Author: akingsnorth

Sedhiou, Sept 2017

Hernia International

& “Cirujanos en Accion”.

On Saturday September 2^nd I make an appointment with MaríaFanjul, children’s lady surgeon, in the Gregorio Marañón hospital to collect the generator for electrical scalpel and the mosquito meshes provided by Hernia International for our mission. We are going again together and to the same place, which gives us great joy, and we’ll be accompanied by Luis Rodriguez Bachiller and Laura Gomez Lanz, surgeons in the same hospital, Montse Sanchez Martín, nurse and companion in the Farafenni campaign (Gambia) in 2015, her sister MaríaJesús, medicine student, and Angel Revuelta who will act as reporter and helper in all our needs. MariamaBadji will accompany us and will be essential for drawing up lists of patients, for logistics and supplies, institutional contacts, shifting, etc., as she is always ready to help all of us. Without her we could not have managed.

Sunday 3^rd we meet at 15 hours next to the machine that will pack all the material, that is sutures, instruments, electric scalpel terminals, operation theater linens, surgical gloves, sutures, meshes, dressings, caps, masks, toys for the children, medicines, etc.

We passed all controls without any trouble, waited to be fetched and made our acquaintance with new companions. We all feel that mutual relationship will be perfect, and so it was in spite of a few difficulties along the work. Good relationships are essential are essential for the success of a situation that met with difficulties at the beginning.

We arrive in Dakar at 20.40 local time (two hours less that Spain), and the night would be hard as, having no possibility to come out of the airport, we decided to try to sleep anyhow anywhere. Fortunately the Sanchez Martín family had given us food for the occasion. Thank you! New checking up at 7.30 with some problems with our bags and with the generator. Difficulties over, we take off at 9 and arrive at our destination at 9.45.

Two vehicles are waiting for us. We get ready for the two hours ride that will take us to Sédhiou. We agree to go first to the hotel to wash up and try to rest a while before going to the hospital to unpack and set in place all the material for the operation theaters. But in fact the adventure was just beginning.

Six of us boarded a jeep and a lorry meant for four people. The way is long and the road is full of military and police controlswhich we pass without difficulty. Difficulties begin 20 km before arrival when one of our lorries suffers a puncture in a back wheel. Without replacements, the jeep lends us its extra wheel which the drivers set up in the midst of the heat with all of us waiting at the ditch. We start again, and soon a van stops because of an electrical problem. Don’t ask me, but we repair it somehow we keep going till, at 8 km from Sédhiou it stops again, this time definitely. With the other vehicle we reach a nearby village where we get a rope and try to tow the lorry. The rope splits and we are all left helpless.

By this time we are all tired, sweating, hungry, desperate and only longing to reach the hotel to eat something and then going to the hospital to unload and order all the material. We finally get another lorry to come and fetch us, and so we reach Palmeraie. 

It is 15 hours by now, but we eat something and go to our rooms. At 17.30 we go for the Centre Hospitalier. We are warmly received. Collaboration is perfet, but…

But Dr. Cámara appears and difficulties begin. Backed by his whole team (including the substitute for the director who is at present in China negotiating for a new hospital…) he gives us a lecture about mutual respect and obedience to the chief, that is to himself, and all that he may say. Quite a bad beginning.

Anyway, we do listen to him, and I just plead for mutual respect and that we, as always, are here to help and to operate upon poor patients without asking for anything.

The trouble is that, in spite of our having asked for a list of patients, there are only five ready for the next day. He effort not to get angry is great, but at least we get that while those few are operated, I may see the sick and so get more ready for operation. That first day we get 8 new cases.

We had come with the idea of working for three beds, but soon all our plans collapsed. Dr. Cámara, with plain gestures of disagreement, said no. The problem increased when we discovered that the Senegal surgeons who were going to collaborate in child surgery were in fact reduced to only one NGO (AMRAF) whom, just as in the 2016 campaign, the surgery chief has called to coincide with us.

Given this situation we had no other alternative than calling Dr. Amadou Yéri Camara, the new health chief for the Casamance region, so that he could act as mediator. He very kindly came to the hospital and took note of our requests, promising to transmit our request to another Camara who, as we foresaw, did not obey. It was a very difficult task to perform, and it got even worse when the members of the team began to show their disappointment and their annoyance. But we did not give up. I myself was astonished at my own patience. We had gone there for a campaign and we were going to carry it out, even if we knew it was not going to be as effective as the one we had planned.

Meanwhile we had established a pleasant relation with Prof. Gabriel and his team. It was not rare to see him watching our procedures. Talking together we reached the conclusion that it was essential to make the two missions coincide. I was surprised to know that the same thing had occurred the previous year… and now was repeated.

In short and without entering in further details, the mission was difficult, but it was carried out satisfactorily within the limits we were given. Comradeship was essential, as it also was the help given by the auxiliary staff of the hospital itself.

Xabier, the infirmary chief, invited us all on the 8^th.We had a great time with beers, aperitifs and laughter. But heat, very high heat. Then we walked through the village and saw popular festivities taking photos of them.

Just as in previous times the Sédhiou community held for us in the local Casa de Cultura a warm farewell in which they gave us diplomas and a picture with local motives for the “Fundación Cirujanos en Acción”. There was music, dancing with the members of our team, and supper. As in the previous campaign a representative of the governor of the province, the mayor of the city and the Prefect were present. This time I had to say a few words of gratitude for the way we had been treated and had been trusted. It was not a moment for complaints but for diplomacy, as our work should certainly settle down there. There is a great necessity for it, but all conditions should be made clear. The obstacles experienced in our last two visits should not be repeated.

 The last day of work was normal. We operated upon the last patients and we examined those of the previous day. Fortunately there was no complication. We collected prosthesis and sutures, even though Dr Camara did not like that. After all he never showed any interest in our work. He collaborated with the other NGO, with is alright with us, but he was not interested in knowing what we were doing and how.

There was no problem in our way back except long waiting in the airports and intense heat. In Dakar the family of Mariama (her brother and the daughter of our collaborator who was a student of technical engineering in the capital) were waiting for us and got for us some pizzas that helped us to spend the time. Some of us went collecting souvenirs although in previous days the girls had already collected gifts.

Mission accomplished. Exemplary team. Early morning farewell and recovering a peace of luggage which we had forgotten in the airport at our coming.

We’ll have to talk in order to correct mistakes so as to make future campaigns more and more effective. We’ll have time for that.

Elisardo Bilbao Vidal, General Surgeon

SURGEONS IN ACTION-HERNIA INTERNATIONAL

IN GATUNDU-KENYA. 2-6 OCTOBER 2017

Team Members:

Dra.Mar Pardo de Lama ( surgeon) – Team Leader

Dra.Laura Vega Lopez (surgeon)
Dra,Libertad Martin Preto (surgeon Resident
Dra.Marta Magaldi Mendaña ( anesthetist)
Dr.Jose Miguel Moran Penco (pediatric surgeon)
Miss.Sandra Rivas Losada (nurse)

Finally the day arrived, everyone met at the airport to start the adventure. 3 general surgeons, (1 last year resident), 1 pediatric surgeon, 1 nurse and 1 anaesthetist. We carried large bags for the campaign (full of drugs, toys, surgical material…). The trip  was long, 16 hours, with a scale, final destination in Nairobi. It wasn`t easy to leave the airport, the drugs that we brought in the bags alerted the police and we were retained for 6 hours until they got “the permission of the President” (or that’s what they told us). Outside the airport was waiting for us the man  who would be our faithful driver throughout the mission. He took us to Ruiru, where our hotel was. This was about 20-30 minutes from Gatundu, where we would be going to work. It was a level 4 hospital. China had cooperated and constructed a new building, with “modern” operating rooms and some hospitalization rooms.

We spent the first day in the consulting room,  exploring and scheduling the patients who would be operated the following week, adults and children. As we were collaborating with Hernia International, most of the pathologies were hernias, inguinal and umbilical. Some hydroceles and testicular tumors were also scheduled. We also operated cryptorchids, and a thyroglossal cyst in children. As an exception, we operated an intestinal obstruction that required small bowel resection.

The following days followed always the same routine, we were picked up at the hotel at 07:00 – 07:15, arrived to the hospital at 07:30 – 07:45 and reviewed the patients operated the day before. We used to gift some toys to the children, make the complex cures and explain the recommendations to the discharged patients. Patients loved watching us, always smiling when they saw us coming, some of them even asked us for some photos. We began operating at 09:00-09:30. We had 2 operating rooms, quite modern, one for children and other for adults. About 11:00-12:00 the desired coffee arrived, accompanied by typical breakfast, sweet potato, and the “wase” (similar to the potato but softer, the reality was that its flavor didn`t convince any of the Group). Lunch was at 14.00-15:00. Always the stew beef with vegetables, coleslaw and corn bread, with a basket full of bananas for dessert. 7 to 10 patients by operating room per day. We used to finish rather late, so there was no time for sightseeing. When we arrived at the hotel after work we used to go straight to the dining room and order our deserved and desired “Tusker” (a typical beer there, was our favorite). We had to get used to the African rhythm, everything  was made with a lot of calm, veeeery slow (this was applicable not only at meal time, but also in all aspects of the daily life). During dinner we talked, reviewed the anecdotes of the day and used to connect to the wifi.

Libertad Martin Preto

We worked hard, but the good company and the love for our profession made the experience worth it. We became friends, (between us and with the hospital staff who helped us in the operating room) we learned about each other, we laughed (that above all), we sweated and got tired. All this, added to the charm of Africa, discovering other cultures, other landscapes, made us returning back home with a big smile and unforgettable memories.

I will also say that the working week was followed by 4 days of a spectacular Masai Mara Safari. A new experience, unlike any other, which all of us enjoyed fully.

Luwero, Uganda September 2017

In September 2017, an eager group of doctors touched down in Entebbe, ready for another ‘hernia camp’ at the Bishop Asilli Hospital in Luwero. Three previous attendees (Tim Brown, Scott Caplin, David Hepburn), plus two new additions to the group (Guy Shingler, consultant surgeon and myself, Laura McClelland, ST7 in anaesthetics) under the care of Andy Pilcher (Care for Uganda) and his local staff. They ran as slick an operation as is possible and we were grateful for all of their hard work.

Most team members knew each other. I knew only one person but was sure that we would all be firm friends soon enough. Indeed, there is no greater breaker of ice and general leveller than when one is forced to dangle by the waist from the window of a Matatu taxi, violently vomiting for Britain, much to the hilarity of local Ugandans. When such things occur within two hours of landing, there can be no doubt that the rest of the trip will be just as eventful.

After a very welcome sleep in a guest house, we made our way to Luwero. The Matatu paint work bore no evidence of the Welsh vomit and it was like it had never happened. I would go as far as to say that I had a spring in my step as I skipped off into the dusty horizon. We drove through miles and miles of colour, dirt, poverty, pride, industry, farming, innovation, hope and helplessness. I felt incredibly privileged for all that I had ever had and was thankful for the fact that my children, by dint of where they were born, were dealt a far safer, healthier, easier hand than so many of the young lives that I observed playing at the roadside, lugging cans of water.

After arriving in Bbowa we visited the hospital for a pre-op clinic and visit to the theatre suite. The patients ranged from five months to seventy years in age. Some had travelled for days to get to the clinic. Others had been postponed from the previous year. All were shy in front of the pasty, white-faced doctors and the children made not a sound.

We identified the patients for the following day, delivered pre-op instructions through a mixture of broken English and sign language: possibly not fully understood. By the end of the clinic, we were explaining ‘tomorrow, no eat, no drink, needle in back’, finishing with a smile and a big ‘thumbs up’. 

The next morning was my first experience of providing anaesthesia outside a UK teaching hospital. Dave talked me through his previous experience and we made plans for the general/regional anaesthesia cases. I made up a spinal trolley and an airway trolley in order to provide us with a degree of preparedness, familiarity and control in what I sensed would be a rather different working setup than I was used to. Drugs, kit, a draw-over vaporiser, an anaesthetic machine, some halothane and a large oxygen cylinder all checked and ready – it was time to start.

Our first patient was a five-month-old boy. This was nerve-wracking as such a case would be the preserve of the paediatric anaesthetist in ‘our’ world. A carefully thought out plan and rigorously prepared monitoring, equipment and drugs were all that we bring to the situation and so we just had to do the very best we could. All went well and we breathed a sigh of relief that our first challenge had been safely overcome.

During the week, we performed over 80 procedures on children and adults. The motivation of patients and staff enabled us to operate on a wide range of hernias under spinal block or local anaesthesia, with the occasional use of intravenous analgesia and sedation. The paediatric cases underwent general anaesthesia with or without caudal blocks. Interestingly, only one little girl cried at induction. We took them into the theatre ourselves with the parents trustfully sending them off with a clear warning to behave! 

We did deviate from our ‘hernia’ mission on one occasion as we happened upon an extremely ill 28-year-old man on the ward. He had a perforated duodenal ulcer and was awaiting a review the following day. We explained to the patient and his family that an emergency laparotomy was his only chance of survival but his chance of death was high.

A mere seven hours into the work and we were about to anaesthetise a moribund, under-resuscitated, individual in an unfamiliar environment, among staff who spoke a different language, without standard monitoring or the normal drugs we would use. Nor was there an intensive care unit if we even got that far.

Was this appropriate? Were we interfering in the sociocultural ways of the Ugandan health system? We were present as volunteers and providing our care free of charge, but the post-operative care would be charged to the family. Would they be able to afford it? Were we potentially condemning them to a future of poverty? Their main breadwinner was very likely to die. Were we imposing our cultural values on them?

He made it through his surgery (6 litres of intra-peritoneal pus) and the night with strict post-operative instructions about fluids, analgesia, antibiotics, urine output and observations etc. He was still extremely sick the next day, but we continued to do what we could with improvised physiotherapy and oxygen via a concentrator, when power permitted.

On day two he was worse: pyrexial, hypoxic and tachycardic. All we could offer was the same with regular visits for coughing exercises, chest percussion and brief periods of sitting. On day three, he smiled and said the coughing was making him tired. On day four, he started to sip water and sat in a chair for five minutes. By day five, he was sipping mango juice and eating cake. He stood up, before collapsing back on his bed – we were thrilled.

 We have received regular updates since leaving and he is now back home with his family and his cows. I don’t think we could hope for more. This was achieved without a financial burden on either him or his family.

Watching our young friend come through his ordeal with good attention to basic physiology, medicine and nursing care was one of the most valuable and rewarding experiences of my career to date. I will forever draw on the lessons it taught me.

 At the end of the week, we had a special delivery – all the way from the Sancta Maria Hospital in Swansea. A donated ultrasound machine, shipped over to Uganda, had finally arrived in one piece. A great deal of time, money and effort had gone in to getting it to this final destination and the hospital were in desperate need of a functional machine – would it work?

With a mixture of euphoria, relief and concern, the machine was unloaded and manoeuvred into her new home. We all stood in silence, an audience full of anticipation and hope, praying that the Toshiba Aplio from Wales would do us proud. The radiographer happily wielded his probe on a ‘volunteer’, showing us all his model viscera. The machine continues to do great work for the local community but they can’t change the date format and so all scans will forever be dated December 2010!

 Our work with a bunch of terrific, highly able local staff who had taught us much had sadly come to an end. We hope that we had taught them as much as they taught us. We had safely undertaken anaesthesia and surgery on a large number of people, allowing them a healthier, more comfortable future. And the ‘team ultrasound’ had worked well, justifying what had seemed like an impossible task during the planning phase. 

The experience felt like it had gone by in a flash but similarly, I was often convinced that it had started in a different lifetime. It had shown me many things, some of which I noticed at the time and some which will no doubt continue to reveal themselves as time goes by. I am a better doctor and human for having been on that trip and feel fortunate for the opportunity to have done it.

 My greatest joy, however, is that there was no public vomiting on the return journey.

Mission Report: Chittagong, Bangladesh (6-11^th August 2017)

 Group picture outside of Nurture General Hospital with local doctors and volunteers

 Tucked away from the blaring horns of the main Chittagong roads, between paddy fields and an artillery camp lay Nurture General Hospital.

 The 6-storey Nurture General Hospital

Nurture was founded as a charitable dispensary in 1995 by Mdm Nasreen Baqui. With the help of volunteers, well-wishers and organizations, it has since grown into a six-storied hospital for the disabled and a charitable school for destitute children.

After an overnight flight from Singapore to Chittagong with a layover in Dhaka, our team of 12 volunteers from Singapore returned for our second year of performing free hernia operations. In total, 50 operations were performed including 1 hydrocele repair and 49 inguinal hernia repairs. All operations were done under spinal anaesthesia unless contraindicated or deemed to be too high risk, in which case local anaesthesia was used. We arrived bright and early on the second day and started with screening patients and setting up of equipment. Our excellent anaesthesia team got to work immediately, administering spinal anaesthesia and pre-operative prophylactic antibiotics for the first round of patients.

 Our anaesthesia team comprising of Dr Zheng Zhongxi, Dr Avinash and Dr Yeoh Chuen Jye (L to R)

Dr Avinash administering spinal anaesthesia

 All inguinal hernia repairs were done using the Lichtenstein open mesh repair technique with pre-sterilised meshes kindly provided by Hernia International. We would run up to 5 operating tables at any one time and end the day with screening more patients for the next day. All patients were admitted overnight for monitoring and were reviewed the next day in a daily ward round and discharged to continue follow-up with their local doctors.

Dr Chok and Dr Ling at the daily ward round

“Our mission would like to give a loud shoutout of thanks to Sister Carol Reid from Omagh Hospital (UK) and Dr Aleksander Stanek for donating a diathermy machine for the mission’s use. This most definitely helped improve efficiency and operation performance!”

Dr Darren Chua (L) and Dr Lee Lip Seng (R) performing an open hernia repair

 The assistance of Mdm Nasreen, her twin sons Yasmin and Yasir as well as their dedicated team of volunteers comprising of local doctors and medical students were invaluable in ensuring the success of this mission trip. The warmth and hospitality shown to us makes us look forward to returning again next year.

The team. From left to right. Front row: Dr Yvonne Ng, Dr Ling Xiao Shuang, Dr Teo Qi Tian, Dr James Ngu, Dr Goh Aik Wei, Dr Koh Ye Xin. 2^nd row: Dr Lee Lip Seng, Dr Chok Aik Yong, Ms Wendy Lim, Dr Avinash, Dr Yeoh Chuen Jye. 3^rd row: Dr Zheng Zhongxi, Dr Darren Chua

MISSION TO GANTA CITY, LIBERIA. JULY 2017

THE TEAM

John Hobbiss. Surgeon

Thomas Simon. Surgeon

Ramin Kousary. Surgeon

Takesure Mamvura. Operating Department Practitioner

THE HOST

Ganta City is a market town three hours’ drive (on a tarmacadam road recently built by a Chinese company) inland from the capital Monrovia, fairly close to the border with Guinea. The long-standing low level of health care provision in Liberia was made worse by the civil war 12 years ago, when many hospitals were taken over for military use, and then by the Ebola crisis of 2014, when many hospitals were closed. Both these events served to increase the sense of isolation experienced by Liberian doctors and rebuilding services following them has been slow.

Our host hospital, The E and J Medical Centre is an example of how some expansion of medical services is taking place. It was opened a year ago to provide mainly surgical and gynaecological services. Medical and surgical cover is provided by two doctors with support from a limited number of trainees. Anaesthetic cover is provided by two experienced anaesthetic nurse practioners, who work in both the E and J Hospital and a neighbouring hospital and a recently appointed anaesthetic practitioner working full time at The E and J.  

OUR WORK

We had seven full days of work. We arrived in Ganta City late at night and spent our first day, attending a very impressive welcoming ceremony and then seeing patients in the Out Patient Department (OPD). There had been announcements of our mission on the local radio, informing that we were coming to provide hernia repairs free of charge. About two hundred and twenty people responded to the announcements, many more than could have been operated on during our limited stay. Each responder was given a number and then called in turn to be seen in the OPD. We spent all of the next two days in the Operating theatres and then had a further OPD session on our fourth morning. One more batch of patients were seen in the OPD by Dr George on the fifth morning.

We operated on 126 patients and repaired 135 herniae. 86 patients were adult men (18 years and over), 11 were adult women and 38 were children under 18 years. There were 73 adult inguinal herniae (25 were described as inguino-scrotal); 11 umbilical or other midline defects and 2 femoral herniae. The 38 children all of whom had inguinal hernia repairs (10 were bilateral) with an additional umbilical hernia repair performed in 4. 

COMPLICATIONS

One man had a large scrotal haematoma the following morning which was drained through a scrotal incision. One man, who had a large femoral hernia repaired from below with some difficulty, due to dense scarring from previous surgery in the inguinal canal, had an obvious recurrence of the hernia by the next morning. A repeat repair was carried from above the inguinal ligament, with the pre-peritoneal space being entered through the posterior wall of the inguinal canal and the defect, along with the posterior wall, were then repaired with mesh. One man had a severe headache and neck stiffness on the morning after surgery. We were concerned about meningitis and recommended intravenous antibiotics. Two days later he had been sent home and it seems likely that this was a spinal headache. One infant developed laryngospasm shortly after returning to the ward. Respiratory support with a suitably-sized Ambu bag was required for a few minutes. This left the child with a very distended abdomen for the rest of the day, but his breathing gradually settled and he was back to normal the next day. One infant vomited during surgery and aspirated breastmilk. We learnt that he had breastfed an hour before his ketamine anaesthetic. He had a post-operative tachypnoea and some rib recession later that day but seemed back to normal by the following morning.

It is likely that more complications will develop during the days following surgery. Inevitably some of the patients with big scrotal herniae will develop scrotal oedema and haematomata, in spite of the seemingly very effective scrotal bandages which were applied by the anaesthetic practitioners. The later complication that worried us most was that of wound infection and chronic mesh infection. We had left the country before these problems would manifest themselves and, without a system of formal follow up, we will never know the actual incidence of septic complications. Dr George has said that he will keep us informed of any follow up information of which he becomes aware. 

ASEPSIS AND ANTIBIOTICS

On leaving Liberia and reflecting on our six days of surgery, the aspect of our practice which concerned us most was the potential for surgical site sepsis. It was difficult to be confident that we were operating in an aseptic field during the course of any procedure. The skin was diligently prepared with antiseptic solution but there were many instances when asepsis could not be guaranteed. Our surgical gowns were thin, single use paper gowns as we might expect to wear in an isolation cubicle. They were clean, but not sterile. The drape isolating the surgical site was very often a single-use surgical gown in which a hole was cut to give access to the patient. This was sterile but not fixed in place. The scrub nurses clearly understood the theory of asepsis but sometimes the theory did not convert into practice. The sterilization of drapes and instruments was carried out in a pressure cooker type of container heated on a charcoal fire. When a live ant appeared from a drape as we unfolded it at the start of one case, one couldn’t help wondering how reliable this system was at achieving the required temperatures for sterilization.

We had not brought any antibiotics with us for routine use. Dr George had provided each adult patient with a three-day course of an antibiotic to take home. On reflection, we would have liked to be have been able to give all patients for mesh repair a single intravenous dose of broad spectrum antibiotic at the time of their spinal anaesthetic as a prophylactic against mesh infection. To do this a supply of the antibiotic would need to be brought by the mission team.

On considering the problem of asepsis, we were very fortunate to have an Operating Department Practitioner (ODP), Takesure Mamvura, as part of our team. Whereas the three surgeons were the workers of the mission, Takesure was the educator. He was able set an example on how to maintain asepsis during the procedures using simple suggestions such as covering the feet and lower legs with a drape and using small sterile towels, which seemed to be available in reasonable quantities, around the surgical site beneath the drape. He was also able to lead by example in other aspects of ODP technique, such as the benefits of maintaining a tidy and well-ordered instrument tray, instrument handling to prevent needle stick and scalpel blade injuries and the value of needle, swab and instrument counts. 

PATIENT IDENTIFICATION AND MARKING

Another aspect of surgical practice that could be improved, following the experience of this visit, was that of patient identification and surgical site marking. All patients had a “chart”, which consisted of the two sheets of paper, one with the outpatient note and the other with the nursing note from the ward. Patients came to theatre with a chart usually, but not always, their own. Bringing the wrong chart seemed to occur more frequently with the young children. On one occasion the outpatient note stated “History of left scrotal swelling. No evidence of a hernia today in spite of crying ++. Not for surgery” and there on the table was an infant with a large right scrotal swelling. It would very helpful if every patient who was put on the list for surgery in the clinic was issued with a wrist band with identification details. Probably the name and proposed surgery would suffice. At the same time the surgical site could be marked. The wrist bands and surgical marking pens would need to be brought by the mission team.

ANAESTHETICS

One of the most remarkable aspects of our surgical experience in the E and J Hospital was the quality of the anaesthetic provision. Successful spinal anaesthetics were administered quickly and with great reliability so that additional anaesthesia, in the form of Ketamine or local infiltration, was only rarely required. The three anaesthetic practioners concerned, Abenego Yebakeh, Emmanuel Johson and Brenda Koly deserve great credit for this. In addition to giving the anaesthetic, they were also responsible for organising the operating lists and ensuring that the next patient was sitting waiting outside the theatre as the previous patient was wheeled out. The large number of cases that we operated on bears testimony to the way they worked. It enabled us to achieve a patient turnover rate which would be unthinkable in modern European practice.

One aspect of the anaesthetic practice with which we were not happy was the use of spinal anaesthetic in children. It seemed unrealistic to expect a young child to cooperate with the insertion of a spinal needle. It is true that some did manage, but others resisted and required Ketamine. We would have preferred to see Ketamine used as the first line anaesthetic for these children or at least a dose of Ketamine used prior to the insertion of the spinal needle. 

EQUIPMENT

The mesh provided by Hernia International was perfectly satisfactory. We didn’t initially realise that some packets contained double sheets for bilateral hernia so there was some wastage. We also had with us some meshes donated by Braun Ltd which were very useful for large defects. We used the majority of the large number of sutures which we had taken with us. A good supply of surgical ties was very important, as most procedures were done without diathermy. We had brought some boxes of surgical gloves and extra were supplied by the hospital. Double gloving was regarded as the norm. Thomas Simon had been given several sets of surgical instruments by Braun Ltd. These proved very helpful and future missions would benefit from providing themselves with, if nothing else, suitable dissecting scissors. The hospital provided scalpel blades, but smaller ones for paediatric use would have been useful.

The operating lights provided good illumination but were sometimes difficult to manoeuvre. Also the electricity supply was erratic and a number of blackouts occurred. These were, thankfully, short-lived and hopefully will be less frequent when the planned solar / battery system is installed. Even so, we recommend that surgeons on future missions provide themselves with the reassurance of independent illumination from a good quality headlight.

One of our party sustained a significant needle stick injury during the course of a procedure. The spot test for HIV on the patient was negative. The surgeon concerned had brought a five day course of PEP (post exposure prophylaxis) with him and was reassured by being able to take it.

PAEDIATRIC SURGERY

A significant proportion of the surgery that we undertook was on children and we would strongly recommend that future missions include at least one surgeon who is familiar with groin surgery in children. We felt that the paediatric surgery that we did was potentially the most beneficial of all our work. If a simple herniotomy in childhood can prevent a large inguino-scrotal hernia, in which the vas is densely plastered to the sac (a very common scenario), in early adult life, then so much the better.

The infants who were bought for surgery all had bilateral, irreducible inguino-scrotal herniae. It seems likely that it was the recognition of the high risk of strangulation, with its very grave prognosis, which prompted the mothers to bring their babies for surgery. These were some of the most challenging cases that we were confronted with during our mission. The Ketamine provided no muscle relaxation and seemed (understandably) to be given fairly sparingly to the babies. A sudden flexion of the hip during the course of the dissection was not uncommon. Usually the inguinal canal had to be full opened before reduction could be achieved.

After we had spent our first day seeing patients in the clinic, we decided that we should put the children before the adults on the next days’ operating list and that, in line with our normal practice, we put the youngest children first. We realised, too late, that this meant that we had given ourselves the most challenging cases to do first in the unfamiliar operating theatre with unfamiliar staff. Subsequent missions may wish to pick some reasonably straight forward cases for their first morning.

TEACHING AND TRAINING[JH1] 

The purpose of our mission was to provide the “free of charge” hernia repairs, which had been advertised on the radio, to as many patients as we could. This meant that we needed to do most of the operating ourselves, rather than spend time training the junior surgeons. Clearly, however, if we could train some of the local surgeons to do high quality hernia repairs, which in our case meant either a mesh repair or, in selected cases, a Shouldice repair, then we would leave behind a more sustainable surgical legacy. We had a particular incentive to do some training, as we knew that those patients who had presented following the radio announcement and whom we didn’t have time to operate on, were assured that they would have their hernia repaired as part of the “free of charge” deal by the local surgeons after we had gone. Two of the local surgeons, Dr Charles Manakpalah and Dr Charlie Kinpesa were very capable surgeons. They were taught to do both mesh and Shouldice repairs. We received a message subsequently from Dr Charles to say that they had successfully operated on the remaining patients.

Also assisting us were other surgical trainees of very variable experience. Some of them had not yet acquired basic surgical skills. They were advised to practise their knot-tying and suturing as much as possible before the next mission to the E and J Hospital in order to obtain maximum benefit as from the experience.

ACCOMMODATION AND SUBSISTENCE

We were provided with very comfortable accommodation at Jackie’s Guest House, where we had individual rooms with en-suite facilities, television and intermittent Wi-Fi. One of the pleasures of the week was sitting in the courtyard of the guesthouse in the evenings, drinking the local beer in the company of Peter George and his friends. The breakfasts and dinners provided by Jackie’s were much enjoyed. Food was not included in the $50 per night fee that had been negotiated for us by Dr George and future missions should be aware that subsistence expenses will contribute significantly to the cost of their mission.

There is no hospital restaurant in the E and J Hospital and special arrangements had to be made for lunch. We would advise future missions to discuss the provision of lunch with Dr George. During our week, Dr George usually arranged for food to be brought in from outside the hospital and we ate it in his office. (It is important not to forget to pay for this as otherwise Dr George would have to pay for it himself.). On two occasions we were taken into town in a hospital car and had lunch at Maggi’s Restaurant. This is something that we would recommend, both for the enjoyment of the lunch and for the welcome break it gives in the middle of a busy day. We also recommend that surgeons provide themselves with water to take to the operating theatres (or Coca-Cola if caffeine is required in addition to rehydration). We were aware that, in spite of the air conditioning in the theatres, we were often sweating freely during the long and sometimes demanding sessions. 

CONCLUSION

We would like to pay tribute to the hard work undertaken by Dr George and his support team at The E and J Hospital in preparing for our visit. Missions such as ours require close co-operation between the host and the mission. The support we received at the E and J Hospital demonstrated that it was a very suitable host for such missions.

In the long term it is to be hoped that expansion of medical provision by the Liberian State will enable a service to develop which will begin to tackle the large number of people who would benefit from elective surgical care. For the time being, these people will have to rely upon charitable provision by external agencies. We hope that our mission has paved the way for successful missions in the future.

All four members of our team left Liberia with happy memories of the country, the town, the hospital, the people and the marvellous welcoming and farewell ceremonies that we found so moving. Our heartfelt thanks to all concerned for the hospitality that we received.

 John Hobbiss

Campaign for Hernia Surgery, Ventanilla 2017

On July 29 2017 we eight volunteers started from Madrid, Brisbane, Cardiff and Mexico for Lima to carry out a Humanitarian Surgical Hernia Mission in the Ventanilla Hospital. This Campaign was undertaken by the Foundations “Cirujanos en Acción”, and Hernia International.

The Mission took place from July 31^st to August 10^th in the Hospital General of Ventanilla district. It is a Level II Hospital inaugurated in 2007 which has 100 beds and 5 operation theaters. It has 14 surgeons, 6 anaesthetists and 17 professional nurses. The Surgery Department carries out conventional surgery, abdominal wall laparoscopic surgery, biliar surgery and rectal surgery among others.

The Ventanilla District belongs to the El Callao Province and it is a densely populated community with about 375000 inhabitants, situated at two hours from Lima. The Ventanilla population is mainly poor, and part of the people live in settlements in the nearby hills with any number of huts and heavy environmental pollution owing perhaps to an excessive growing rhythm that has exceeded the capacity of the local resources. The “Ventanilla” name (small window) comes from innumerable caves and passages that looked like small windows from the sea and which pirates used to hide in them the treasures stolen from the forts and ships they attacked.

 Voluntaries for the Ventanilla Mission 2017: 

The Mission was made up by eight volunteers, four consulting surgeons, one consulting anaesthetist, one resident, one nurse and one in charge of Logistics, Communication and Documents.

Dr. Manuel Cires – General Surgeon – Navarra, Spain

Dr. Rafael Chaves – General Surgeon – Cardiff, England

Dr. Hugo Mc Gregor – General Surgeon – Brisbane, Australia

Lady Dr. Estefanía Villalobos – General Surgeon – Mexico City, Mexico

Lady Dr. María Remón Izquieta – Anaesthetist – Navarra, Spain

Lady Dr. Justine Etuláin – Resident 4, Anaesthetics – Madrid, Spain.

D.U.E. Lola García – Nurse – Madrid, Spain

María Orbe – Logistics, Communication and Documents – Navarra, Spain

The team was directed and coordinated by Dr Manuel Cires, with the co;;aboration of Dr Luis Bernaola, Chief of the surgery service of the Ventanilla Hospital.was directed and coordinated by Dr Manuel Cires, with the collaboration of Dr Luis Bernaola, chief of the surgery service of the Ventanilla Hospital.

We also had the valuable collaboration of all the enthusiastic staff at the hospital, including anaesthetists, general surgeons, nurses, helpers, cleaners, cooks, administrators and others.

Operating Theatres

The Hospital has five operation theaters in a single surgical area. Four of these were put at the disposal of the Campaign, leaving the other for urgencies in General Surgery and Obstetrics.

Of the four available operation theaters two are conventional and the other too are small, prefabricated and temporarily adjoined to the main building. They had the necessary resources for work, but the largest number of material, including surgical sutures, nets, electrical scalpels, antibiotics, analgesics, anaesthetic products among others were provided by the voluntaries themselves.

A system was established by which the majority of the patients were discharged in the afternoon and only a few with more complications were sent to the Short Stay Department.

The Patients 

Patients were contacted before our arrival through announcements of our Campaign in the local media by surgeons there, as also through volunteers who visited poor areas in Ventanilla with our proposal for free interventions for all. Still, in some cases there was no discrimination made and people with greater resources were also treated.

The selected ones were previously evaluated by local surgeons and anaesthetists with a special study and reasoned consent, and they received due information on the whole procedure as well as instructions for their preparation including personal hygiene. As a result, all patients were properly prepared and at peace.

The way from our residence in the San Miguel area in Lima to the Hospital at about 40 km. distance took more than one hour on account of the heavy and irregular traffic of cars and lorries on the Panamerican road.

Our activity began at 7:45 hours with the introduction of the team of volunteers to the patients and their relatives in the hospital hall; then María Orbe, our expert in logistics and communication, gave them further information and answered their questions, thus informing the patients and their relatives and facilitating the team’s work.

The patients in the surgical area were first attended to by local doctors who collected the data for a proper control of the whole surgical activity; they were then questioned and reexamined by the surgeon and the anaesthesist in full detail.

The type of anaesthetic was in general local, although a good number of operations were performed under local anaesthetic and sedation, and a few under general anaesthetic.

In each operation theater the surgical team was made up by a Campaign surgeon assisted by resident doctor or surgeon, an anaesthetist, a nurse for the instruments, and a helping nurse.

We carried out the check list according to the OMS Manual for verification before and after each intervention, as this is the practice in the Ventanilla Hospital.

Results

Number of patients:         177

89 men and 88 women

Number of proceedings:   200

            · Inguinal hernias: 79 – Umbilical: 85 – Epigastrical: 27 – Incisional: 8 – Others: 1

Distribution of inguinal hernias according to their classification as a help to fix the complexity of the operation.

–      H1: (hernia inside the inguinal canal) n = 42

–      H2: (hernia settled in the superficial ring) n = 27

–      H3: (inguinoscrotal hernia) n = 10

Complications

7 cases:

1 Coming loose of suture in umbilical hernia when carrying out a new suture.

1 Slight inguinal pain of ingyuinal hernia treated with analgesics and antiinflamatories.

1 Seroma of incisional hernia treated with aspiration and ambulatory drainage.

2 Inguinal and inguinoscrotal hernia treated in a conservatory way.

2 Inguinal umbilical wound hernia and inguinal hernia treated with local cures and antibiotics.

Discussion of results

Of the 200 surgical procedures realized 7 complications were reported which did not need surgical intervention; the infection rate was 1%, a very low value, taking into account that the majority of the patients had not received any antibiotical profilaxis. The seroma was treated in ambulatory sessions with punction and drainage, and the hematoma was treated in a conservative way.

Observations

The personal at the hospital kept excellent asepsical measures during the whole campaign.

The nurses in charge of the instruments kept an excellent discipline and technique in the operation theatre.

–      Washing of hands: with clorhexidina foam.

–      Antiseptical preparation of the premises: they used clorhexidina soap to prepare the area.

Formation and Teaching:

An important teaching activity took place during the Campaign, so that the residents in surgery and anaesthesiology took an active part in diverse surgical and anaesthetical procedures under the supervision of voluntary surgeons and anaesthetists.

The last day of the Campaign we volunteers carried out an Academical Session with the following themes:

–      Humanitarian Help: origin and actual state of the Hernia International and Surgeons in Action Foundations. Results of the 2917 Campaign in the Ventanilla Hospital, Dr. Manuel Cires.

–      Surgery in the last century. Multidisciplinary handling of surgery in the last years. Dr. Rafael Chaves.

–      Presurgery preparation in patients with giant ventral hernias: botulinica toxin, principles and technique; progressive and preoperative pneumoperitoneon. Dr. Estefanía Villalobos.

Surgical block. Standards and recommendations for the patient’s safety.

The Campaign ended on August 10^th. Dr Wilber Espinoza, Director of the Hospital, addressed the voluntaries and gave thanks for the notable effort as well as for the high level of satisfaction of patients and relatives, and invited repetitions of new projects in the future. We were later given a diploma and were invited to a farewell supper in Lima.

ConclusionThe campaign has meant a great effort for all of us. It began several months before our trip to Lima with the creation of the voluntary group, unknown persons from different countries and cultures, who

The fifth mission of Hernia International to Brazil

The mission was carried out in collaboration with the Brazilian Hernia Society from July 23-29^th, 2017.  The regional focus of this mission was the state of Rio de Janeiro and was based out of the city of Rio de Janeiro as well.  This included a one day conference on July 27^th, bringing together faculty from the mission and healthcare providers from around the country.  The team of 12 surgeons was lead by Dr Christiano Claus, along with local coordinators Heitor Santos, Luciana Guimaraes, and Marcio Cavaliere.  The group also included myself and Arunkumar Baskara from the US.  We repaired 125 hernias in over 100 patients at six different hospitals across the state, including: Laurenco Jorge Municipal Hospital, Iraja Hospital, Gaffre Guinle University Hospital, and Ipanema Hospital in Rio de Janeiro; Japuiba State Hospital in Angra dos Reis; and State Hospital Adao Periera Nunes in Saracuruna.  The operations were aided by local volunteer surgical scrub techs and nurses, some of whom traveled with us from surrounding areas, as well as the residents from the local hospitals.  Anesthesia coverage was provided by the hospitals.  Traveling to the hospitals outside of the city provided a brief glimpse of the beauty of the state, as if the city doesn’t offer enough!  Of course, there were plenty of social opportunities to get to know each other, including an awe-inspiring dinner at a famous Churrascaria in Rio de Janeiro.

Heidi Miller, MD MPH  

MEMORY OF THE CAMPAIGN 16 June – 3 July IN THE HIPÓLITO UNANUE HOSPITAL, TACNA, PERÚ

After 4 months of preparation, the day came at last to start towards the Hipólito Unanue hospital in the Tacna region at the South of Perú. In the airport we all gathered with Teresa to prepare the bags with our equipment. This is always a great moment when the members of the team come to know each other in between chaos and nerves. We are 9 persons, 4 general surgeons, 1 paediatric surgeon, 2 anaesthetiologists and 2 nurses. For some of them this is their first mission, although most of us have had some previous experience

We land at Lima after a 112 hours flight, and there Dr. Herrera, who is coordinating all our Tacna mission, is expecting us. He takes us at once to the centre of Lima where we see the Main Square and the Cathedral.

We come back to the airport to catch our Tacna fight, where on arrival we are met by a great welcome committee headed by the Health Regional Director, Claudio Ramirez. They give us flowers and take us to our hotel.

We settle down in 10 minutes and proceed to the hospital with all our material. There are more than 70 patients waiting, and we begin, together with Dr. Chura, coordinator of the Tacna mission, and Dr. Carpio, to organize the program for the next days. Most of the patients have already gone through the proper preparation, and have been evaluated by cardiologists, anaesthetiologists and surgeons, what has meant quite an effort for the hospital staff.

 The day after our arrival we start operations. With the help of the local surgeons we are able to operate upon 17 patients on that first day. We had 4 tables in 2 different rooms. Lady Dr. Pilar Murga, anaesthetiologist, together with nurse Almudena Ceballos in one room, and nurse Mercedes Contreras in the other. Paedriatic surgeon José Miguel Morán and general surgeons Lucía Catot, José Manuel Hernandez, Claudia Tinoco and myself went from one room to another according to need, always with the help of hospital surgeons, residents,students and nurses.

I want to underline the work of the nurses Almudena and Mercedes as well as Isaac, René and Delia who very efficiently organized the whole work.

In this way we began our daily work with Marathon timings with began at 7:30 h. with heavy work side by side with the hospital staff, so that by the end of the mission we had operated upon 170 patients with almost 200 procedures, with the greater part of patients being given leave on the same day. Those who had to be hospitalized were evaluated at the beginning of the next day. The operations were chiefly inguinal and umbilical hernias, some of them very large because of a long evolution, and incisional and epigastric hernias. Only a few children were operated upon, as there was little information and collaboration by locals.

In the midst of all this work there were always some moments to disconnect, particularly at the meals with the delicious traditionally Peruvian dishes prepared by Carmen and her daughter Vanesa, and also in our walks after work through the city of Tacna. One day Dr. Chura and Isaak took us to the seashore to admire the Pacific Ocean which many of us had never seen before.

Besides that daily work we also organized some teaching days where a workshop on operation theater work and experiences was carried out and three talks were given: “Inguinal hernia treatment through open hernioplastia mesh” (Lady Dr. Gay Fernandez); Inguinal hernia treatment by laparoscopic way. Tapp and TEP” (Dr Hernandez Gonzalez) and “Surgical calendar for children” (Dr. Morán Penco) with a large audience from hospital staff and students.

After 10 days of hard work came the farewell. They organized a function with the hospital director and the national health surgeon where they gave us a thanksgiving document from the Tacna community.

The mission in the Tacna Hipólito Unanue hospital, the first in the region, had been a success, and both the hospital staff and the patients are looking forward to new campaigns. All this has been possible thanks to good work relationships and to the outstanding persons of the team, together with the great persons who made up the team and the collaboration of the Hipólito Unanue hospital staff, chiefly Dr. Chura. Without of course forgetting Dr. Herrera and Martha Vasquez who helped us from Lima.

With the satisfaction of a work well done we started for Cuzco to see one of the marvels of the world before coming back to our usual routine.

 Korogwe Hospital, Tanzania – May 2017

                                                The team and the mission

In May 2017 Hernia International arranged for a team of surgeons and anaesthetists to be deployed to Korogwe Hospital in Tanzania. Mr Alex Stanek, a consultant surgeon from Northern Ireland led the team. With him were senior consultant surgeon Mr Biku Ghosh and consultant anaesthetist Dr Patrick Stuart. Trainees Mr Vernon Sivarajah (surgical registrar), Dr Christina Croitoru (surgical SHO) and Dr Jonny Guy (anaesthetic SHO) also joined the team.

The hospital was located in the small town of Korogwe some 300km (6-8 hours) northwest from Dar Es Salaam (the place of peace). Korogwe is primarily a transport junction and of relative anonymity despite sitting on the outskirts of the beautiful densely forested Usambara mountains.

Our journey took us from the UK to Dar Es Salaam were we stayed overnight before making the 8 hour mini-bus journey to Korogwe. On our arrival Sister Avelina Temba (Nun and chief surgeon) and her team were present to welcome us. During our introductions the importance of missions like ours couldn’t have been clearer. We were told that on average there were 10 deaths per years from complications related to hernias and that of the ones that were repaired there was a 60% recurrence rate. We would later witness the importance of the mission first hand when we performed an emergency femoral hernia repair on a young lady who was acutely unwell for days with a strangulated hernia and small bowel obstruction.

                                                                   The hospital

The hospital itself was a blast from the past, a 1950s build consisting of approximately 100 beds divided into traditional nightingale wards.

Our journey took us from the UK to Dar Es Salaam were we stayed overnight before making the 8 hour mini-bus journey to Korogwe. On our arrival Sister Avelina Temba (Nun and chief surgeon) and her team were present to welcome us. During our introductions the importance of missions like ours couldn’t have been clearer. We were told that on average there were 10 deaths per years from complications related to hernias and that of the ones that were repaired there was a 60% recurrence rate. We would later witness the importance of the mission first hand when we performed an emergency femoral hernia repair on a young lady who was acutely unwell for days with a strangulated hernia and small bowel obstruction.

There were three operating theatres. Two were large, with one just about suitable for basic general anaesthesia and the other for spinal anaesthesia. Both rooms had state of the art, donated anaesthetic machines but they were lacking readily available key components necessary for safe anaesthesia (more on this later). Both rooms had descent theatre lights and semi-functional air conditioning. The third theatre was a tight squeeze and can only be described as a small bedroom with a theatre table and a standing theatre light. Non-the-less it worked well as a theatre for performing smaller hernia repairs under local anaesthesia.

The surgical sets often had an array of instruments, which were a little worn but were usually fine to use. To help with future missions we donated 200 instruments most of which were brand new. We were very fortunate to have three fully functioning diathermy machines.

Equally as important as the facilities and equipment was the full compliment of Korogwe staff who supported us and were essential to the smooth running of the mission.

                                                           Day to day

Our days would begin at 7.30am after a hearty breakfast with a short ride from our accommodation to the hospital. The pre-operative patients were assessed and listed for their operation by us at the end of the previous operating day.

The local doctors clerked, bled (viral screen), consented, marked and canulated them so that they were ready to go by the morning. Before we started operating we would review our post-operative patients from the previous day to ensure that they were well. We operated in all three theatres simultaneously and so had a continuous flow of patients, which was facilitated by the theatre staff. Lunch was provided by the hospital and was usually a mixture of ndizi-nyama (plantains with meat) or samaki (fish) with ugali (maize) and vegetables. The afternoon theatre lists would run until about 6pm after which we would see the pre-operative patients for the next day.

                                                              Operative record

Over 5 operative days we performed 64 procedures on 50 patients. The most common procedure were inguinal hernias repairs of which there were 32. Five of these hernias were the typical large inguino-scrotal hernias of the developing world and 2 were recurrent hernia repairs. Other procedures included 17 umbilical hernia repairs, 10 hydrocelectomies, 2 epigastric hernia, 1 cord spermatocele, 1 large incisional hernia repair and 1 emergency femoral hernia repair for a strangulated hernia. We also provided anaesthetic support for a category III C-section, which was undertaken by Sister Avelina.

With the expertise of our consultant surgeon Biku and consultant anaesthetist Patrick we were able to safely offer paediatric surgery to 14 children, the youngest of which was 18 months old. We utilised all three theatres and operated on 16 patients under general anaesthesia, 19 patients under spinal anaesthesia and 15 patients under local anaesthetic.

One of our most challenging cases was our very first. We performed a large incisional hernia repair in a 65-year-old gentleman under spinal anaesthesia, which later had to be converted to a general anaesthetic with ketamine. He made a slow but steady recovery and was discharged 5 days later. To avoid an inevitable seroma and because we didn’t have a redivac (negative pressure) drain, our surgical SHO Christina came up with a novel negative pressure drainage system using a 50ml and 10ml syringe and some tape.

The first two days were highly productive having undertaken 33 surgical procedures. Unfortunately heavy monsoon rains and floods made it difficult for patient to get to the hospital and as such our productively slowed. We did not get disheartened as this gave us more time provide training to the local surgeons in the technique of mesh repair for inguinal hernias.

                                     Practical anaesthesia in a resource limited setting

Patrick and Jonny our anaesthetist performed valiantly with such limited resources. They had to adapt their normal practice and improvise when needed. To keep things simple and safe the kids received halothane to breathe and our surgeon Biku gave them local anaesthetic as he cut. The vaporiser can easily be used to provide halothane anaesthesia without too much fuss. Most of the adults received spinal anaesthesia using a single shot of bupivacaine. There were limited drugs, syringes, needles etc. Fortunately the anaesthetist brought 100 doses of bupivacaine and some emergency medications – worth their weight in gold.

The anaesthetic machines in theatre were only functional for monitoring and even then there was a lack of ECG adhesive pads. This was overcome by the application of some lubricating gel and tape to the bare lead electrode. The anaesthetic machines were missing key components. Crucially and somewhat frustratingly the plug from some of the machines did not fit the three-pin socket. All that we needed was a normal kettle lead fitted with a three-pin plug to fire up the world class monitoring system. In addition, CO2 absorbers were missing, which would have provided a readily usable ventilator and circle system.

One of the biggest problems was the limited provision of pressurised oxygen. Only a single large cylinder, which lasted about 10 hours was available. Replacing it wasn’t easy but Avelina’s team did well to source a small cylinder, which again is now unfortunately in the red zone. In addition there was only one regulator without which oxygen cannot be delivered. The lack of pressurised oxygen is probably the biggest issue to address as it is essential for keeping patients safe. It would be important before any future mission to request that Sr Avelina looks at finding a way to have one large cylinder being topped up, while at least two full ones are physically present in the hospital.

                                                Shopping list for future missions

Visiting surgeons and anaesthetists need to consider how best to equip themselves prior to leaving. One important factor to mention is that patients who are planned for a hernia repair have to pay a small sum of money. This buys them a physical operation but not always the materials and drugs that come with it for example antibiotics, anaesthetic, syringes, needles, sutures etc. As a result we brought most of the materials ourselves.

With three theatres running at full capacity there is potential to undertake 90-100 procedures. We have provided a brief list of materials based on our recent mission.

Surgical materials needed:

·        Gowns

o   Korogwe do have their own re-usable gowns but we brought in excess of 200 disposable gowns ourselves. They should be able to accommodate for future missions without the need to extra gowns.

·        Gloves

o   Will need plenty for the team and korogwe staff

·        Face masks and theatre caps

·        Mesh

o   Sterilised and of the mosquito brand

·        Sutures

o   Lots of 2/0 vicryl, 2/0 prolene, 3/0 monocryl

·        Local anaesthetic

o   They only had plain 1% lidocaine and adrenaline was available separately.

o   Safer to take lidocaine and bupivacaine pre-mixed with adrenaline.

·        Diathermy plates

o   They have a metal plate which they re-use

o   Recommend disposable plates, which we reused.

·        Diathermy pencil tips

·        Drugs – Antibiotics, analgesia

·        Dressings, needles, syringes

Anaesthetics materials needed

·        Oxygen regulators

o   Only one available at present

·        CO2 absorber and breathing circuits

·        Laryngoscope

o   I would suggest that one is not left there as they are very easy to misplace

·        Intubation/airway equipment

·        Paediatric masks, airways and LMAs

·        IV cannulas

·        Nitrile gloves, tape and cleaning solution

·        Anaesthetic drugs

                                                                       General

·        Malaria prophylaxis and repellent is essential especially for a mission in May (very wet season).

·        US dollars as well as Shillings, which can be bought from the airport or from banks close to the hospital.

·        Tourist visa ($50 from the airport) – it’s a lot cheaper than a business visa.

Cost of the mission and accommodation

Our flights from various parts of the UK to Dar Es Salaam cost approximately £350 when we booked a couple of months in advance. Most of us landed late on the Saturday and spent the night at the Best Western Plus Colosseum Hotel in Dar Es Salaam (£100). Early on Sunday morning our mini-bus (£280 to total), which was arranged through Sr Avelina took us to the hospital and later to our accommodation – the White Parrot.

The White Parrot was basic but served all of our needs. Bed and breakfast was a modest £20/night. They had their own restaurant for dinner, which was also great place for a nice cold Tusker beer or Fanta after a long sweaty day at work.

                                                       Many people to thank

Above all, the biggest thank you is to Hernia International for opening doors for teams like ours to provide a service for the people of Korogwe.

Also, we are hugely thankful for the efforts of our team leader Alex, who behind the scenes been carefully masterminding every aspect of the mission. Our team, most of whom had not worked with each other before were excellent. We all appear to have just clicked, mucked in, and battered on through the work with great efficiency, warmth and good humor.

Finally, the team in Korogwe led by Sister Avelina has been marvelous. From the red carpet treatment meeting the officials on day one, to the generosity, hard work and willingness to accommodate shown by the staff. It was a pleasure to work with them through Hernia International and we look forward to future missions.

Vernon Sivarajah

Benin, April 21-29, 2017

Cea-Cea Moller-team leader,

Richard Turner – surgeon and hardest worker

Christine Russell-surgeon and bold French speaker

Philip Gribble-anaesthetist and educator

Paul Scaife-surgeon and fastest runner

Clancy– teenage anaesthetic nurse student scribe scout interpreter!

         This is a small mission hospital in Dangbo that provides general medicine–adult and paediatric, maternity, an immunization and an HIV/AIDS service. It has a functioning pathology laboratory. There is a departmental hospital about half an hour away where the patients for emergency caesarian are sent. There is no full time surgical team in Dangbo, just charity missions from other countries–particularly one paediatric surgical team from Spain. This was the first mission from Hernia International.

We were 4 surgeons, 3 from Australia and 1 from the UK, 1 GP anaesthetist from Australia and 1 mission aide from Australia. Communication between us and the local staff was in French. Some patients spoke French but mostly the local staff translated for the patients between French and Fon.

            During the week we had a visitor from Porto Novo, a training surgeon, Dr Juste. He had been a general practitioner at the hospital in Dangbo and often assisted visiting surgical teams. He had thus been inspired to enter surgical training. He recounted that surgical training was a very expensive exercise and that his parents had to support him financially. When he qualified he said that he would find it difficult to come back to Dangbo to operate because the patients would not be able to pay him. In the hospital in Porto Novo they did not do mesh repairs of inguinal herniae but performed a Shouldice repaire

Pre-arrival

         Yellow fever vaccination and a visa are required to visit Benin. The 4 Australians needed to send their passports to London to obtain the visa. The process of returning the passports to Australia was somewhat precarious!

         It is difficult for the hospital director Sister Opportune, to communicate by e-mail. She finds ‘WhatsApp’ to be more efficient when arrangements are being made for the missions.

Arrival

         At Addis Ababa airport extensive questions were asked about the goods we were bringing in but the Hernia International introduction letter, the itemized list of contents plus the fact that we were only staying overnight meant we were allowed through. At Cotonou airport we were also questioned about the goods but the mission authority paperwork from the local health directorate in French was enough to allow us in the country with the donated medical supplies.

         One of the nuns and a driver met us at the airport in the hospital ambulance/bus. The drive to the hospital lasted just under an hour over very potholed roads with dense traffic and the impression of many near misses!

Accommodation

We stayed about a 500m walk from the hospital down a dirt road in a paved compound of 2 large buildings, the use of which is donated by the owner who lived in Porto-Novo. This was luxury compared to the local population’s housing. Each of our 3 large rooms was air conditioned with an en-suite. Cold drinks, including beer, were supplied in an insulated box with ice added occasionally. Bottled water was provided. No bedding or towels were provided.

            There was no access to internet other than by walking to the local hotel (about 1km away) to use their Wi-Fi. For the Australians, no phone coverage was possible. Our English surgeon Paul was able to get somewhat intermittent coverage.

Food

         Breakfast, lunch and dinner were provided by the nuns in their dining room at 5 minutes walk from the operating theatre. It was delicious, with either an African or a French focus. We ended up cutting back on lunch and snacking in the theatre store room so we could get our programmed work finished.

Patient Preparation

         In preparation for the visiting teams, advertising is in the form of word-of-mouth, through the church network, radio commercials, through family and friends and even a man on a bike riding around with a megaphone informing the community at large. The patients write their name with their problem and contact details down in a book at the hospital pharmacy. The prospective patients are then vetted by the local doctors before being seen by the team.

         Surgeon Richard flew in from Australia, arriving Friday night, and on the Saturday saw 100 patients who needed surgery. He programmed 10 patients each day for the Monday to Friday that we were to be operating. There were 45 inguinal herniae (2 bilateral), 1 large incisional hernia, 1 large neck keloid scar and 5 other minor procedures.

         Each patient had routine bloods including HIV status pre-op. Only 1 of the 50 patients was HIV positive.

Theatre

         The theatre is a fairly small room (approx. 5 x 5m), with 2 operating tables, separated by a wooden screen. Thankfully it is air-conditioned! When we walked out of theatre during the day it felt like walking into an oven!

         There is no pre-anaesthetic or recovery area; the patients return to a post-op ward which is in the adjacent building. For the week, this post-op ward was staffed by Gabin, a surgical nurse who came from Porto-Novo for this purpose and even slept in the ward for immediate access to the patients. He had some help from a nurse assistant.

         Oxygen is provided by a large cylinder. Suction is a stand-alone ‘Medpap’ machine with foot pedal; for both surgical and anaesthetic use. There is a Drager ‘Fabiusplus’ machine which can provide ventilation (VC & Manual Spont. only) along with a monitor providing a screen with readout for SpO2. No airway gas monitoring is available. Both paediatric and adult circuits are present with spares. A ‘Laerdal’ bag is also present. Oxygen tubing, connections, ETT tubes, iGels & LMAs are also available, numbering in the 10s for each (inc. paediatric). At least 4 intubating stylets and 4 Cook’s-brand bougies were available. IV access was well supplied with cannulae ranging from 14 – 22g. There was a large number of various spinal needles (20 – 27g) along with 5 central line kits.

         Presumably left-overs from previous teams, there was a surprisingly wide variety of drugs available, although many ampoules were out of date. IV drugs we found on arrival included :

AdenosineAdrenalineAlbumen 20%AmiodaroneAmpicillinAtropineBupivacaineBuscopanCa ChlorideCalcitriol

CeftriaxoneClindamycinDiazepamEtomidateFentanylFlumazenilFrusemideGentamicinHaloperidolHydralazine

KetamineLignocaineMetaclopramideMetronidazoleMidazolamMorphineNaloxoneNeostigmineNitroprusside

OndansetronPolaraminePropofolRocuroniumSteroids (5 types)SuggamadexSuxamethoniumThiopentoneTranexamic Acid

         In the store room was an eclectic array of equipment, ranging from a multitude of sterile gloves and dressings to a variety of instruments and even an old portable U/S machine. Suture material and small disposable drapes seemed reasonably plentiful.

         Operating gowns were limited in number; for most operations yellow infection control gowns were used. We had brought only 30ml syringes. Small syringes were not abundant, making measurement of small volumes difficult (e.g. when mixing adrenaline in to LA). Another surprising deficit was in small stainless steel gallipots for mixing. The array of instruments is generally adequate, the most prevalent issue being the blunt dissecting scissors; bringing sharp scissors would have made a material difference to the operating.

         Sterilisation is done on site with a turn-around time of approximately 45 min. It was unusual for us to have to wait for this.

          Sister Ruffine was an able scout nurse in theatre. She managed the pace of the patient flow related to sterilized trays being available and laying out the next sterile set up for each patient.

         Power was generally reliable, although it was not unusual to have brief outages (for 2-3 minutes) throughout the day. The main inconvenience was waiting for the diathermy to re-boot. Fortunately, this had no effect on the air-conditioning. Whilst we had brought head-torches as a fallback, these were rarely used.

The operating lights are of reasonable quality and reliable; spare globes were available and we did use one.

         Each day commenced at 8:30, although the first patient usually arrived at about 9. Operating was divided between the two beds; ‘1’ being next to the anaesthetic machine. Cases were planned with the potentially more complicated ones being for bed 1 although spinals were available for bed 2 if required.

         Scrubbing is at a simple sink with Chlorhexidine and alcohol; the tap is a simple knob i.e. not able to operated once scrubbed.

Operations

         Local protocol outlines every patient receives IV Ampicillin 1gm, Metronidazole 500mg, Gentamicin 80mg & Diclofenac 75mg. This is continued for 24 hours post op. A glass bottle of IV fluid also comes with each patient in their small cardboard box.

         Each table was manned by 2 surgeons with 1 operating and 1 assisting. This was ideal given the very scarred cases that we found. Gabin the ward nurse was an enthusiastic surgical assistant on the occasion when we were down to 3 surgeons instead of 4. Half of the patients had large herniae but even the smaller reducible cases had a surprising amount of scarring at the external ring and of the sac to the cord.

         We programmed 10 patients per day and didn’t finish until 8 or 9 at night.

Anaesthetics

         Spinals were required for 50% of cases. These were generally reliable although 3 men had bony obstruction; 5 required supplemental sedation and on 2 occasions, the operations exceeded the duration of the spinal. Only one patient required Ephedrine for hypotension (asymptomatic; given out of caution, especially due to Phil’s concern about the accuracy of the sphygmomanometer, rather than physiological sequelae).

         Our impression was that slightly larger volumes of ‘heavy’ Bupivacaine 0.5% were needed for the spinal anaesthesia for good effect.  The usual dose would have been around 2.8ml; here, easily 3.2 – 3.4ml was needed.

         Sedation was primarily with Ketamine but supplies of this were limited (over half of the stock found on arrival was out of date). Fortunately, the alternative of Midazolam and Fentanyl was available. Propofol was used twice, again, from found stock.

         Due to lack of gas monitoring, no recovery ward or dedicated nursing staff, as well as intermittent unreliability of the oximeter, the decision was made to avoid GA with paralysis. Sevoflurane was the inhaled agent available, no NO2 or air mix was possible, so GAs were managed on 100% O2. Two GAs were given (in both cases secondary to failed spinal insertion), both on LMA without mishap. Recovery occurred in the theatre unit until both were clearly responsive to voice alone. Oxygen was used sparingly for events of demonstrated reduced saturations <94%.            Post-op analgesia and management was done by Gabin, the surgical nurse in the post-op ward. It appeared that the range of analgesia extended to oral agents and IV Diclofenac. As such, all patients were given either local infiltration of 0.5% Bupivacaine or TAP blocks at the end of the operation (including patients with spinals).

Post-Op

         The expectation by local staff was that all patients would go home the following day. The ward is essentially a large room with closely spaced beds. It was notably hot and humid with the only medical facilities apparent being the IV flask holder and a sphygmomanometer.

         Close assessment of post-op pain was not possible secondary to the language barrier but patients greeted us with smiles and waves, so the assumption was that the experience was within their expectations. The patients, in French or in Fon, when they got the chance thanked us and said “God bless you”.

Student Participation

         15 year old Clancy accompanied her mother Cea-Cea on this trip as mission aide. Her participation was vital to the smooth running of the mission. She took primary responsibility for documentation of the team’s activity. She also proved adept in performing as a de-facto anaesthetic and scout nurse as well as in some English/French translating.

Suggestions for next time

Surgical

         * Program 8 patients per day

         * Theatre nurse volunteer

         * Good scissors

         * Sterile gowns

         * A new diathermy machine – one of the 2 didn’t seem to be working very well

         * Diathermy handles and blades

         * Scrotal supports

         * Gallipots

         * Self retaining retractors

         * Large sterile drapes that cover the whole patient

         * Local anaesthetic

         * 2^nd Mayo instrument trolley

Anaesthetic

         * Oximeter, BP, capnography

         * Small syringes for mixing

         * Large non-sterile gloves for Phil

         * Laryngoscope

         * Portable U/S

Other

         * Theatre snacks!

         * Room shelving for storeroom

         * Clear plastic organizing boxes

         * No-touch tap to install for scrubbing (and plumber!)

Overall we had a wonderful time and I would recommend this mission to anyone with a sense of adventure and some heat tolerance. At least one French speaker per mission would be ideal. Cea-Cea loved the African “tissu wax” fabrics the locals wore. The staff arranged for a local woman to display some samples so she could buy some to take home at a very cheap price. We all left very quickly after the last operating day so unfortunately we could not do the sightseeing trip to the river that Sister Opportune had planned for us. Next time!

Cea-Cea Moller

Team Leader