s medical engineering skills were utilised from dawn ’til dusk; endless equipment was repaired and serviced…. operating theatre light, diathermy machine, anaesthetic machine, suction unit, theatre tables, Mayo operating stands, sharpening of dissecting scissors and repairing a washing machine that had not worked for more than one year… not to mention helping with the recovery of the generator! He was a huge asset to the day to day “fine tuning” that enabled us to work with greater efficiency. From our experience it would seem highly beneficial to encourage/actively seek out medical engineers to be part of the missions.

Alas, the week went by all took quickly, and our connections with people made it hard to say goodbye. However, we had a little time to step back and reflect on the experiences of our week with our journey back to Accra stopping off at a small town on the Volta Lake, enjoying the sights of boat building, fishing, markets and the wonderful colours of daily life.

The feedback was positive, and our considered opinion was that future missions to Dodi Papase would be worthwhile. We are hugely grateful for the welcome by Dziwornu and staff and all their hard preparatory work, along with the learning that we all take away, and the insight into Ghanaian culture, food and customs that we experienced.

For the whole team: Margaret (RN)

GATUNDU KENYA- REPORT 2018

Gatundu is a small village of about 20.000 inhabitants in the province of Kiambu, an hour by car from Nairobi, which is famous for being the birthplace of Kenya’s first president (JomoKenyata) and of the actual president, UhuruKenyata, his son. Even though there are many religions known there, the Catholic one is the main one. The city’s infrastructures are primitive, without asphalt on the streets, and with a population that lives on a rent of15 per person and day. Rice, vegetables and other products of the field are the basis of the economy and the fare in Gatundu.

Preparation for the mission

The Gatundu campaign 10/2018 was organized according to the administrative authority of the “IV Gatundu Hospital” (Dr. Gitau) in the period of two weeks between September 28 and October 12 in 2018, with a total of 10 days for surgical activities which were carried out on 3 surgical tables simultaneously (one for children and two for adults). With a view to operate upon 6 patients per operation theatre and session we formed we formed a team of 10 from the “Cirujanos en Acción” Foundation (one pediatric surgeon Dr. Morán, three general surgeons, Dr. Ramirez, Dr. Fajardo and Dr. Sanchez-Relinque, two anaestesists, Dr. González and Dr. Agullló, one family doctor, Dr. Sabater, and three nurses Mr Gomez, Missis Gall.) We offered to extend our operations to include goiter).

Two weeks before the beginning of the campaign we were told by the hospital administrative authority that we would operate for five days, while we had dedicated much time and effort for three months. Finally the intercession of Dr. Teresa Butrón extended the period to 7 days, but only to operate on two tables simultaneously (a third one being ready in case of great need); we were also told that they had been able to get 85 patients in all, not more.

We have carried out the protocol visits to External Health in the respective provinces, strictly following the rules for vaccination and profilaxis required in a visit to Kenya. We got our visas contacting by mail the embassy to receive them by registered mail which is better in practice than the electronic visa.

The journey

The journey to Gatundu begun with our two groups starting on the morning of Friday 28 December, one group from Málaga (stopping at Estambul and arriving in Nairobi at 2.15 a.m. on 29^th September) and another starting from Madrid (with stop in El Cairo and arriving in Nairobi at 3.45 a.m. on 29^th September.) Due to a delay of more than 1 hour in the starting of the Málaga-Estambul flight, the Málaga group lost the connection to Nairobi and had to remain 24 hours in Estambul, arriving in Nairobi on the morning of September 30. The meeting of the whole group took place on the morning of Sunday 30 September at breakfast time. For 6 members of the team this was the first “Cirujanos en Acción” campaign.

We had 480 Kg of medical and surgical material to take to Gatundu, 400 from Málaga and 80 from Madrid. In Málaga we had serious problems when registering at the Turkish Airlines desk, as the person in charge absolutely refused to cooperate (while the land people were charming). We had to leave 65 Kg of material in the airport ad they wanted us to pay 2900 extra euros for extra luggage. This lack of cooperation on the part of Turkish Airlines is so glaring in contrast with other airlines that I think we should try new strategies to avoid that trouble in the future, as the behavior of the airlines does not fit with our preference for the most deprived people. 

The arrival in such places always implies some kind of conflict as the sensibility of Air Companies does not fit at all with the commitment of our Foundation to work for the poorer people.

The arrival in these places always implies some trouble in customs, so that it will be convenient to get some kind of help to accelerate matters. No kind of communication was established in spite of all our efforts. We found help in the document the Kenya ambassador in Spain gave us and in which he indicated the in an official document our presence there and all the material we carried with us. I want to record my thanks to the ambassador Bramwe Waiaula and to Mr. Javier Gomez, member in the Kenya embassy, for their help in all moments.

Even so, and in spite of all documents you can show them, they will always try to show that some papers are missing and that we had to pay customs taxes. We have to stand firm, to insist that we are coming to help the people and that we do not need any more documents.

STAYING PLACES AND TRANSPORTATION

We are staying at the Maxland Hotel, half an hour by car from Nairobi and about 20 minutes from the Gatundu Hospital. It is a fine hotel, clean and with a good image, equivalent to a 3-4 star in Spain. It has a very clean and large swimming pool ready for use, the rooms are cleaned daily, the beds have mosquito nets and the baths are very decent. It has wifi that works very well in the common zones (hall and dining room) and not so well in the rooms. Every morning they gave us breakfast at 6.30 a.m. with bread and the possibility of fruit, cereals, black beans, bacon and scrambled eggs, and you could also take an omelet prepared with the ingredients you wanted. Next to the hotel is a shopping centre with a great supermarket in which you can buy anything at a good price, and where we went daily (it closed at 10 p.m.) for whatever we needed. Every night the members of the team met in the hotel dining room for dinner with the team members, as there were no places to walk and no other eating options to choose. Dining out in Nairobi is only advisable if you are ready to put up with two hours to go and two to come back in terrible traffic, as we did on Saturday 6^th October as a farewell. The hotel price including breakfast about 35 american dollars, and it can be paid in that money or in KSH, the local Kenya money equivalent to 0.015 (so that 100 KSH make one dollar).

Transport from the airport to the Maxland and back both ways to the hotel to the Gatundu hospital took place in a 12 places jeep supplied free by the Hospital. I can only say that the driver, Cyrus, is a serious person, that he drives very well and he has given us much safety in spite of the traffic being horrible in that zone of the country, constantly through roads without asphalt, without traffic lights, and with cars and motorcycles overcharged and often on the wrong side.

THE HOSPITAL

“Level IV Gatundu Hospital” is a hospital recently built (2013) with the help of 11 million dollars by the Chinese government (all the notices in the hospital are in English and Chinese) which helps the old hospital actually in partial use. The new bloc has 5 heights, a low one for urgencies and admissions, two por hospitalization with six rooms with eight beds each, occupied by our operated patients (even so with an occupation not above 50 percent) and two zones of operation theaters, one of gynecology in the second story and another in the third one with two operation theaters (“Theaters 3 & 4) in which we had worked daily. The operations theaters are roomy and relatively new, although they lack much material as could be expected; the lights of operation theater 3 have not worked in the hole week, and operations have been possible thanks to the use of photophores which I recommend to bring always with us. There are two respirators that work very well and a Valleylab electric scalpel which works well. In the other operation theatre we have worked with the electric scalpel we always carry with us.

The recuperation room is very rudimentary, it was empty and we kept there patients been observed for a while after operation by some nurse in the hospital till they could be sent to a room. The operation room area has also a little room in which we have kept our material, and a place for the staff in which they daily sent us our half-morning breakfast with tea, coffeeand greens, and a lunch with rice and greens. They also brought us bottled mineral water. For sterility we had an autoclave which worked by heat (there are no gas systems) and which gave us trouble only one day when the whole village was left without supply and we were left without any water. We had taken with us three boxes of specific material for hernias, although the hospital has a number of boxes full of passable surgical material but without any order. There were no right angle dissectors in any box, and most of the Kocher pincers had no grasp at all.

The staff in the operation theatre and other helpers was excellent and very dedicated, whether the chiefs (David Karuga and Weru Kennedy) or the helpers and students that helped us. I want to mention particularly the lady doctor responsible for the coordination of doctors and patients, Victoria Kithinji (Vicky for us) who showed a great human value, professionalism, availability and capacity to communicate with our team.

SURGICAL ACTIVITY

During the 7 days of surgical activity in the Gatundu Hospital we worked on patients selected by local doctors and listed day to day by them. We also worked on some surgical cases that came to the hospital, given the scarcity of surgeons. On the whole we worked on 82 patients (42 adults and 40 children) with 104 surgeries divided as follows:

ADULTS: 17 inguinal hernioplasties (7 Rutkow-Robbhins& 10 Lichtenstein); 3 umbilical hernioplastics; 15 total tiroidectomies; 3 traumatic wounds; 2 Hiatic hernias (Nissen); 2 hiatic hernias (Nissen); 2 hidrocelectomies; 2 queloidal surgeries in the auricular pavilion; 1 eventration; 1 fimosis; 1 over infected fascitis;1 autologos skin insertion; 1 giant testicular tumor of germital stock; and 1 pediunculated wart.

CHILDREN: 16 umbilical hernias; 14 criptorquidial; 10 inguinal hernias; 6 hidrocels; 3 fimosis; 1 hipopasdias; and 1 case of non differenciated genitals.

We have had only 2 post-operative complications, a minor one (inguinal post-operative) and a mayor one(disnea and larynx ‘estridor’ which was treated with a temporal traqueostomy). A week after coming back to Spain I personally contacted the patient and lady doctor Kithinji who informed me that an indirect laryngostomy had been made in which can already be observed a proper performance of the vocal cords so that we can expect that the patient will be decanulated in the following weeks. All patients, except the one mentioned above, were dismissed the next day and no complications have reported. Even today we are in daily contact with lady doctor Kithinji to solve all her doubts in the follow up and revisions of the patients operated upon.

TEACHING ACTIVITY

On the first day we received the visit of Dr. Gitau who proposed to have an activity with the CME (Continued Medical Education). It was an excellent idea and we fixed Thursday 4^th October at 8 a.m. The presentation was a success with a great interest on the part of the young internal doctors of the hospital. The place was full for an activity that took 60 minutes with contributions from lady doctor Fajardo (“Basic concepts of inguinal hernia and its treatment), Dr. Morán (Timetable for children paediatric surgery) and Dr. Ramírez (“Options for surgical treatment in the multinodular goiter”.

EXPENSES

All the expenses of the campaign were contributed by the ten volunteers, and they divide as follows:

Journey (by plane both ways): 4627 euros

Maxland Hotel: 4150 euros (45 euros for person and night)

Meals and transportation: 15 euros for person and day (1350 euros)

Instruments afforded: 825 euros. 

From the point of view of patients operated and hours spent we can say that the aim of the mission has been accomplished.

From the point of view of the organization, once we arrived in Kenya everything went well: hotel reservations, transport, operation theater and collaboration on the part of the Hospital staff.

I think that to organize such a mission it is essential to have a direct and clear communication between the leader of the same and the local collaborates of the Hospital in order to define the type of pathology and the way of working (essentially the number of working days, the number of operation theaters available and the number of patients). I believe this aspect can definitely be improved because we have planned a human team and the medical and surgical material that has overvalued the expectative of the work to be carried out. I ask the local coordinators to improve this aspect in future missions.

Finally the fact that in 7 days were operated only 23 hernias in adults leaves me with mixed feelings. It is true that we have operated for very complex and exacting cases, but very few patients were recruited for hernia in a campaign run by “Hernia International” and “Surgeons in Action”.

While saying that some points could be improved I am delighted to say that I would come again to Gatundu in order to help the people there.

Hernia International (Spanish Team) mission at Mongolia. 2018

 The Team:

Enrique Navarrete de Cárcer, surgeon. Team Leader. Sevilla

Francesc Marsal Cavallé, surgeon. Tarragona

Juan Carlos Gomez Rosado, surgeon. Sevilla

Jose Lozano Cavalo, anesthesist. Sevilla

The cities:

1. Hospital General Básic de Tsetserleg

Tsetserleg, also transliterated as Cecerleg (Mongolian: ????????, lit. ‘garden’) is the capital of Arkhangai Aimag (province) in Mongolia. It lies on the northeastern slopes of the Khangai Mountains, 360 miles (600 km) southwest of Ulaanbaatar. It has a population of 16,553 (2000 census, with Erdenebulgan sum rural territories population was 18,519), 16,618 (2003 est.), 16,300 (2006 est.)

Tsetserleg is geographically located in the Bulgan sum in the south of the aimag. It is not to be confused with Tsetserleg sum in the north. In 1992 Tsetserleg was designated as Erdenebulgan sum, which has area of 536 km².

 2. Second General Hospital Ulanbaator.

Ulaanbaatar, formerly anglicised as Ulan Bator /?u?l??n ‘b??t?r/ (Mongolian: ???????????, [????m.b??t???r], Ulaγanbaγatur, literally “Red Hero”), is the capital and largest city of Mongolia. The city is not part of any aimag (province), and its population as of 2014 was over 1.3 million, almost half of the country’s total population.^[1] Located in north central Mongolia, the municipality lies at an elevation of about 1,300 meters (4,300 ft) in a valley on the Tuul River. It is the country’s cultural, industrial and financial heart, the centre of Mongolia’s road network and connected by rail to both the Trans-Siberian Railway in Russia and the Chinese railway system.^[3]

The city was founded in 1639 as a nomadic Buddhist monastic centre. It settled permanently at its present location, the junction of the Tuul and Selbe rivers, in 1778. Prior to that occasion it changed location twenty-eight times, each new location being chosen ceremonially. In the twentieth century, Ulaanbaatar grew into a major manufacturing center.Ulaanbaatar is a member of the Asian Network of Major Cities 21. The city’s official website lists Moscow, Hohhot, Seoul, Sapporo and Denver as sister cities.

The tour:

One way, was made from the city of Barcelona, ​​in flight with the company China Air, with a stopover in Beijing. The duration was 16 hours including the technical stopover at the Beijing airport, where we need to go through the security check again. Fortunately, there were no delays or customs incidents. We do not carry clinical material or medicines. Only about 80 meshes already sterilized and properly packed.

Upon our arrival at Ulaan Bataar International Airport, both Enkhee (in charge of all the coordination and logistics of the mission), as well as Dr. Sinchan and Dr. Chadraa and Telmen, staff surgeons and resident of the Second General, were waiting for us.

The first week of work was performed at the basic general hospital of TseTserleg. The transfer there, was made immediately from the airport. The city was located 600 Kms west of UlanBataar. The trip was organized completely by Enkhee and we traveled in an SUV and a van for luggage. We traveled for 11 hours along the Mongolian steppe, stopping several times to stretch our legs, recover strength and take some pictures of the landscape.Dr. Naranthuya, head of surgery at the hospital and her staff, were waiting for us at the destination. We met the hospital in the surgical area and reviewed the patients the next day.

The accommodation is made free of charge (thanks to the hospital staff’s deference), in a small hotel very close to the hospital. Breakfast, lunch and dinner was always prepared in the hospital, also free of charge The working week at TseTserleg was Monday through Thursday, since on Friday we needed to travel back to the capital UlanBaatar, to be there on Friday night. 

Dr. Naranthuya and her team, together with the surgeons who accompanied us, had selected all the patients of the week and we reviewed them every day. The majority were patients with inguinal and umbilical hernias, and 2 large incisions. 4 children and 7 adults. There were no more selected patients and 2 were rejected for surgery due to severe concomitant pathology. A bilateral inguinal hernia was performed using a laparoscopic TAPP approach. 

All the patients left the following day. There were no complications.The collaboration of all the hospital staff was complete, and their hospitality similar. Breakfast and lunch was made every day at the hospital and dinner at a cafeteria near the hotel, which was also booked and paid for by the hospital. The infrastructure of the hospital is basic, and the operating rooms (2) meet the minimum conditions to be able to work: sterilization center, basic instruments, modern anesthesia system, electric scalpel and adequate light. However, the catalog of sutures is scarce and in small quantity. They do not have meshes for the repair of hernias, and although there is a modern laparoscopic tower, the laparoscopic instrument is obsolete. Antibiotics, analgesics and anesthetic drugs are basic and scarce.

After the return trip (12 hours) to the capital on Friday, restful rest in a great hotel near the Second General Hospital, which Enkhee achieved thanks to his good work. Saturday dedicated to know the capital and surroundings. On Sunday we went to the Hospital, to meet Prof. Naraa and his team, made up of several surgeons and residents, who made us a great welcome, with food and Vodka included. Visit to the facilities and visit the patients scheduled for Monday.

From Monday to Thursday, surgery to double the operating room and on Monday to three simultaneous operating rooms. The facilities are great, with a modern and functional surgical area. The collaboration of Prof. Naraa’s team was complete. Daily we were accompanied to review the patients of the previous day and the few who were admitted several days. The control of the patients was complete by the local surgical team.

In total, 25 patients underwent surgery in 4 days, all of them with large incisional hernias, or recurrent or large inguinal hernias. 7 of the patients were operated by local surgeons and assisted by a team surgeon.  There were no complications, and all the patients had left on the Saturday of our departure.

On Thursday afternoon, we devoted 3 hours to presentations and videos about the new techniques of abdominal wall, the clinical guide of the EHS and the types of meshes available today. They were followed with a lot of interest by the whole department of surgery, and non-facultative personnel.

The only drawback is the absence of surgical meshes, which usually do not have. The catalog of sutures is correct in quantity and variety.

Once again, the infinite kindness of all the hospital staff, from Prof. Naraa, to all the Staff, residents and auxiliary surgical staff. We have definitely felt at home or in our hospital in Ulan Bataar.

In summary:

The experience has been absolutely positive. The hernia pathology is prevalent in that country, although it is not a health problem. Perhaps it would take more training from local surgeons, so that they can master all the modern techniques in wall surgery. Local surgeons in both the capital and rural hospitals are eager to know and develop modern techniques for the repair of hernia pathology, but may not be able to access it for organizational or economic reasons.

I think Hernia International has a fundamental role in teaching and training Mongolian surgeons.

For future teams that wish to cooperate in this country, I summarize some tips:

It is a fascinating country to know. The kindness and hospitality of its inhabitants, it is worth experiencing.

Trust completely in Enkhee: elle is in charge of the coordination and organization of everything related to logistics and transfers.

It is essential to carry some basic surgical material, especially for work in rural hospitals, with worse infrastructure. This includes sutures and surgical meshes. No need to take medication or anesthetic equipment.

There are modern and fully functional laparoscopic towers, but with laparoscopic and scarce obsolete material, especially in rural hospitals. Local surgeons demand teaching in laparoscopic abdominal wall techniques.

The general infrastructure of the country is acceptable, although the distances are large and require a day of travel both on the way and on the way back. The local food is excellent, although very different from the European or American. In Ulan Bataar, there are restaurants or places to eat all kinds of foods.

Mongolia is a great destination for Hernia International teams. The sanitary infrastructure of the country is improving, but local surgeons demand training and training in modern open and laparoscopic techniques, to be able to implement them in the portfolio of services of their hospitals.

Enrique Navarrete de Cárcer

Team Leader