Author: akingsnorth

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

KAMUTUR CAMPAIGN. BUKEDEA DISTRICT.

UGANDA. SEPTEMBER 2018

SURGEONS IN ACTION FOUNDATION

1.      TECHNICAL REPORT:

a.      DATES:

A team of 8 people: 3 general surgeons, one pediatric surgeon, one anesthesiologist, two surgical nurses and one professional photographer.

8 packages with a total of about 240kg of surgical material and medicines.

Departure from Madrid on Friday 9/14 at night and arrival in Madrid on Tuesday 9/25 in the morning.

Saturday 14th: Very long car ride from 9:30 am in a typical Ugandan taxivan from Entebbe, crossing Kampala, with a technical stop to pick up two oxygen bullets, which will travel all the way with us, until arriving at Kamutur, a village in a rural setting in the Bukedea district, at 19:30h in the evening. We crossed roads of all kinds, fortunately during the dry season, we enjoyed the Ugandan landscape, we stopped to eat typical chicken legs and fried livers on skewers, and we even had time to change a wheel for a blowout.

Sunday 15th to Friday 20th: Surgical interventions, from 8:00 am to 8:00 pm, in 2 simultaneous operating theaters.

b.      ADULT PATIENTS:

95 procedures performed in 83 adults, 34 in women and 49 in men.

As a summary, it can be highlighted:

-36 inguinal hernias, 5 bilateral. Mosquito mesh provided by Hernia International and PLP meshes contributed by the volunteers have been used.

-2 infraumbilical laparotomies for two right ovarian masses resections, one 7cm and one 20cm, previously diagnosed by ultrasound provided by the patient.

-3 large incisional hernias with PLP retromuscular mesh (Rives)

-14 hydroceles, including 3 scrotal masses of doubtful diagnosis that required orchiectomy.

-1 breast tumor, quadrantectomy.

-30 soft tissue procedures, including keloid scars, some very complex, and several tumors up to 15cm in diameter.diámetro.

c.      PEDIATRIC PATIENTS:

14 procedures were performed in pediatric patients, 7 in boys and 4 in girls, from 2 to 17 years of age.

Inguinal hernias: (raphias) 4 rights, 1 left. 3 of them associated with hydrocele.

Other procedures: 3 soft tissue tumors, 1 cord cyst, and 1 ganglion and 1 hydrocele.

It is important to point out that, even though we had a pediatric surgeon with us, and we advised it to the hospital with sufficient time, there has not been a recruitment campaign for pediatric patients, fearing that they were not finally operated. Unfortunately, in the two campaigns prior to ours it was not possible to operate on this type of patients, and that has meant that the influx has been very low. Hopefully, this trend will be broken as of our campaign, and a more constant pediatric care will be consolidated in the next ones.

Total procedures: 109

Total patients: 94, 56 men and 38 women.

d.      COMPLICATIONS:

Until the time of leaving Kamutur on Friday evening, all patients were discharged on the same day or after a night of hospitalization, with no complications, except for patients with laparotomies or with drains after eventroplasties, which remained for up to 3 days, or patients with a long distance from the hospital, who stayed for up to two days. According to a subsequent report by Moses Aisia, head of the Hospital, and Dr. David Oikia, physician in charge, there have been no complications in any patient.

2.      CAMPAING REPORT

a.      THE PLACE

Uganda is a country in East Africa, bordering Kenya, South Sudan, Congo, Rwanda and Tanzania. It is an independent country, belonging to the Commonwealth, since 1962. It has had a very convulsive recent past, and currently maintains a relative socio-political calm, with a presidential regime led by Museweni, which has governed since 1986. It is divided into 111 districts and a capital city, Kampala. More than 80% of the population is Christian. Each woman has an average of more than 6 children. Life expectancy is estimated around 52 years. The district of Bukedea, where Kamutur is located, is a district with about 120,000 inhabitants, in a rural environment, and with 80% of its population below the poverty line.

The Holly Innocents Health Center (HIHC), is a private hospital center, created from nothing,  thanks to the enormous work of Moses Aisia, a social worker, who began to build the center after a terrible personal story, and is getting basic health care to an entire region of the district. The entire project, which is fully structured and planned, will turn it into a Hospital with all the basic services, although at the present time there is still much work to be done and a large investment of money, personal and material resources is necessary. At present, it gives attention to gestation and delivery, it has a hospitalization area, laboratory with basic diagnostic tests, and a surgical pavilion in the process of construction, very advanced. Among the health personnel, hospital nurses, midwives and surgical nurses stand out, with a great capacity for work that we have been able to confirm, and a doctor paid for by the center itself, Dr. David Oikia, who carries out commendable work with scarce media, and who stays in the hospital from Wednesday to Sunday, alternating his activity with that of university professor in Mbale, in a government post, on Mondays and Tuesdays. Recently, the center has been certified as Level 4, which in the Ugandan health system corresponds to what we know, saving distances, such as Community Hospital.

The hospital center is clean and tidy, and our fundamental workplace, the surgical pavilion, although still unfinished, has allowed us to work in two operating theaters with enough fluidity, understanding the circumstances in which the surgical campaigns of our Foundation normally take place, quite far from European standards applied to an operating room. In any case, we have maintained a circuit of asepsia-antisepsia more than acceptable, using a pressure autoclave and organizing the instruments in small kits, helped with all the sterilized single-use material that we carry with us. Although we did not have surgical lighting, still without acquiring, we have been able to work with “alternative” lighting with sufficient security. We have organized a circuit for transferring patients from the hospitalization block to the operating room. We have enabled a pre-surgical waiting area and a postanesthetic recovery area with two beds inside the pavilion. We have been able to work with 3 local nurses very efficient and willing, to which we thank their great capacity and joy.

b.      THE TEAM

On September 14th, Friday night, we started from Madrid a team of 8 people:

-Carlos de la Torre Ramos, pediatric surgeon,

-Rocío Fernández Sánchez, general surgeon,

-Ana Gay Fernández, general surgeon,

-Beatriz Revuelta Alonso, anesthesiologist,

-Nuria Agulló Marín, nurse,

-Gustavo Sánchez Bravo, nurse,

-Sergio Sánchez Agulló, photographer,

-David Fernández Luengas, general surgeon.

This campaign has been carried out by a team from the Surgeons in Action Foundation. This is the second campaign in the HIHC of the Foundation, after the first of a team held in December, still without having the surgical pavilion. In addition, in April there was a campaign of Hernia International, an organization that initially contacted the HIHC, but they had very poor results, for various reasons that it is not time to analyze, but differ a lot from what our team experienced. This location of the HIHC is likely to become one of the locations most valued by our organization, due to the enormous needs of the population, the great willingness of all the local hospital staff to collaborate and participate in the campaigns, and the improvement of the facilities projected or in the execution phase, very advanced taking into account how it is all in Africa.

Together with the medical team, this time a professional photographer participated in the campaign, with the aim of collecting audiovisual material to make a documentary film about this place, its reality, its needs, and the task that the Surgeons in Action Foundation has out here.

c.      LOCAL STAFF

In the hospital there is only one doctor, Dr. David Oikia. For our work, we counted on 2 nurses in the operating room (Florence and Esther Norah), who did circulating work together with our nurses, and cleaning and sterilization. In addition, we work with two hospitalization nurses (Karoline and Emmanuel). In addition, two guards performed all the work of circulating patients. It is fair to acknowledge to all of them the enormous effort made and the joy with which they have shared the work with us. His deficiencies in surgical training have been replaced with his dedication and willingness to work. We were very pleased to note upon our arrival the cleanliness of the facilities, which we were able to verify how it was maintained day after day by the cleaning team.

It was very exciting the party-ceremony of welcome to the team, in the back garden of the hospital, where there were speeches, gifts, dinner … and many dances, in a demonstration of gratitude that we deeply appreciated.

Moses Aisia, director of the center, sets an example with an enormous capacity for work, and transmits that implication to all the staff. He is the real engine of the hospital, the one that deals with getting financing to finish the project, designed by him, and was always with us pending of anything that we needed.

We have lived in the hospital center, in 3 rooms with very basic resources.

d.      EQUIPMENT

The hospital has very limited means. Focusing on the surgical pavilion, it is worth mentioning:

-The pavilion is unfinished, so it still can not be used at full capacity according to its projected structure. The exterior construction and the partition of the different rooms is finished. Only some rooms are paddled on floors and walls. There is still no running water and electricity. Therefore, there is no light of any kind installed yet.

– At present the projected operating rooms (3) are not yet operational, since the work is not finished. In this campaign we have used two rooms that are projected as offices when the pavillion will be finished. In those locations we have achieved the basic conditions to turn them into an operating room. In addition, we were able to use a large main room already finished as a warehouse and as a waiting room, another unfinished room as a sterilization room, and another room as a postanesthetic recovery room.

-With regard to the equipment:

Two electrocautery generators are available. One of the two, we were not able to make it work, and it’s going to be sent to repair. Instead we used one that we brought, happily. It is essential to carry both the adhesive grounding plates and the scalpel terminals, since there are practically none there.

They have just acquired an anesthesia machine, which is not yet operational because it is necessary for the company to send a technician to finish checking it and put it into operation, an appointment that is planned immediately, so that it is operative for the next team that goes to operate there.

Currently there are two complete oxygen bullets, which we ourselves collected from Kampala.

We have used an oxygen concentrator that we have transported from Spain, and that we have left there, thanks to the donation of the company Oximesa, managed by our pediatric surgeon Carlos de la Torre.

We have used a diesel engine por electric power that the hospital has, and that has worked correctly for the use of these equipment.

The light for the operating room has been provided by the frontal lights that we all carry from Spain, and which have been essential at some moments.

The two main actions to be carried out in the pavilion, well known by Moses, are the electrical installation, through solar panels, and the piped water.

Regarding the surgical instruments, there is a basic reserve of surgical instruments in the hospital, but we have taken surgical instruments to make about 6 basic kits, which have allowed us to work with fluidity, supported by the cleaning and sterilization in the autoclave by the local nurses.

Regarding fungible material and surgical clothing, the needs are enormous.

We have used much of the material we have worn, including gauze, compresses, gloves, dressings, disposable sterile drapes, sterile disposable gowns, iv anesthetic medication, IV antibiotics for prophylaxis, mosquito mesh and antiseptics for surgical scrubbing, among other things. Without this material, to propose a campaign of these characteristics to this place is impossible. The next teams must bear in mind the need to provide all this material.

e.      ANESTHESIA, ASEPSIA AND SURGICAL EQUPMENT

All adult patients have undergone surgery under spinal anesthesia, supported according to the cases with more or less deep sedation. In soft tissue tumors, as a general rule, local anesthesia has been performed with sedation.

In children, surgical procedures have been performed by general anesthesia in spontaneous ventilation, with the oxygen concentrator, and no doubt thanks to the experience and professionalism of our anesthesiologist.

We have transported all the necessary medication from Spain. There we found a small assortment of medicines from other previous missions, or acquired by the hospital, but, without a doubt, it is very important that any campaign that is organized, at least for now, has the need to ensure its own anesthetic medication.

Basically, they have a “sterilization” room where they keep the packages with the sterile material, and where an autoclave of type “express pot” is put on a wood fire, with a pressure gauge. The system itself is rudimentary, but effective to achieve sterilization of the material.

Surgical clothing is very scarce, with few cotton cloths. We use a large amount of disposable cloths that we carry from Spain, as well as disposable gowns.

All of our adult patients with mesh implants receive a dose of cefazolin 2g iv in the anesthetic induction, which we have taken.

Regarding the surgical material, the situation is equally bad, as it corresponds to the type of hospital it is. We carried a lot of material that is essential that other missions also carry, from gauzes and compresses to sterile gloves, drains, dressings, steri-streaps, sutures, elastic bandages, etc.

Of course, there are no meshes for performing hernioplasty. We have taken a large quantity of meshes “mosquito”, sterilized thanks to the work of Hernia International, which sterilizes, packages and labels individually, and from here we take this opportunity to thank. In addition, we have taken some polypropylene meshes with a larger surface area and some double-layer mesh to ensure a special need that has not been met.

The surgical instruments are very scarce. We have used our own instruments divided into small kits.

f.       OUR LIFE AT KAMUTUR

The alarm clock sounds at 7:00 a.m. It’s time to get up, take a big bucket and go to the hospital well, in the middle of the central square to fill it with water. There is a lot of hustle and bustle at that time, and you always find a child in the well who gladly applies it to the crank of the well to fill the bucket. Then you have to go through the kitchens to add enough hot water, to your taste, and approach our “shower”: a stay with walls of approx. 1,5m high, outdoors, where we could improve the technique of the “shower cube”. The mornings are fresh, about 20º max. After (or before, according to tastes and needs) we enjoyed a wonderful communal latrine, which I do not intend to describe here, but which is far from what any of us understands as a bathroom.

All meals were made in a nice covered terrace, with a menu basically the same every day, clean, cooked there, and enough to feed, without great difficulties. Practically all the members of the team have suffered, to a greater or lesser extent, a gastrointestinal disorder, which in no case has been serious, nor has it prevented our daily work. If anything, it has deepened our knowledge about the operation, cleaning schedules and presence of native fauna in communal latrines.

Our life in this place has been very simple. We have always felt very well treated and very accompanied. Apart from the hospital life, which occupied a large part of the day, our social life was limited to conversations around the table. Especially at night, when, after dinner, we enjoyed one (or two) wonderful bottles (75cl) of Nile beer, some days even something “cold”, with an entertaining conversation. Some confessions about anecdotes of our lives that I will never reveal will remain for the secret of our team.

Our rooms, one for the 3 boys, one for the three girls, and one for Nuria and me, were quite basic, with the beds as only furniture, but clean and comfortable enough to spend a week. There is a bathroom with shower-sink and toilet bowl finished, but still without pipe water, so it is useless, for now.

We have paid $ 70 each for the room and the food, for the whole week. .

Communication with the outside world can only be done through the Ugandan telephone network, through SMS or international tariff calls.kits.

The concept “tourism” is very far from this place. Kamutur is in the middle of nowhere, in a rural environment where families still live in traditional huts in the countryside, without any basic services, and dedicated to a subsistence economy based on agriculture and livestock. There is a primary school, which we were able to visit, that serves the children of this community, with very basic resources.

Regarding the rest of the country, we have been able to complete an in-depth learning about the road network and the landscape of a large part of its territory, since we have made some 1600km in less than 3 days, in a taxi-van whose amenities I will not describe, to visit, at the end of the trip, the famous Bwindi Imprenetrable Forest, and its no less famous mountain gorillas. An unrepeatable experience, in every way.

CONCLUSION

In short, we consider that this campaign has been a success, both for the number of patients we have been able to operate, without complications, and for the satisfaction of the team for the great deal received by the authorities and local staff. Moreover, if possible, after the bad experience of the previous team of Hernia International that was in April. This report aims to serve to demonstrate that, with obvious improvements that need to be undertaken by the hospital management, it is perfectly feasible to carry out surgical campaigns safely in this center.

I believe that this place should be an important work goal for our organization. There is a lot to do, and the people here are eager to receive help.

Strengths of this place:

– Moses Aisia, true engine of the hospital. His ability to start, from nothing, this center, is incredible.

– The hospital itself, a true center of hope for this place, with a very needy population, immersed in poverty.

– The treatment we have received and the willingness of the staff to work with us.

Improvement objectives:

– Complete the surgical pavilion. This task is fundamental, and should be carried out as soon as possible. Includes complete work, equipment, and communication corridors with the rest of the hospital. In addition, as planned, it is convenient to carry out the surgical hospitalization building next to the pavilion.

– Medical material: To date, any campaign must have the need, already explained, to carry with it necessary medical material. It would be highly advisable to progress in supplying the hospital with this material, by the center’s management.

– Hosting of team members. A space must be adapted for the correct rest and basic hygiene.

Budget: For information purposes, and without going into too much detail, it must be said that the campaign in Kamutur is more affordable for the surgical team than other locations. This is due to two fundamental reasons. One, the cost of the flight, not especially expensive. The other, the costs of accommodation and maintenance, which have been almost non-existent ($ 70 for the entire 6-day stay), in addition to road transport, about $ 450 round-trip all the equipment. In the budget has not accounted for the cost of all the material we have contributed, in total about 240kg.

COST (ONE PERSON): Aprox. 900€

TOTAL COST: Aprox5.600€

Fdo: David Fernández Luengas

Campaign leader

Surgeons in Action

Report on hernia mission Brazil July 2018- Dominique Robert

 Brazil is a bit far away from Australia but worth the trip, lovely people, good surgical setting and competent surgical teams. Joao Pessoa is a big town, 1,800,000 inhabitants mainly living in blocks of flats around 30 levels. There are food outlets and fruit and vegie shops everywhere. Their beer is light and their Caïpirinas are absolutely delicious.

Day one was at teaching hospital Santa Isabel, 5 operating theatres well equipped, day 2 at Itabaiana, a rural local hospital one hour out of town, day 3 at Mamanguape, another rural hospital, one hour out of town but very active, day 4 hospital Santa Isabel, day 5 hospital Universario a very big teaching unit with everything available, day 6 at Santa Isabel. There are long working days because of the time spent in transportations around. Recruitment of patients does not seem to be an issue as the cities are big. I did or assisted for 23 hernias on 22 patients. There was no hernia done under local anaesthesia as the Brazilians Anaesthetists are in favour of spinal analgesia which they master very well, no problem on my side and it seems easier for their recovery units.

We were very well treated and fed in every hospital, the Juniors have an active role and are very keen on learning, ask questions and do not hesitate to challenge our techniques. I was a bit surprised we did not have to operate on more children. I think this was worthwile both for them and us. There was good companionship during all these days and I am quite keen on returning next year After time was very good too with plenty more restaurants, drinks and good food, quite often with the surgeons we worked with during the day.Excellent ambiance.

Thanks to Christiano and Christiano, Pericles the local surgeon organiser and all the Junior and senior surgeons Brazilian or from overseas we worked with, Andrew, Leo and Gail accomplished anaesthetist and Whatsapp Champion.

Benin 2018 Report

Mission report, Dangbo, Benin July 2018

The team this year consisted of 3 surgeons, Christine Russell, Richard Turner (both from Australia) and Thorbjorn Somers from Denmark + Anaesthetist Philip Gribble with critical care nurse Amy McLennan. This was our second trip to Dangbo in southern Benin; the mission in 2017 had demonstrated multiple, impressively large hernias and the workload was significant

The Hopital Auberge de L’Armour Redempteur is run by the local catholic nuns and only operates with visiting international teams; there are several visits a year from Spanish teams who clearly provide a broad & regular service. Mme Opportune is the leader of the nuns and a doctor to boot, though was not available to assist with the surgery. The operating conditions were basic but clean, the single operating room having two beds to work with [and is air conditioned]. The anaesthetic equipment was basic, the monitoring largely non-existent, and the Oxygen supply being one large cylinder and only in theatre.

We arrived in the Saturday prior to operating on the Monday. Sunday, we were presented with over 60 people to evaluate and many came for review with non-hernia issues [enlarged thyroids, metastatic disease, multiple unusual skin lumps, a 7month old with cleft palate, a 15yo inter-sex pateint]. Preparatory assessment had been done locally but was a little variable; 3 patients were cancelled as having uncontrolled HT [>210] and one had severe LVF.  Whilst we were there to focus on hernias, we were able to include several hydrocoeles, a couple of haemorrhoidectomies as well as keloid & lipoma removals in to our operating list. Of the 41 operations, 25 were hernia repairs.

Despite basic conditions, we were wonderfully looked after by the nuns, picking us up from the airport 90 min drive away; accommodation and food [and the evening beers] was all provided for us. The accommodation was spartan, but air conditioned, and the showers hot. There are no local facilities to access ‘extras’ though we really didn’t need anything; we did, take some theatre snacks which was a nice comfort. There is no reliable wifi service and phone contact was patchy to existent.

The weather in July/August was also noted to be far more pleasant than in April when we last visited; then it had been hot and humid building to the wet season, this time mid-20’s and far more comfortable.

From Australia, we had been supported by 2 local service groups [Rotary & Lions] to pre-purchase medications locally [especially Ketamine and Morphine], as well as bringing 2 pre-used diathermy machines from Australia to supplement their local equipment, all of which was very gratefully received.

One of the nuns, Sr Ruffina, performed the task of operating room manager and worked extremely hard, both before and after our work day, as well as Gabin Hounnou , the sole, post-op nurse. The aftercare was limited as it was a communal ward [in a separate building] with up to 10 people, but Gabin managed to perform admirably with limited equipment.

All operations were performed under either LA + sedation, or spinal; all hernia operations were planned TAP block under U/S guidance + infiltration. No GA was made available due to the lack of post-op care and the absence of a recovery area].The memorable morning of 2 patients singing a call & response duet at high volume (under the influence of the Ketamine) was a clear – and very

funny – highlight.

All the surgeons noted the difficult and ‘stuck down’ nature of the Beninoise hernia, so even apparently small examples provided a surgical challenge. The clear gratitude was also a delight and privilege; possibly the most rewarding post-op round one could have.

Suggestions for a future visit

# Prior liaison with Fr Martin of the Dangbo diocese allowed us to get him to order medications locally; we gave him 4 months warning and he was obliging to trust us to bring the money when we arrived. This worked very well we were guaranteed of critical supplies without having to transport it from Australia.

# The monitoring is basic to non-existent; we took 3 finger oximetry probes and left them there but  self-supply may be sensible. Capnography would have to be imported as well; ECG’s can be done but only if the patient is sent to the capitol, 2 hours drive away.

# Language was an issue for us, with only 1 fluent French speaker. Many patients do not speak French, only the local Fon, which makes communication even more challenging. The local support was ever present, though no interpreters were available. Without fluent french, there are clear difficulties.

 – one suggestion may be to bring a French vocabulary list for common medical terms as an adjunct

# The issue of duplicate medications and equipment was noted. The resident, residual supply of medications is large and somewhat eclectic & most of what we arranged was additional to requirements [though given the unreliability of storage in Dangbo, we ended up using mostly our own, ‘fresh’ supplies]. Whilst it may be difficult in Dangbo, information of what is present prior to a team visiting would be very helpful to direct resources to what is needed. This may be tricky, due to difficulty in email communication and limited local resources, though any prior information would certainly give a better service

# One specific suggestion for a next time would be to bring wrist bands for identification. The combination of the language barrier, unfamiliar names & difficulty in recognising patients clearly opens the door for error. A simple name + operation would significantly improve patient safety and surgical flow.

# Surgical practices [eg fasting times, post op care, routine preparation] have advanced in western practice compared to Dangbo and providing standardised information at the beginning would be helpful.

# Bring simple cleaning equipment [alcohol wipes, hand gel].

# We noted minimal supply of N Saline for mixing drugs; possibly bring a few 250ml bags of NS for this, eg 1 a day.

# Dr Gribble brought a hand held U/S machine for TAP blocks that was very useful and improved post-op analgaesia significantly; this was also utilised in pre-op assessments to aid in diagnosis.

# An Ampoule breaker would have been very handy; the local glass ampoules frequently shattered &/or were very difficult to crack

The local instruments vary widely in quality and we did leave several self-retaining retractors [for example] that were needed.

Whilst our visit this year did not have the same challenges as 2017, certainly the appreciation from both the patients and the nuns was obvious. Dangbo is a small unit but the HI mission provides surgical access to a group of people who have otherwise minimal opportunity. We left with the clear message that they would like us back.