Comprehensive Report on the Outreach by Liberia Physicians and Surgeons Without Borders (LPSWB) in Collaboration with Hernia International UK at C.B. Dunbar Government Hospital
Introduction
From June 25 to June 29, 2024, the Liberia Physicians and Surgeons Without Borders (LPSWB), in collaboration with Hernia International UK, conducted a free hernia surgery campaign at C.B. Dunbar Government Hospital in Banga City, Bong County, Liberia. This outreach aimed to provide essential surgical care to patients suffering from hernias, thereby improving their quality of life and reducing the burden of untreated hernias in the region. This mission marked the first collaboration between Hernia International and C.B. Dunbar Government Hospital.
Team Composition
The medical team comprised highly skilled professionals from various specialties:
Dr. M. Peter George – Consultant Surgeon, Team Lead
Dr. Ayun Cassell III – Consultant Urologist Surgeon
Dr. Abraham Ajami – Specialist Internal Medicine & Emergency Response
Dr. Michael Kempeh – Specialist General Surgeon
Dr. Arthur Wuoh – Specialist General Surgeon and Medical Director
Dr. Ambrous Fawenneh – Medical Officer
Dr. Brooks – Medical Officer in Rural Rotation
Momoh Sonnie – Nurse Anesthetist
Roger Corcor – Operating Theatre Technician
Mission Overview
Arrival and Preparation: The team arrived on June 24, 2024, and began preparations for the surgeries.
Surgical Campaign: Surgeries commenced on June 25, 2024, and continued until June 29, 2024.
Patient Recruitment: Dr. Arthur Wuoh, Medical Director and Specialist General Surgeon, was responsible for recruiting all patients who underwent operations.
Data Collection
Data collected during the mission was categorized to reflect various aspects of the outreach, including patient demographics, types of hernias operated on, surgical outcomes, and postoperative care.
1. Patient Demographics
Total Number of Patients Operated On: 108 procedures
Age Distribution of Patients:
Mean age: 31.69 years
Age range: 0.2 to 73 years
Age Group
Frequency
Percent
Cumulative Percent
0 – <10
23
21.3%
21.3%
10 – <20
15
13.9%
35.2%
20 – <30
14
13.0%
48.2%
30 – <40
16
14.8%
63.0%
40 – <50
16
14.8%
77.8%
50 – <60
9
8.3%
86.1%
60 – <70
10
9.3%
95.4%
70 – <75
5
4.6%
100.0%
Total
108
100%
100%
Gender Distribution of Patients:
Gender
Frequency
Percent
Cumulative Percent
Female
35
32.4%
32.4%
Male
73
67.6%
100.0%
Total
108
100%
100%
2. Types of Procedures
Procedure
Frequency
Percent
Herniorophy
51
47.2%
Herniotomy
11
10.2%
Lipomectomy
10
9.3%
Cesarian Section
9
8.3%
Hydrocelectomy
9
8.3%
Myomectomy
6
5.6%
Umbilica Hernia Repair
4
3.7%
Cystecyomy
3
2.8%
Hysterectomy
2
1.9%
Fistula
1
0.9%
Mayo Repair
1
0.9%
SUB-TAH
1
0.9%
3. Surgical Outcomes
Number of Successful Surgeries: 108 procedures
Complications Encountered: None
Length of Hospital Stay Post-Surgery: 1 night
Patient Satisfaction and Feedback: Very Good
4. Postoperative Care
Postoperative Recovery Protocols: Hernia International Standards
Follow-up Schedules: Managed by the Hospital Management
5. Anesthesia Given
Anesthesia Type
Frequency
Percent
Cumulative Percent
General Anesthesia (G/A)
36
33.3%
33.3%
Spinal Anesthesia (S/A)
72
66.7%
100.0%
Total
108
100%
100%
6. Diagnosis Percentages
Diagnosis
Frequency
Percent
Cumulative Percent
Adhesion
1
0.9%
0.9%
Bowel Aneste
1
0.9%
1.9%
BIH
5
4.6%
6.5%
Hydrocele
7
6.5%
13.0%
Infected Cyst
1
0.9%
13.9%
LIH
18
16.7%
30.6%
Lipoma
10
9.3%
39.8%
LISH
1
0.9%
40.7%
Myoma
9
8.3%
49.1%
Obstructed Labor
7
6.5%
55.6%
Ovarian Cyst
1
0.9%
56.5%
Previous C/S
1
0.9%
57.4%
RIH
36
33.3%
90.7%
RISH
2
1.9%
92.6%
Testicular Cysts
1
0.9%
93.5%
Umbilical
5
4.6%
98.2%
Umbilical Hernia
2
1.9%
100.0%
Total
108
100%
100%
7. Procedures Performed by Doctors
Doctor
Frequency
Percent
Cumulative Percent
Dr. Cyrus
2
1.9%
1.9%
Dr. Fawsenneh
16
14.8%
16.7%
Dr. George
35
32.4%
49.1%
Dr. Kempeh
35
32.4%
81.5%
Dr. Massaley
11
10.2%
91.7%
Dr. Wuoh
6
5.6%
97.2%
Dr. Yohn
3
2.8%
100.0%
Total
108
100%
100%
Summary of Findings
A detailed analysis of the data collected during the mission indicates a high success rate with minimal complications, reflecting the expertise and dedication of the medical team. Patient satisfaction levels were very high, and there were no significant complications encountered.
Conclusion
The collaboration between Liberia Physicians and Surgeons Without Borders and Hernia International UK at C.B. Dunbar Government Hospital was a significant milestone. This first mission successfully provided much-needed surgical care to numerous patients suffering from hernias, showcasing the importance of such outreach programs.
The team of collaborators began to be formed at the end of February 2024 under the leadership and coordination of Dra Teresa Butrón and under the umbrella of the Non Profit Organization “Cirujanos en Acción” (Surgeons in Action) and the collaboration of Hernia International Foundation. In a very short period of time, it could be formed a team of twelve people, including general and paediatric surgeons, paediatrics intensivist, anesthetists and nurses.
All volunteers collected all the consumable material needed for the campaign, including surgical gowns, drapes, surgical fields, sutures, meshes of different types and sizes, bladder catheters, sterile and operating gloves as well as drugs (local and general anaesthetics, muscle relaxants, antibiotics, opioids, analgesics, etc) and anaesthetic material such as spinal needles, epidural catheters, Laryngeal masks, endotracheal tubes and rest of the material.
The 12 de Octubre University Hospital, in Madrid, donated a large amount of medication including anaesthetics, analgesics, antibiotics and vasoactive drugs through the anesthesiologist of that hospital, Dr. Ana Hermira.
The University Hospital Virgen de las Nieves in Granada, through Silvia Montalbán, a nurse at the hospital, donated a large amount of material, including surgical gowns and sheets, electric scalpels and intravenous access equipment.
The air tickets were taken through Angelis (freelance of Halcon Viajes Company) with the company Turkish Airlines, which allowed the transport of 2 bags of 23 kg per person + cabin baggage.
VISA. Without a doubt, obtaining VISA from Nigeria’s Embassy in Madrid, was the greatest difficulty that we had to face and that seriously jeopardized the completion of the campaign. Thanks to the efforts of Teresa Butrón and Dolores Delgado and their persistence we were able, just three days before leaving, to obtain VISA for Nigeria for all the members of the team. It is possible to apply for the VISA online and make the payment and after that it is necessary to go the Nigeria’s Embassy in Madrid to present the VISA application form, the invoice and the passport. Therefore, all the cooperators living outside of Madrid had to send their original passports by mail to one of the team members in Madrid to present them all together as a group. We got the VISAS only three days before leaving for Nigeria. For all of those reasons it seems advisable and it is our recommendation, to start the process at least six weeks in advance.
Dr Austin Ella, Associate Director Program Management from Catholic Caritas Foundation of Nigeria (CCFN) and Catholic Secretariat of Nigeria Building was our local contact in Nigeria and our interlocutor with Bishop Wilfred Chikpa Anagbe.
The group of volunteers left Spain from different cities (Málaga, Valencia, Madrid) between Friday and Saturday, April 19 and 20, 2024. Ten of the team members met at the Istanbul airport while two of our surgeons arrived at Abuja a day before the rest of the team
The campaign ended on Saturday, April 27, 2024 and we arrived to Spain on Monday 29th.
PATIENTS.Altogether 155 patients were operated on during the campaign period
ADULTS PATIENTS: A total of 93 surgical procedures were performed in 80 adult patients. There were 14 females and 66 males. Age ranged from 16 to 76 years (median 50; interquartile range 36-62). The following procedures were done:
Lichtenstein: 69 cases
Nyhus: 10 cases
Lipoma removal: 3 cases
Pre-peritoneal mesh repair: 2 cases
Rives-Stoppa: 2 cases
Hydrocelectomy: 2 cases
Reinforced suture + umbilical prefascial hernia repair + fascia plication: 1 case
Nuck’s cyst removal: 1 case
Onlay: 1 case
Orchiectomy: 1 case
Haemorrhoidectomy: 1 case
Most of the cases under spinal anesthesia (77 patients), saddle block (1 patient) and local anaesthesia plus sedation (2 cases)
PAEDIATRICS PATIENTS. 99 procedures were performed in 75 paediatric patients. Seventeen females and 58 males. Age ranged from 3 months to 16 years (median 6; interquartile range 3-10).
Herniorrhaphy: 92 cases
Herniorrhaphy plus hydrocele: 1 case
Hydrocele: 4
Orchidopexy: 1 case
Dermoid cyst resection: 1 case
Several cases of the initially scheduled were left without being operated on due to the lack of enough time.
All the members of the team agreed about the need to know more in depth the scheduled cases to made a more appropriate surgical list of patients. It was the first mission there in Makurdi and probably the situation will improve in future missions.
We also had the opportunity to participate in two cases of urgent caesarean section: fetal distress in one case and previous caesarean section in the other. Both patients were operated under spinal anaesthesia and two general surgeons from CeA helped Dr Thadeus Aende in the surgery and also did it the nurses of the team. It was very gratifying for all of to participate in that task and see the good evolution of mothers and newborns.
COMPLICATIONS: Once the team left Makurdi Hospital, the follow up of patients was done by Dr Thadeus Aende, a local doctor. Up to now, there have been four early minor complications: one adult patient experienced a recurrence of his inguinal hernia and, in the paediatric population, a boy developed a wound abscess drained while the team was still in Makurdi, one more a reactive hydrocele and, lastly, a possible recurrence of a hernia or simply a local edema difficult to know from the pictures Dr Thadeus Aende sent to the paediatric surgeons.
Nigeria’s economy is the second-largest in Africa, the 39th-largest in the world by nominal GDP, and 27th-largest by PPP. However, the GDP per capita places it in 149th place out of 196 countries and the Human Development Index prepared by UN which shows the standard of living indicates that Nigerians are among those with the worst quality of life in the world.
Benue state was created on February 3, 1976. It lies roughly in the middle of the country. Benue has a population of more than 4,5 millions inhabitants. The state comprises of several ethnic groups being The Tiv the dominant ethnic group, occupying 14 local government areas, while the Idoma and Igede occupy the remaining nine local government areas. Most of the people are farmers while the inhabitants of the riverine areas engage in fishing as their primary or important secondary occupation. The people of the state are famous for their cheerful and hospitable disposition as well as rich cultural heritage. Makurdi, the State capital was established in the early twenties. Being a river port, it attracted the establishment of trading depots by companies such as UAC and John Holt Limited. Its commercial status was further enhanced when the Railway Bridge was completed and opened in 1932. In 1976, the town became the capital of Benue State and presently serves also as the headquarters of Makurdi Local Government Area.
THE TEAM was composed by a total number of 12 volunteers:
General Surgeons: Teresa Butrón Vila (team leader). Antonio Rafael Barrasa. Saray Ayllón Gámez. Elena Fernández Segovia.
Paediatric surgeons. Alejandro Unda Freire. Mª Dolores Delgado Muñoz.
Paediatric intensivist. Emilia María Tallo Martínez.
Anaesthesiologists. Ana Hermira Anchuelo. Santiago García del Valle
Nurses. Mª Josefa Fornier Coronado. Nuria Guardiola Morales. Silvia Montalbán.
LOCAL STAFF. El Dr Thadeus Aende was the only doctor available at the hospital even though there were a large number of volunteers carrying out tasks of organization and identification of the population. Father Peter Paleva was the Area Health Coordinator. Mr Nicholai Ahor was the Administration Secretary.
HOSPITAL. It is a small building all in a single height, with several wards for adults, men and women, and children. It has a laboratory for basic determinations and a microbiology laboratory with basic capacity to perform cultures and diagnostic test for pathologies such as malaria and HIV. The room we use as an operating room is a large elongated space, equipped with air conditioning (the only space in the hospital except offices), without running water and equipped with minimal material: oxygen cylinders, two basic monitors (ECG did not work correctly) and 3 very rudimentary operating tables, one of then without the possibility of modifying height or changing the position of the patients. There was no anaesthesia machine available. There was no recovery room so the adult patients had to go directly to the ward, not far from the OR. For the children Dr Emilia Tallo created a small room as a space where to look for the children several minutes after the operation. The heat and humidity in that space was terrible and that made Emilia’s work very difficult and to be grateful for all of us. Several portable pulse oxymeters led by cooperators alleviated partially the monitoring deficit.
EQUIPMENT.Surgical instruments available at the Bishop Murray Hospital such as forceps, separators or scissors are not in very good condition and no suitable sizes for some of the longer and more aggressive interventions. It was completed with the paediatric surgical material carried by Alejandro Unda. There were
2 diathermy generators, one from the own hospital and one brought from Abuja and the team could transport 2 more units from Spain even though we have to use only one of them. The surgical lights were scarce and very poor in intensity and difficult or impossible to handle.
ANAESTHESIA. The lack of an anaesthesia machine made the task of Dr Ana Hermira and Dr Santiago Gª del Valle very difficult since they had to combine spinal anaesthesia with regional anaesthesia of the trunk with sedation or even general anaesthesia under spontaneous breathing. We made Dr Ella aware of the need to acquire a simple anaesthesia machine for the future campaigns and, thus, a report was sent to him with a description of the minimum characteristics and capabilities that anaesthesia should have.
ASEPSIS:Sterilisation was carried out with a heat-operated autoclave in a room adjacent to the operating room.
OUR DAILY LIFE
We arrived at Abuja International Airport on Saturday 20 April at 20:00. There were no difficulties with customs formalities and from there we were transferred to the Catholic Residence from Bishop Office and Caritas Organization only a few kilometres away from the airport where we met the rest of our colleagues. In that residence we had dinner and spent the first night.
Early in the morning of Sunday 21th April we went to Makurdi by car and it took 4 four and a half hours to made the 280 kilometres. Once at the hospital we had a colorful and pleasant welcome ceremony after which they offered us a meal to, immediately afterwards, inspect the operating rooms and the rest of the hospital, review the available material and unpack and organize the large amount of material that we moved from Spain.
We had lunch in the hospital and the food was of good quality but it is important to warn the cooker, Rosario Joyn Egbol and Dr Celeste Conde (also Medical Director of the Hospital), not to add spice. Delicious were also the great variety of mangoes we could taste.
After the daily work we took dinner at the residence. The rooms were comfortable with shower and, most importantly, air conditioning. It is important to take with you some towels.
We worked during 6 days (Monday to Saturday inclusive) from 8:00 to 20:00 or even later several days. On Wednesday 24th the Bishop offered us a nice dinner in the garden of the residence. We had no time even to visit the city center neither the riverside of the imponent Benue River.
On Sunday 28th we were invited to a religious ceremony and after that we came back to Abuja’s airport. The trip was made difficult by two car breakdowns that delayed our arrival at the airport to such extent that we almost missed our flight and were allowed to carry only our hand luggage and had to leave the rest of the equipment in Abuja under the care of Dr Austin Ellla who was later in charge of sending all the material back to Spain several days later.
CONCLUSION
Strengths of this place: Probably there is a huge amount of population who would benefit of a surgery from CeA. The people were very warm towards us and expressed continuously their gratitude. A lot of local volunteers, poor organized ass it was the first mission but they helped us a lot with the management of patients and families.
Improvement objectives: It would be very useful for future campaigns to have an anaesthesia machine and a new basic monitor of vital signs. It is desirable to improve the surgical lights as well as the surgical tables because they must have the capacity to vary their height and change the position of the patients during surgery. Also is important to improve the cars for the transport from Abuja to Makurdi and back to the airport since the space for the people and equipment was very limited. Have running water in the operating room, as occurs in other areas of the hospital, could facilitate work and help reduce the chance of surgical infections.
BUDGET:
COST FOR PERSON:Flight tickets between 600 and 750€. Hotel and maintenance provided by the local organization without cost. VISA 100€. Total amount around 700-850€ per volunteer.
We started the trip on the morning of 27/04. 7 members of the group will leave from Vigo and 1 from Gran Canaria. We have a long journey to our final destination, the Police Hospital in Freetown, Sierra Leone. We meet in Madrid, where David and Nuria are waiting for us to deliver the diathermy generator that we have to take with us. In the end we check in 11 bags of between 20 and 23Kg of material. We fly with Royal Air Maroc, with a stopover in Casablanca.
We bought the plane tickets through Angelis, an agent of Halcon viajes.
To enter the country you need a Visa, which can be easily obtained online via the link on the Spanish foreign ministry’s website. It costs $85 and takes a few days to be issued
1.2 ADULT PATIENTS:
As a ventilator was not yet available, only pathologies that were amenable to spinal anaesthesia and local anaesthesia and sedation were performed.
Surgery was mainly performed on abdominal wall pathology, hydroceles and large lipomas.
1.3 PAEDIATRIC PATIENTS:
No paediatric patients were operated on in this campaign, as general anaesthesia cannot be performed.
Inguinal hernia: 91, all repaired with Lichtenstein technique
Epigastric hernia: 8
Umbilical Hernia 3
Femoral Hernia 2
Hydrocele: 20
Testicular tumour: 2
Lipomas: 19
Mandibular tumour: 2
Sebaceus cyst: 1
Oral mucosal lesion: 1
Urgent reviews: 3
1.5 Total patients
1.6 COMPLICATIONS:
As complications, 3 patients required immediate postoperative reoperation: 2 haematomas in giant inguinoscrotal hernias and 1 seroma of 1 giant sebaceous cyst on the scalp. All complications resolved without further incident. To date, one month after our return, we have not been informed of any incident.
2. CAMPAIGN REPORT
2.1. THE PLACE
The hospital has 2 operating theatres, including a sterilisation room. The surgical material available is sufficient for hernias and other simple pathologies, but there is no material for laparotomy, thyroid surgery or surgery on children.
There is air conditioning in the operating theatres, which is to be welcomed, although due to the constant power cuts, it does not cool as much as we would like.
They have an autoclave for sterilisation, which they hardly use, because they find it too slow. They use pressure cookers, which worked correctly, except for one day, when we were stopped for 3 hours due to a problem with the closure of the cooker, which was finally solved.
It has 2 diathermy generators that work correctly, but only one of them can be used, because the other one does not have a grounding plate (it is an old, metallic plate). We used the generator we took with us and the other one, which worked properly for 4 days. Then the connection to the plate broke and they couldn’t fix it, so we spent 1.5 days with only one scalpel.
They have 3 mixed rooms, where patients are accommodated before and after the operation. There is a permanent nursing staff there, although the care is quite poor, given the poor training of the local staff and the limited means available.
2.1. THE TEAM
General surgeons:
Ana María Gay Fernández
Enrique Moncada Iribarren
Cristina Roque Castellanos
Paula Fernández Rodríguez
Anesthesiologist:
Miguel Ángel Pereira Loureiro
Yolanda Sanduende Otero
Nurses:
Verónica González Casal
Eva Sánchez Hernández
2.2. THE LOCAL STAFF
Dr Konteh, the hospital director, who is in charge of organising the campaign.
A surgical assistant (Kelly), who can help in the surgeries.
A preventivist, who is very helpful, and who helps us a lot in the operating theatre, especially in speeding up sterilisation and getting supplies when we run out.
The male nurse Francis, a hard worker, is also a great help in everything.
The nurses in the rooms are in charge of taking IVs from the patients before the operating theatre and post-operative care.
2.4 EQUIPMENT
Diathermy generators: 2. Neither of them have a plate and ours cannot be attached.
Operating theatre lamps: they have 2 lamps, which are quite deficient. One of them stopped working on the 3rd day of the campaign, and it was not possible to fix it. It is essential to carry a headlamp for the surgeries.
Consumables: sterile surgical gowns and drapes are not available. They have equipment to take peripheral lines and IV systems.
Medication: poor availability, although some things we ran out of they did get, such as antibiotics.
2.3. ANAESTHESIA
In the surgical block we had only 1 monitor that allowed us to measure O2 saturation and PANI, but it did not have electrocardiographic recording.
For this reason, we brought an automatic blood pressure monitor and a portable pulse oximeter that allowed us to have minimal monitoring on the second operating table, material that we left at the hospital in Freetown.
This double monitoring allowed us to tansfer 2 patients simultaneously to the 2 surgical tables that we placed in the same operating theatre, where we proceeded to perform spinal anaesthesia and some deep sedation, in cases of supra-umbilical pathology (some lipomas).
There were 2 oxygen concentrators that worked properly and an oxygen bullet to which we connected the ambu, but which we did not have to use at any time.
In the operating theatre there was also 1 very old aspirator.
Outside the operating theatre they had a NON-functioning Aestiva Datex-Ohmeda ventilator, so no other anaesthetic option other than local or regional, or light sedation, was ever considered. Stored in a corridor, there was another older ventilator which was also non-functional.
On arrival, the equipment available was generally scarce: some O2 goggles and ventimask, and little else.
The campaign brought from Spain all the material and medication necessary to perform intradural anaesthesia/local infiltration (lidocaine, bupi isobara and hyperbara, mepivacaine, prilocaine), sedation (propofol, ketamine, fentanyl, midazolam), as well as iv/vo antibiotics, and general emergency medication (atropines, adrenalines, amiodarone, antihistamines, corticoids in different doses, antiemetics). As for analgesics, in addition to opiates, we carried conventional IV analgesia for each operation, and oral analgesia for the first 24 hours postoperatively.
There was no stock of medicines.
As we had calculated the campaign for about 100 patients, and we exceeded expectations, we ran out of spinal needles, antibiotic prophylaxis and benzodiazepines, material and medication provided by the hospital itself, although the prophylaxis had to be done with ceftriaxone, and the needles were 24G-25G thick gauge without an introducer, which posed us greater technical difficulty on occasion.
The activity we carried out was:
Type Anaesthesia
Type of surgery
A. Spinal
Intradurals
110
Hernias and infraumbilical abdominal wall
Sedation
Local + Sedation
16
Lipomas, epigastric hernias
Deep Sedation
4
large and/or deep supra-umbilical or dorsal lipomas
Total
130
Tras la intervención incluíamos analgésicos (2 AINES y opiaceo o asociacion de rescate) para las primeras 24 h del posoperatorio.
No tuvimos complicaciones importantes y entre las leves, escasa o nula hipotensión con algún episodio de náuseas/vómitos, y algún caso de analgesia insuficiente.
2.6. ASEPSIS AND SURGICAL SUPPLIES
Sterilisation: autoclave. Pressure cookers
Surgical instruments: there is material for small operations, such as hernias. There are few separators. There is no Roux type. There is also no specific material for thyroid or child surgery, so if at any time this type of surgery is considered, it will be necessary to bring material.
2.7. OUR LIFE IN FREETOWN
We land at Freetown airport at 2:00 a.m. Dr Konteh, director of the hopistal and organiser of the campaign, is waiting for us there with Abu, a security policeman who accompanies us to the hospital every day. We collect our luggage and pass through customs without incident thanks to Dr Konteh’s help. Then we go to catch the bus (about 15 minutes), which takes us to the ferry, which takes about 45 minutes. We arrive at the hotel at about 5am. After a few hours rest we head to the hospital. While the nursing and anaesthesia team open the material packs and get everything ready for the surgeries, the surgical team is ready to see the potential surgical patients. Patient recruitment was extensive. On arrival we had more than 300 surgical candidates. However, no one had done a screening, so we saw many non-surgical pathologies, or pathologies that could not be operated on in a campaign where general anaesthesia is not possible. Finally, after many hours of seeing patients and after recruiting 145 patients for surgery, we decided not to continue with the screening, so that we could start operating that same day, late in the afternoon, almost at night. We scheduled the surgeries for later days.
The day after our arrival we were received by the Chief Inspector of Police (Mr. William Fayia Sellu), in a brief ceremony held at the police headquarters, and he gave us our permits to work in the country.
Thus began a very hard campaign, with intense heat during the day and night, working daily from 8 in the morning, extending most days until more than 9 at night, since an average of 25 patients were operated on per day. In the end, despite having two operating theatres, we decided to use only one, with two tables, to speed up the work.
We started the day with breakfast at the hotel. They provide coffee, powdered milk, juice and you can order omelettes and pancakes. At 8 a.m. we are picked up by Dr Konteh with Abu, a 15-minute drive to the hospital.
On arrival, while the first patients are being anaesthetised and everything is getting underway, the surgeons visit the patients from the previous day, so that they can be discharged and make room for the patients who will be operated on that day.
We make a short stop for lunch. Pizza, chicken, pasta and a few other things can be ordered from a nearby restaurant. The local staff bring them every day, although you have to order well in advance, so on many days we just ordered bread and fruit and added cold meats that we had brought in our suitcases.
In the evening we dine at the hotel, having ordered our orders in the morning before we left. The offer is similar to that of the lunch restaurant: rice, pizza, chicken or pasta.
On the 4th day of the camp, the connection of the scalpel plate they have in the hospital broke, and it was not possible to fix it, so we were left with only one scalpel. We decided to continue on 2 tables, exchanging the scalpel that we had brought with us, as one surgery was finished, we started on the next table, with everything already prepared. This, of course, delayed us a lot, and it was impossible for us to keep to the schedule, which was already complicated to carry out. Therefore, we prioritised patients with hernias and suspended several lipomas that do not pose any risk and can be operated on in successive campaigns.
Finally on the last day they got another generator that worked properly and we operated on the remaining 11 patients, somewhat simpler hernias than in the previous days, to avoid complications. After finishing all the work, we collected and packed the diathermy generator and some more material to take back to Spain.
After resting for a while at the hotel (they let us stay in the rooms until the afternoon), Dr. Konteh and Abu picked us up to take us to the beach area, where they had prepared a farewell dinner for us. Beforehand, we met up at the hotel with my colleague and friend, Dr Marta Lado, an internist working in Sierra Leone, with whom it was impossible to meet for the rest of our stay, as our working days were too long. I met Dr Lado almost 20 years ago when we were both training in Spain. Her eagerness to train in infectious diseases took her to Sierra Leone 10 years ago. She came for a few months, but stayed during the Ebola outbreak at the time, and the country and its people got to her. She works with an American NGO (Partners in Health), carrying out health plans, as well as participating in the WHO’s outbreak emergencies group. By coincidence, Dr Lado was Dr Konteh’s mentor, so she is also joining us for the farewell dinner. It is a great pleasure and honour to have her and her knowledge of medicine and the country we are in. She can certainly be a support in future missions if needed.
During dinner, we are given gifts: a police T-shirt and a notebook with our name engraved on it. After dinner they play music and we dance until it is time to leave for the airport.
Dr Konteh accompanies us there, and thanks to his contacts, we avoid paying the departure tax, which is about 100 euros per person.
The return journey is uneventful until we arrive in Madrid, where we realise that one of the checked-in bags has not arrived. We recover it in Vigo that same week.
And now back, with the satisfaction of a job well done, we bid farewell until the next one. This mission has been particularly hard at times, with many hours of work, more than expected, with a lack of means and material, as well as a lot of heat. But as always happens in this type of campaign, the team spirit and mutual support, makes us draw strength from nowhere, to continue and that everything runs smoothly. Thanks to all the team, for the effort and the desire, and above all for coming back for another year…
CONCLUSION
3.1 Strengths of this place:
Sierra Leone is a country with a very poor health system. There are few doctors, and especially few surgeons and almost no anaesthetists. As a result, there is a huge number of patients, adults and children, who are potentially surgical. The Police Hospital, despite its shortcomings, is prepared for such campaigns. Dr Konteh is able to organise the campaigns and solve problems as they arise. The hospital staff is well adapted to the work, improving as the campaign progresses.
3.2. Improvement objectives:
– Prior screening of patients is essential. To rule out non-surgical pathologies and inoperable surgical pathologies during the campaign. It is very difficult to see such a large number of patients in such a short time, and above all, it is a significant waste of time, as more than half of the patients we screened in this campaign had no surgical pathology, or were not susceptible to surgery during the campaign due to the type of pathology.
– Improve pre- and post-operative care: in future campaigns it would be interesting to have nursing staff who can instruct local staff in this care: post-operative analgesia, wound care, correct channelling of IVs, taking of vital signs, etc., especially if the aim is to operate on more complex pathologies, as the knowledge of local nursing staff is very limited.
– Obtain a respirator that works properly.
– In future campaigns, if a respirator and a monitor can be obtained, three simultaneous operating tables could be set up.
4. BUDGET:
4.1. COST PER PARTICIPANT:
Participants travelling from Vigo, single room hotel: 2.021,10
Participants from Vigo, double room: 1.839,25
Participant from Gran Canaria, single room: 2.009,26
St. Augustine Muheza Designated District Hospital,
P. O. Box 308,
Muheza,
Tanga Region,
Tanzania.
E-mail: office@teule.or.tz
Host Surgeon. Dr Michael Boniface
This was the first Hernia International team to visited Muheza. Dr Michael Boniface, a surgeon working at St. Augustine Hospital, had joined the Hernia International mission to Korogwe in June 2023, where his contribution had proved invaluable. It was at his request that this mission to Muheza was organised.
Muheza is described in Lonely Planet, as a “scrappy junction town” on the road to Tanga. We found it to be a lively market town with bustling stalls selling locally grown produce, including pineapples, bananas, rice and, we were surprised to see, potatoes. The abundant motor bikes made crossing the road from one market stall to another particularly hazardous.
Muheza is situated on the coastal plain, just south of the Usambara mountain range that stretches across northern Tanzania from near to the Indian Ocean coast in the east to Mount Kilimanjaro in the north-west. The hills are visible to the north of Muheza, but the surrounding countryside is relatively flat and not as scenic as the rolling hills around Korogwe, 60 km to the west.
CUSTOMS AND TRANSPORT
We were met at Dar Es Salaam airport by Dr Boniface, whose presence proved to be invaluable in enabling us to bring our equipment and medicines through customs. Fernando and Steffen came on a Turkish Airlines plane via Istanbul. Their four large cases, full of equipment and drugs, were not transferred onto their flight from Istanbul. They arrived in Dar Es Salaam the next day, by which time we were all in Muheza. Turkish Airlines agreed to fund a taxi to transport them to Muheza but persuading the airport customs department to allow them through proved to be more of a problem. It required a member of staff from St Augustine Hospital (a hospital pharmacist was “volunteered”) to travel from Muheza to Dar Es Salaam airport, a day’s journey by bus, with a letter from Steffen which explained the contents of the cases and authorised the customs personnel to open and inspect them. The Customs Officers must have accepted what they found, as all the bags and their contents arrived in Muheza on Thursday, our fourth working day. Their arrival was timely, as we had just about run out of the antibiotics and analgesics that the rest of us had brought.
On the night of our arrival at Dar Es Salaam, we stayed at an airport hotel (the Transit Hotel had functioning air conditioning and was perfectly satisfactory) and travelled to Muheza the next day in the St Augustine minibus, arranged by Dr Boniface. It was a six-hour journey on a tarmacked road, with a pleasant stop for lunch halfway there.
We arrived in the late afternoon, in time to organise our equipment in the operating theatres and to see the patients that Dr Boniface had arranged to come to the hospital for consideration for surgery the next day.
THE OPERATING THEATRES AND THEATRE STAFF
We had the use of two spacious, air-conditioned operating theatres. Both had a single but satisfactory overhead operating light. Power cuts were common, however, and although they were usually short lived, headlights were essential. There was only one diathermy machine, so that all the surgery in one of the theatres was done without the use of diathermy.
Both theatres had anaesthetic machines, and monitoring equipment (pulse oximetry and ECG trace). Bottled oxygen was available. None of our patients received a general anaesthetic. Nearly all patients had a spinal anaesthetic only. A few patients required supplementary boluses of ketamine. This was required when the procedure was unusually lengthy and in the one patient in whom both bupivacaine and lignocaine were ineffective. The one child, who underwent groin surgery, had local anaesthetic and ketamine.
We had specified that we planned to operate on hernia cases only and that we did not wish to operate on young children. We worked in the two theatres for the five days. We aimed to arrive at the hospital at 8 am each day and were asked by Dr Boniface to finish our day’s work by 6 pm. This was to allow the significant number of theatre staff, including the sterilising unit personnel, who were required to support our mission, to leave the hospital in reasonable time. The hospital provided a cooked lunch in theatre for all the theatre staff, including us. We were asked to contribute to the cost of this food, which we were very happy to do.
THE WORK
We operated on 51 patients, repairing 41 inguinal hernias, of which 31 were primary and 10 were recurrent. Nine were irreducible inguino-scrotal hernias (Kingsnorth grade 4). None of the recurrent hernias had had a previous mesh repair, but in many of them we encountered intense fibrosis. It was the recurrent hernias that provided us with the biggest surgical challenges of the week. There was one incarcerated inguinal hernia in a man who had presented urgently the previous day.
There were 4 umbilical hernias and three midline hernias. We were also asked to see a 47-year-old lady with a large discrete mass at the top end of a previous caesarean section wound, almost certainly an endometrioma. This was excised.
We operated on 13 hydroceles and undertook one ligation of a patent processus vaginalis on a 13-year-old boy.
PERIOPERATIVE MEDICATION
Our intention was that all patients who were to have a mesh repair, should have an oral dose of broad-spectrum antibiotic at least half an hour before their procedure and then a two-day course of antibiotics and oral analgesia (a paracetamol / ibuprofen combination) postoperatively. Each patient was given an envelope containing their post-operative medication as they left theatre. Instructions on how to take the medication was written on the envelope in English and Swahili. When we saw the post-operative patients on the morning ward round, we discussed their medication with them and examined the envelopes. It seemed that most of them were taking their medication appropriately.
ACCOMMODATION
We were initially told that we could stay in residential accommodation within the hospital complex. At the time of our visit, however, this accommodation was being prepared for visiting medical students. We were booked into The Sige Lodge, one of the few hotels in Muheza. It proved to be very satisfactory. There were enough rooms, all of which had air conditioning, although the intermittent power cuts meant that the air conditioning didn’t always work. As we arrived, a router was being installed to provide us with wi-fi, but that, at best, only provided a weak signal, which was usually inadequate. There was a pleasant open air dining room in which we were served omelettes for breakfast each morning. Dinner was provided by an external caterer. A lady, with whom, by the end of the week, we felt we were good friends, would arrive at the hotel each evening by tuktuk, bringing the food that she had cooked during the day with her. In spite of the wet and muddy dirt road to the hotel, she was always smartly dressed, spotlessly clean and greeted us with a smile. She took great pride in her cooking and with her food and the bottles of Kilimanjaro beer provided by the hotel, we had no complaints.
EXPENSES
By far the largest individual expense for future missions to Tanzania is likely to be the cost of temporary registration with the Medical Council of Tanganika. The Council have changed their policy on this and now charge medical staff on short term charity work the same as those doctors and nurses applying to do full time work. For us this was $200 per application.
Otherwise, Tanzania is not an expensive country. The minibus transfer from Dar Es Salaam to Muheza was $500, in our case split between the nine of us on the way there and seven on the way back. Dinner, bed and breakfast cost $30 a night. The Sige Lodge required payment in cash (US dollars). The Dar Es Salaam hotels accepted credit card payment.
REST AND RELAXATION
One of the bonuses of a mission in Tanzania is the variety of leisure activities that can provide relaxation afterwards. Two of our team travelled to Arusha at the end of the week and went on safari in the Ngorongoro Crater before flying back from Kilimanjaro International Airport. Three of the team travelled back to Dar Es Salaam and then took the ferry to Zanzibar for a short holiday there. Some of us were content to have one very comfortable night at The Slipway Hotel in Dar Es Salaam before flying home the next day.
CONCLUSION
We all agreed that we had a very worthwhile week at the St. Augustine Hospital and would strongly recommend Muheza as a venue for future Hernia International missions. Dr Boniface understands the work of Hernia International, he communicates well and can be relied upon to provide efficient organisation at the host hospital.
CAMPAIGN IN EMIRATES HOSPITAL. BOPOLU CITY, LIBERIA FEBRUARY 1-11, 2024
-TEAM
Second Surgeons in Action campaign, in conjunction with Hernia International, taking place in the city of Bopolu, Gbarpolu County, Liberia. It was scheduled for the end of 2023, but was suspended due to the proximity of local elections, which finally passed without problems.
Bopolu is a small town in Liberia, capital of Gbarpolu County. Emirates Hospital provides healthcare to a population of 55,000 inhabitants. The local network has 14 basic health clinics, provided with midwives, but the hospital is responsible for all medical, surgical and obstetric care.
Local coordination, as in previous campaigns, was carried out by Dr. Peter George, County Health Officer of Gbarpolu County, a local surgeon very involved in assisting and improving the conditions of his hospital and its neighbors.
The surgical team is made up of 12 volunteers: -Laura Baumgartner Lucero. Anesthesiology. Burela (Lugo) -Rocio Díez Munar. Anesthesiology. Madrid. -Pilar Murga Pascual. Anesthesiology. Badajoz. -Carlos Delgado Miguel. Pediatric Surgery. Madrid. -Sara Ramallo Varela. Pediatric Surgery. Santiago de Compostela -Lucía Corrales Fernández. Nurse. Burela (Lugo) -Maria Jesus Nieto Berrocal. Nurse. Badajoz. -Monica Ruiz Maleno. Nurse. Almeria. -Monica Torres Díaz. General Surgery. Cee (A Coruña). -Estefania Villalobos. General Surgery. Mexico. -María Quirós Rodríguez. General Surgery. Burela (Lugo) -Antonio Satorras Fioretti. General Surgery. Burela (Lugo). Coordinator.
The facilities for carrying out administrative procedures on the part of the Liberian Consulate in Madrid were scarce, and on the part of the Liberian Embassy in Paris, non- existent.
We provided a total of twenty-four suitcases of material collected by the volunteers and medication (donated entirely by the Hospital Publico da Mariña of Lugo), weighing 550 kg (two of 23 kg per volunteer).
The departure was on Thursday, February 1 at 6 p.m. from Madrid, with Royal Air Maroc, on a flight with a stopover in Casablanca, a technical stop in Freetown (Sierra Leone) and arrival in Monrovia, two hours late, at 6 a.m. Friday February 2nd. There we discovered the loss of four suitcases of material (one of them with a third of the medication) and the breakage of another.
After the claim procedures, we began the trip aboard three official vans, with a stop at the A La Lagune hotel for breakfast. Then, five and a half hours for 250 miles of travel along roads packed with cars, motorcycles and tuc-tucs, which are transformed into dirt tracks, with more potholes than ground.
After a difficult journey, we arrived in the afternoon at the town of Bopolu, where we were offered a warm welcome by the local population, with endless dances and speeches. Later the material was unloaded and prepared in the hospital facilities to start the next day.
-ACCOMMODATION
*HOTEL
The Lorine Guest House is a hotel that is very close to the hospital. It offers spartan single rooms with mosquito nets, acceptably clean, filled with mothballs to repel insects. They lack running water, so each bathroom has a large basin with auxiliary buckets for washing and using the toilet. Power only runs at night and plugs are compatible with European ones, so no adapters are required.
At night, on the patio, they have cold beers to spend a relaxed time. Collect and wash personal clothing was offered.
*FOODS
-Breakfast and dinner at a location between the hotel and the hospital. Food was based on vegetables, rice, chicken, eggs and tilapia, all spicy. Various fruits. -Lunch: they bring something frugal and fruit to the hospital. -Water always available. Beer at dinner.
*INTERNET
Connection was offered by the coordinator with a local router that we had with us. Frequent network loss, but it could be used every day
-HOSPITAL
Emirates Hospital is a new building with 150 beds. It has shared rooms for men, women and children, without air conditioning and poor hygienic conditions of beds and treatments. There are modern facilities but they are not functional (they have an ultrasound, a CT scan or computer equipment that have never been used). The main problem is the absence of supplies and replacements.
Electricity depends on solar panels and is only available from 9 a.m. to 9 p.m. Surgery cannot start earlier and there is no provision to extend the day.
We had a large operating room with air conditioning and a respirator that uses Isoflurane (and could work with Sevorane if available or carried). In that operating room a second table was set up for regional anesthesia. In an adjacent room without an O2 connection (a concentrator is used) a third table was installed. No overhead lamps (there are, but they don’t work). Acceptable lighting with auxiliaries and in some cases with frontals.
A large unequipped resuscitation room was used as a warehouse for storing materials and medications and as living room Problems in the supply of O2. Leak in the main tanks not repaired and absence of spare portable cylinders.
In addition, there was another operating room – which we did not use – used by the local team for cesarean sections with a respirator without O2 intake. It could use Halothane or Isoflurane in pressure control.
Despite their commitment to provide two electric scalpel consoles, we only had one and it worked wrong. Fortunately it was supplied with the two generator we had brought from Spain.
Only very basic boxes for hernias were available (we carry 2 adult hernias and 2 pediatric hernias). Sterilization in a small steam autoclave in the surgical area itself was at least rapid although very limited.
There was a minimal laboratory (hemoglobin, glucose, serology). The scheduled patients had previously been tested for HIV, hepatitis B, malaria and syphilis. If needed, there was the possibility of a blood bank.
The staff, who are largely volunteers, are quite disorganized. Difficulty in knowing the location of each patient, whether it is pre- or postoperative or whether it requires special attention. The medical records must be marked to avoid repeating patients.
The commitment to provide surgical gowns and drapes was initially fulfilled until stocks of sterile material were exhausted. At that time we were offered non-sterile examination gowns (insisting that this is what they use there) that did not meet the minimum conditions of asepsis. Thanks to the experience and expertise of our veteran nurse María Jesús, the material could to be sterilized, which allowed the campaign to be completed.
The training of local personnel was scarce, with hardly any medical personnel attending our daily activities. Auxiliary personnel were trained in material sterilization techniques.
-DAILY ACTIVITY
At 7:50 a.m we met in the hotel courtyard to walk in five minutes to the place (a fenced warehouse) where they served us breakfast. In another ten minutes we walked to the hospital around 9 a.m.. We changed and did the first visit with the headlights until the light came on. It was then when the operating room began to activate and surgery was started around 9:30.
During the morning and afternoon, with a brief break for eating, three tables were non- stop operated. In addition, patients previously selected by the local team were assessed and daily programming was carried out. On the third day, some patients who were scheduled for follow-up were reviewed. In addition, discharges were given providing doses of analgesia for the immediate postoperative period.
It didn’t end before 8pm, occasionally extending the day until the power went out. If we could, we took the opportunity to shower in the hospital itself. Later we returned by car (the lighting was non-existent and we were not advised to go walking) to the place where we had dinner and then to the hotel, where we took advantage of some time to relax with a cold beer.
-SURGICAL ACTIVITY
During the campaign we worked for seven days, in morning and afternoon shifts with a short break in between, on three simultaneous surgical tables. 173 patients have been operated on, with a total of 223 procedures, which makes an average of eight patients per table per day.
*ADULTS:
A total of 131 adults, 97 men and 34 women, aged between 16 and 80 years. In 22 cases they had several associated pathologies, so 153 procedures were performed.
98 inguinal hernias have been operated on (17 inguinoscrotal, 12 bilateral, 11 recurrent and two emergency due to strangulation that did not require intestinal resection although an appendectomy was required).
Other pathologies were umbilical/supraumbilical and epigastric hernias (11) and incisional hernias (4) for which mesh plaacement was mostly performed, hydroceles (11, two bilateral), large lipomas (22) and other soft tissue tumors (6 cysts and keloids).
82 regional anesthetics were used, 41 local with sedation and 8 pure local. Most patients were discharged the next day and no complications were recorded other than a hematoma that drained.
It should be noted that several patients were rejected, due to questionable diagnostic indication or anesthetic risk, who were later operated on by the local team, and whose evolution is unknown…
*CHILDREN
42 patients were operated on, 22 boys and 20 girls, aged between 6 months and 17 years, all under general anesthesia. In more than half, two or even three procedures were carried out, which raised the number to 72 procedures.
34 inguinal hernias (5 bilateral), 16 umbilical hernias, one hydrocele, two cryptorchidisms, one cord cyst, 4 circumcisions, 3 appendectomies (due to discovery of appendix in hernia sacs) and 4 soft tissue tumors (one of them a large cervical lymphangioma).
Furthermore, the two longest and most complex interventions were a pelvic burn involving the thighs, anus and genitals, and a burn with foot retraction. Both required laborious surgeries with skin grafts, with an initially very satisfactory result.
No significant complications were recorded. Two other cases of complex burns that had been scheduled were operated on without prior notice by the local team, to our great astonishment.
-RETURN
On Friday the 9th we finished the campaign, materials were collected and loaded into the cars. On Saturday morning there was a farewell event in the town hall, with a new session of lively and colorful local dances, endless speeches and delivery of thank-you gifts. Finally we left Bopolu and returned along another somewhat better but also heavy road to Monrovia.
Our idea was to do some sightseeing, but since the city offered nothing to see, we returned to the Hotel A La Lagune where we took some rooms that allowed us to use the pool, take a shower and rest for a while in the afternoon, before leaving. at 23:30 towards the airport. The night trip of more than an hour was bumpy, with one of our cars colliding although without any consequences.
The return flight took off on Sunday the 11th, delayed, at 4:30 a.m. and after making a stopover in Casablanca we arrived in Madrid at 6:30 p.m. without further incidents. A suitcase with a generator was lost, but luckily it turned up a few days later.
-BILLS
From the initial budget for accommodation, food and transportation that was proposed to us and seemed exaggerated by the forecasts, as it really was, a reduction of almost 50% was negotiated.
-Visas: $100 per person……………………………………………..…………$1,200 -Madrid/Monrovia/Madrid plane tickets 960 ticket + 40 insurance: $1,000 per person………..………………..$12,0000 -Accommodation *Bopolu: $25 per person per night (8): …………………………….……… $ 2,400 *Monrovia: $90 for a room of four and pool……………….…………………. $360
-Transportation: $50 per person…………………………………………… .… $750
TOTAL…………………………………………………………………….… .. $ 20,015 EXPENSE PER VOLUNTEER: $1,670
-PROPOSAL FOR NEXT CAMPAIGNS
The Emirates Hospital in Bopolu is a center well equipped to carry out surgical campaigns. There is a good selection of patients and the facilities are appropriate. Looking ahead to future actions, teams should make certain considerations.
-Absence of sterile conditions in their usual practice.
-Lack of gowns and cloths. Disposable sterile gowns were initially used (they were even cut down to use as a drape) until they ran out. Disposable non-sterile gowns were offered. They can be resterilized in an autoclave. Laundry and autoclave in the hospital. Consider bringing cloth material, if they can offer resterilization.
-Few surgical instruments. Boxes must be brought
-The agreed electric scalpel generators were not provided, so they must be brought.
-Anesthesia equipment that could work with Sevorane.
-A full-time nurse is needed to manage sterilization.
-Loss of luggage with Royal Air Maroc. Distribute materials/drugs to minimize the consequences of loss.
The team of collaborators began to be formed in the month of August 2023 under the coordination of Dr. Teresa Butrón and the Non profit organization Cirujanos en Acción (Surgeons in Action) with the collaboration of Hernia International Foundation. It was prepared in two months and a half and it was made possible with the help of Lizz Beth, secretary of the Gatundu Hospital Director.
She responded very quickly and clearly to all questions related to documentation needed to obtain the temporary permissions (Passports, VISA, C.Vitae, diplomas and profesional certificates of professional suitability). The hospital provided transport from the airport to the hotel in Tikka and daily from the hotel to the hospital in the morning an back to the hotel in the evening.
All volunteers collected all the consumable material needed for the campaign, including surgical gowns, drapes, surgical fields, sutures, meshes of different types and sizes, bladder catheters, sterile and operating gloves as well as drugs (anesthetics, muscle relaxants, antibiotics, analgesics and anaesthetic material such as spinal needles, epidural catheters, endotrachael tubes and rest of the material.
MBA company in Madrid donated 3108€ in laryngeal maks of differents shapes and sizes.
It is very remarkable that the team components could get 3 electrosurgical units to be used during the campaign and one of those was delivered to Gatundu hospital after the end of the working period.
The air tickets were taken through Angelis (freelance of Halcon Viajes Company) with the company Turkish Airlines, which allowed the transport of 2 bags of 23 kg per person + cabin bagage.
The group left from various parts of Spain on Friday, November 24, 2023. The whole group gathered at Istanbul Airport to leave for the 12 members of the expedition to Nairobi. The campaign ended on Saturday, December 2, 2023 and we arrived Spain Sunday 3th.
PATIENTS. A total de 118 patients were operated on during the campaign period
ADULTS PATIENTS: A total of 60 surgeries were done on adult patients with the following procedures performed:
Hernioplasty prefascial 31 cases
Lichtenstein 25 cases
Incisional hernia 3 cases (Rives Stoppa, resection and resection plus reconstruction)
Preperitoneal hernioplasy plus left PSC 1 case
PAEDIATRICS PATIENTS. 58 cases in infants and children; 10% female and ranging from 1 to 14 years of age (median age 4 years).
Undescended testicles: 31 cases, two of them bilateral
Inguinal hernia: 15 cases
Umbilical hernia: 6 cases
Supraumbilical hernia 1
Hydrocele: 4
Ectopic testis: 1
COMPLICATIONS: Once the team left Gatundu Hospital, the follow up of patients was done by Dr Chacha. There were no relevant complications in the first 30 days after surgery
CAMPAIGN REPORT
THE PLACE. Kenya is a big country located in the east central coast of Africa. Kenya’s population was reported as 47.6 million during the 2019 census compared to 38.6 million inhabitants in 2009, 30.7 million in 1999, 21.4 million in 1989, and 15.3 million in 1979. This was an increase of a factor of 2.5 over 30 years or an average growth rate of more than 3 percent per year. The population growth rate has been reported as reduced during the 2000s, and was estimated at 2.7 percent (as of 2010), resulting in an estimate of 46.5 million in 2016. According to the 2022 revision of the World Population Prospects, the total population was 53,005,614 in 2021 compared to 6,077,000 in 1950, and around 1,700,000 in 1900. The proportion of children below the age of 15 in 2010 was 42.5%, 54.9% between the ages of 15 and 65, and 2.7% of the population was 65 years or older. Worldometers estimates the total population at 48,466,928 inhabitants, a 29th global rank. Kenya’s GDP per capita, an indicator of its standard of living, was 2.081 in the year 2022 (Spain $30.103), and it ranks 152nd out of 192 countries, what means a very low standard of living.
Gatundu is a small town of about 20,000 people located at 1600 meters de altitude in Kiambu County with a population of 1,600,000 habitants and is situated about an hour’s drive from Nairobi. The town’s infrastructure is very poor, with most of the houses and shops located on both sides of the main road. The population lives on a dollar a day. Rice, vegetables and other farm produces are the staple food. The V Level Gatundu Hospital was built in 2013 with the financial support of the Chinese Goverment. In 2016, its clinical activity began and in recent years there has been a very evident deterioration in the architecture with structural repairs currently underway.
Another wing is currently under construction and will be used for oncology. It is an annex to the old Gatundu Hospital, consisting of several single-storey pavilions connected to each other, with large green areas.
The hospital has 5 floors and, in the third floor is the surgical area with two large operating rooms which are called theatres 3 and 4. There are two anesthesia machines fully operational but with basic monitoring that does not include capnography or inspired gas analysis.The post-anesthesia recovery area is very poor, consisting only of 3-4 beds without any monitoring and with the possibility of administering oxygen through a facial mask or nasal cannula. Surveillance in this space by local staff is quite limited but, due to the proximity to the operating rooms and the work of Dr Amanda García with the pediatric population, we were able to do direct clinical surveillance of the patients and intermittently monitor SpO2. using portable pulse oximeters brought from Spain
THE TEAM was composed by a total number of 12 volunteers:
General Surgeons: Teresa Butrón (team leader). María del Mar Viana Miguel. Juan Pablo Alarcón Caballero. Jesús Manuel Bollo Rodríguez.
Neurosurgeons. Alina Costache
Pediatric surgeons. Alejandro Unda Freire
Pediatric intensivist. Amanda García Palencia,
Anesthesiologists. Irene Merino Martín. Santiago García del Valle
LOCAL STAFF. Dr Clifford Chacha Mwita, Gatundu hospital’s surgeon, our contact there and and the person responsible for coordinating all the clinical activity that we carry out there, actively participated as a surgeon in several cases, teaming up with Dr Butrón. We had support, both in the operating room and in the hospitalization ward, from local general medicine doctors. Since we were able to have 3 operating room tables from the first moment and there were only two anesthetists in the volunteer team, we were able to count on the collaboration of a team of local anesthesiologists, some displaced from Nairobi like Dr Ruth Muiruri, Dr Eric Karuri and Dr Isaack Karaba. We also have the help of nursing and auxiliary personnel in the 2 operating rooms used
EQUIPMENT. The surgical instruments available at the Gatundu hospital such as forceps, retractors and scissors are not in very good condition and there are not adequate sizes for some of the longer and more aggressive interventions performed. There was no diathermy generators available although fortunately the team was able to transport 3 units from Madrid.
ANAESTHESIA. The paediatric population was operated under general anesthesia in most cases by the Dr Irene Merino. The anaesthesia in the adults patients was done by Dr Santiago Gª del Valle and the local anesthesiologists and it was general anesthesia in 17, cases, general plus epidural in one case and spinal anesthesia in the remaining 42 cases.
ASEPSIS AND SURGICAL MATERIALS: Sterilisation was carried out with a heat-operated autoclave.
OUR DAILY LIFE
We arrived at Nairobi International Airport on Saturday 25 November at 3:00 am. There were no difficulties with customs formalities and from there we were transferred to the Maxland Hotel in the town of Tikka, about 60 minutes from Nairobi. Maxland hotel is very secure as it is within a fenced compound with access controlled by security guards. The rooms are single, with en-suite bathrooms and beds with mosquito nets, and are very clean and hygienic. It has wifi which works very well both in the rooms and in the common areas (hall and dining room). Breakfast is buffet style. There is a shopping centre next to the hotel with small shops, a pizzeria and a big supermarket with a great variety of products
After resting for a few hours, we travelled to the Gatundu Level V Hospital, 20 minutes away from Maxland hotel, for what would be our transport and driver (Mr Samu Macharia) for the duration of the campaign. We arrived at the hospital and we were wellcome by Dr Chacha. That same day we started unpacking the equipment and organised it in the two surgical rooms available as well as to check the monitors and anesthesia machines available. Surgeons and anesthesiologists we went with Dr. Chacha to see the patients ready to operate the following day. This clinical visit was repeated every day in the evening. At the end of the day we came back to the hotel to buy some food and drinks in the market near the hotel before dinner.
We worked during 6 days (Sunday to Friday inclusive) from 8:00 -19:00, even later several days. The last surgery performed ended at 18:00 the Friday, december 1, 2023. On Saturday 3rd, 4 volunteers left the hotel to visit the Masai Mara Park to return to Madrid on the 5th of December, the rest of us went to Nairobi National Park a wonderful place where we saw a great variety of big wild animals such as rhinos, Monkeys, buffaloes, etc.
CONCLUSION Strengths of this place: Very good organization in the selection of patients to prepare the daily surgical report, both in the pediatric population and in adults. Possibility of having three surgical tables throughout the period. It is very important to have the collaboration of local professionals, both surgeons, anesthetists and nurses. Improvement objectives: It would be very useful for future campaigns if the Gatundu hospital could have an electric scalpel unit and Dra. Butrón made this known to both Dr. Chacha and the hospital director during a small farewell ceremony.
BUDGET:
COST FOR PERSON: Flight ticket 650€, Hotel (room plus half board) 340€ (42€ per day x 8 days). VISA 60€. Total amount 1050€ per volunteer.
PREPARATION: The campaign took place from October 28th to November 5th. To accomplish this, a Spanish team consisting of a general surgeon, a urologist, two anesthesiologists, two final-year general surgery residents, and four nurses traveled to Korogwe. For the preparation of the expedition, we had Dr. David Siwiti as our contact. The organization began almost a year before carrying out the mission. Via email, we provided him with the relevant documentation for each volunteer: passports, resumes, good practice documents, a list of the materials/drugs we were carrying, etc. The process was laborious, and we had to send that documentation on different occasions. Another setback that arose was the creation of a technically governmental tax, for which both doctors and nurses were required to pay extra fees to be able to practice. After negotiating for months, the hospital in Korogwe took on those charges.
Simultaneously, we sought funding to acquire surgical consumables and inventory material for the group: a charity concert was held in May 2023, and we requested hospital material from the University Hospital of Vic. The donation of material was valued at approximately 3000 euros from the social responsibility fund. Regarding inventory material, a basic hernia kit was purchased at factory prices through the collaboration of Sucmosa SA (Medicon®).
The purchase of tickets was kindly managed by Cirujanos en Acción, and subsequently, we made a donation for the corresponding amount to the NGO.
Finally, weeks before the expedition, Dr. Siwiti reserved a minibus for the journey from Dar-es-Salaam to Korogwe for 1000 euros round trip. He also reserved the number of rooms we specified at the Korogwe Executive Lounge hotel.
Although there is the option to obtain the visa online, the website did not function correctly, so we completed the procedures upon arrival in the country. We did not encounter any issues in this regard.
THE COUNTRY:
The United Republic of Tanzania is a country located on the east coast of Central Africa. The name originates from the union of the words “Tanganyika” and “Zanzibar.” The current United Republic of Tanzania was formed on April 26, 1964, when Tanganyika, which had been part of the German colony of German East Africa and later came under British rule at the end of World War I, gained independence on December 9, 1961. The Republic of Zanzibar, which achieved independence from the British crown on December 10, 1963, joined in a single state. The capital is Dodoma, although the most populous city is Dar es-Salaam. There are 120 Bantu groups that make up the majority of Tanzania’s population (61,741,120 inhabitants). Swahili and English are spoken.
Its economy is based on agriculture, which represents half of the GDP. Fishing, especially in Lake Victoria, is also one of the most widespread occupational activities in the country.
The doctor density is 0.03 per 1000 inhabitants. The mortality rate is high, particularly among children due to malaria and among adults due to HIV. 43.74% of the population is concentrated between 0 and 14 years, and the average age is 17.6 years. 14% of children are malnourished. School life expectancy does not exceed 8 years, and child labor accounts for 21% of the population aged 5 to 14.
THE LOCATION:
The cooperation took place in Korogwe, a city of approximately 60,000 inhabitants located in the Tanga region (Northwest Tanzania). To reach it, volunteers flew to Julius Nyerere International Airport, from where they traveled 300 km on sparsely paved roads to reach Korogwe Town Hospital in Magunga (founded in 1952). In Korogwe, there is a significant Catholic congregation, the Congregation of the Sisters of Our Lady of the Mountain of Usambara, created in 1954, playing a crucial role in assisting the local society, including coordinating healthcare through Dr. Avelina Temba, who is also a surgeon. The hospital is a single-story building:
1- New part used for emergencies
2- Old part, which includes:
* Floors divided into male, female, and pediatric sections. All beds have mosquito nets. Each room has a table serving as a nursing control station.
* An office for outpatient consultations where patients were assessed and selected for the interventions we performed.
* A surgical area with 3 operating rooms. The smallest was used by the local medical team for cesarean sections and some other gynecological surgeries. Our group used the other two operating rooms, rudimentary but suitable for the type of surgery we conducted.
THE TEAM:
– Raül Guerrero (Expedition Leader – General and Digestive System Surgery)
– Víctor Parejo (Urology)
– Sara Fernández (Resident Physician in General and Digestive System Surgery)
– Wassim Al Ashtar (Resident Physician in General and Digestive System Surgery)
– Pau Benet (Anesthesia and Resuscitation)
– Anna Casanova (Anesthesia and Resuscitation)
– Marta Guitart (Nurse)
– Núria Soler (Nurse)
– Judit Masramon (Nurse)
– Carlota Andreu (Nurse)
OUR OBJECTIVES:
– Provide medical-surgical assistance to patients in the targeted area who require it.
– Preoperative optimization of patients when deemed appropriate during the preoperative visit.
– Postoperative monitoring of patients and resolution of any complications.
– Ensure proper follow-up once the surgical team returns to the home country.
– Identify unfavorable points for improvement.
– Training of general surgery resident physicians.
– Training of local healthcare professionals through active participation.
– Cultural exchange between the local and European cultures.
THE OPERATING ROOM:
It is worth highlighting some peculiarities of the operating rooms so that those who come after us know what to expect:
– Both operating rooms have a rudimentary but acceptable surgical table. The armrests are two wooden planks.
– General anesthesia cannot be performed. There are two ventilators that, at the time of our mission, were not functioning.
– Between the two operating rooms, there is a handwashing area, but there is no iodine soap or chlorhexidine. Surgical washing had to be done with regular hand soap.
– Electric scalpels can be used, although, as expected, their functionality is not the same as in our environment. The scalpel plates have been reused so many times that they don’t stick, so it would be interesting for future groups to bring some replacements.
– Before our contribution, the hospital had very basic and outdated inventory materials (forceps that don’t grip, needle holders that don’t hold the needle properly, Kocher or Crile forceps that don’t close well, etc.). Regarding sutures, they have some that are rarely used in our environment, such as Catgut®, Dexon®, Nylon, and Silk.
– Regarding lighting: one of the operating rooms has a lamp with a halogen bulb that functions well, although it breaks down repeatedly. The other operating room is equipped with a floor lamp that does not provide much illumination. Both operating rooms have windows that help mitigate the lack or inadequacy of lighting.
– The temperature is quite correct, as there is air conditioning.
– It is not customary to clean the operating room after each surgery. Before starting the day, the hospital staff mops the floor with bleach, but due to the humidity in the environment, most days, we had to start surgeries with a wet floor. Additionally, the smell of the surgical area at the beginning of the day resembled a mixture of chemicals and blood.
– Worth mentioning: the surgical gowns are reusable cloth. They are washed and left to dry outdoors. Since we went during the rainy season, we usually had to put on damp gowns to comply with the surgical schedule for the day.
– It is common to find multiple insects inside the operating room.
– There is a barrier between the surgical area and the rest of the hospital, although it is not always respected. In fact, the stretchers entering the operating room to take out patients come from outside the surgical block.
PATIENTS:
63 patients were operated on (48 men and 15 women) between 3 and 83 years old.
Pediatric patients: 7
After filtering patients in consultations, 6 interventions were canceled due to comorbidity (severe heart or respiratory failure) or non-surgical pathology.
Upon arriving at Dar es-Salaam airport, we collect our luggage, go through passport control, and pay for visas (they accept dollars and euros). Dr. David Siwiti awaits us outside the airport: through a contact of his in customs, we have no problems entering the country with all the material and drugs we are traveling with. After that, we get on a cramped minibus with barely functioning air conditioning to go to Korogwe: we are charged 100 dollars for the round trip, a price we find abusive. After a long 8-hour journey (the distance is 280 km, but dense traffic and dilapidated roads don’t help), we arrive at the Korogwe hotel on October 29th at 23:00. It takes almost 24 hours to reach the destination from Barcelona.
The hotel is more than decent. In addition, the half board we chose includes breakfast and dinner in a buffet style. The Wi-Fi connection is valid for sending text messages but not much more.
The next day, we head to the hospital, and after a brief visit to the center, we proceed to prepare the surgical rooms where we will perform the procedures for the next 5 days. Simultaneously, two doctors from the team reassessed the patients who had been previously selected by the local team.
From October 29th to November 3rd, our routine was as follows: breakfast at the hotel at 7:00 am. Transfer to the hospital at 7:30 am. While anesthesiologists and nurses prepare the operating rooms, surgeons check the condition of patients operated on the previous day. After that, surgeries begin in both operating rooms.
The lunch break takes place around 1-2 pm, at the entrance to the surgical block. One cannot be very demanding with the diet since it is based only on chicken and rice. The expenses for lunch were covered by the hospital as well, which we appreciated. We are aware that groups that came before us had to pay high amounts for this reason. We also used the lunchtime to socialize and fraternize with the local staff. Afterward, interventions continue until late afternoon. Some days, the local staff asked us to finish earlier (5 pm), and we agreed.
After arriving at the hotel, there is little usable time left. In the best-case scenario, if there is still sunlight, you can walk around the area and see how teenagers play soccer during sunset or how some adults pick oranges from the trees.
Then, there is only time for a shower, a briefing of the day during dinner, and rest.
It is worth mentioning that in various surgeries, the local medical team collaborated with our group by assisting in surgeries and performing some anesthetic techniques. For us, the teaching of local healthcare staff is almost as important as the patients who undergo surgery. It should be noted that the ultimate goal of cooperation should be that local people can function independently.
As compensation for the intense work, on Saturday, November 4th, thanks to Dr. Siwiti’s management, we visited Mkomazi National Park, where we spotted various animals such as giraffes, gazelles, zebras, rhinoceroses, …
On Sunday, November 5th, we left very early in the minibus for Dar es-Salaam airport for the return to Barcelona.
PROS/CONS:
Pros: The local staff is attentive and pleasant, always trying to help and solve problems if they arise.
To improve:
– The circuit and communication for managing/sending data with the local link should improve.
– In the operating room: lighting; scalpel plates; repair the ventilator to be able to perform surgeries under general anesthesia.
– Improve hygienic measures in the operating room.
FINANCIAL REPORT
Below is a breakdown of the individual economic cost associated with the project:
**BREAKDOWN OF INDIVIDUAL PERSONAL EXPENSES:**
– Flight ticket: 837 euros/person
– Visa: 50 euros/person
– Meals and accommodation: 350 euros/person
– Transportation: 100 euros/person
– Standard medical insurance (IATI SEGURO®): 36.90 euros/person
Austrian-Swiss-Liechtenstein-Slovenian Team Mission 2023
Ngarenairobi Tanzania, Oct. 28th-Nov 5th, 2023
The Ngarenairobi Health Centre (NHC)in Siha District in Tanzania hosted a Hernia International Mission for the second time. Again, it was organized by the Congregation of Spiritus Sancti Fathers (ALCP OSS), especially Father Damian, who has similar organization skills as Rev. Sister dr. Avelina Temba in Korogwe. On the other side, the organizer was Dr. Gorjanc from Krankenhaus der Elisabethinen in Austria. Our Tansanian surgical and anaesthesiological friends dr Kombo, dr. Joseph, dr. Cosiano, Fanuel and others were again helpful in preparing enough patients for a successful mission.
The travel from our homes to NHC took us 12-24 hours, according to flight connections. Michael, Katalin and Wolfgang are not just skilled anaesthesia team but also keen mountaineers and summited Mt. Meru Mountain (4566m) in the days before the mission. Some members of the team were on Zanzibar island on deserved holidays just before the mission.
We all met on Sunday on October 29th at the Provincial house of the Congregation and from there and back we were transported to the NHC daily (about 30 min one way by minibus). Our team consisted of 12 members: 3 surgeons-consultants, 1 plastic and reconstructive surgeon, 2 anaesthesiologists, 1 radiologist, 2 scrub nurses, 1 nurse anaesthetist, 2 medical students (one from Mwanza, Tanzania). Additionally, 4 local doctors from Tanzania were present on different days of the mission. We imported 300 kg of medical equipment and drugs in 15 bags. Again, there were no difficulties at the customs due on-time application of our gear at the TMDA (Tanzanian Medicine & Medicine Devices Authority), but still additional help of father Damian was required at customs of the entry airport (Kilimanjaro) for some of us.Checking patients for surgery was our first task on sunday evening and monday morning. There were more patients than the year before. There were many thyroid patients, we operated on all who were euthyrotic. The turnover of the patients was fluent. Parallel operations on 2 and sometimes 3 tables, enabled 57 procedures on 54 patients in 5 days. Twelve patients were children (22%) and 42 were adults (78%). 31 patients (57%) were female. The most frequent operations were hernia repairs (inguinals, umbilicals and epigastrics), followed by thyroid resections, lipoma excisions, Jaboulay`s (Winkelmann) procedure for hydrocaele operation and other smaller operations (one orchidopexy due to undescended testicle in child. Other diagnoses/operations were operations for benign lesions and other smaller excisions. In inguinals in children, Mitchell-Banks repair was performed and Lichtenstein repair with LDPE mesh was performed in adult patients with inguinal hernia. The youngest patient was 3 years old. Thanks to the excellent anaesthesia team and Ligasure device (which we brought with us) we performed 6 subtotal goiter resections in big benign goiters and unfortunately had to cancel 4 more due to untreated hyperthyrosis. All resected thyroid glands were histologically examined (costs are 30$/specimen in Tanzania). The resections were subtotal in order not to demand postoperative hormone substitution. In case, this might still be necessary at T3/T4 check in 3 months, it will be provided (in Tanzania costs for oral Levothyroxine are 20 $/month/patient). Maria performed 58 ultrasound examinations with her potable US (32 in women, 26 in men). She did the interpretation of abdominal X-ray in a patient with acute abdominal pain and in a patient with hand problem. Again, ultrasound enabled exact diagnosis in many patients and made many decisions easier. In patients with goiter this was the only way to plan the exact extent of the resection.
In OT 1 (good lights, diathermy which we brought last year is working), mainly general anaesthesia was performed, while procedures in OT2 (head lamps, diathermy) were first spinal anaesthesia, but then our anaesthesia team used a mobile respirator that they brought along (Oxylog 3000) for general anaesthesia. In OT 3 (improvised from recovery room), we used head lamps and local anaesthesia and did not have diathermy available.
Scrub nurses Manuela and Sofi prepared tables and selected instruments and material in 3 Ots. Manuela is experienced from many missions and always scrubbed in for thyroid operations. HI- missions with possible large/complex hernia- and other operations should always have an experienced scrub nurse in the team.
Lea as plastic surgeon together with Christoph mastered some reconstructive surgeries (contractures) after burns and performed many aesthetic excisions of skin disorders.
We had one postoperative haemathoma after lipoma excision – it was evacuated surgically on the same evening. Again, we took enough time for every single procedure, without hurrying, which was important in all and not only in HIV-positive patients. A normal working day started at 8 am and ended at 4-6 pm. Normally, after a good breakfast we did not take lunch break (some biscuits, soft drinks, coffee and tea were sufficient between operations). We all met every day again at dinner at 7pm.
Team Members:
Dr. Michael Wirnsperger – consultant anaesthesiologist, LKH Bludenz, Austria
Dr. Katalin Wiese-consultant anaesthesiologist, Krankenhaus Feldkirch, Austria Wolfgang Walser – anaesthesia nurse, Feldkirch, Austria
Dr. Marija Jekovec – consultant radiologist, Ljubljana Medical Centre, Slovenia Manuela Logan, scrub nurse, Liechtenstein
Prof. Mirko Omejc, MD, PhD – consultant surgeon, Ljubljana Medical Centre, Slovenia
Andrej Omejc – medical student, Ljubljana, Slovenia
Edward Edmund – medical student, Mwanza, Tanzania
Dr. Christoph Sträuli, MD-consultant surgeon Grabs, Switzerland
Dr. Lea Lisborg Mračević – resident plastic and reconstructive surgeon
Assist. prof. Jurij Gorjanc, MD, PhD, FRCS, FEBS AWS – consultant surgeon, team leader, Krankenhaus der Elisabethinen Klagenfurt, Austria
Total operated patients: 99 patients (of which 40 were pediatric patients, aged from 20 months to 17 years)
Patients seen in consultation: 130
Complications (within 7 days of our arrival):
– none seen, patients came back day 3 post operatively for check-up.
CAMPAIGN SUMMARY
THE LOCATION
Sisters of Nativity General Hospital was established 2006 by Bishop Athanasius Atule Usuh (Bishop Emeritus of Makurdi Diocese) and went into operation on 1st May, 2006. The hospital is located in Jikwoyi Phase 1, a suburban area south-east of the Federal Capital Territory, and an under-served area with a fast-growing population. It is roughly 15-20km from the City Centre in the outskirts of the town of Abuja with bustling life just outside the compound. The Compound is secluded and a safe place to be in. The nuns live here and took great care of us.
The hospital consists of different departments: Surgical department, emergency department, medical care, HIV projects, vaccinations center, facilities for child-mother care, maternity, laboratory and testing etc.
Concerning the surgical department there were two operation theatres. One was reserved for the current Hernia mission, the other was used for acute surgery, for cases such as caesarean sections.
We created a three-bed operating theatre, making it possible to perform 3 operations simultaneously, which we found very efficient, also making it possible to collaborate with each other with difficult cases.
The operating theatres were equipped with air conditioning, allowing for a comfortable work environment. We were intermittently affected by short power outages, before the hospitals generator kicked in – so our headlamps became crucial to allow us to continue operating.
We brought 2 diathermy machines, one of which one was donated to the Hospital (by funds from Hernia International).
All adult and teenage patients (youngest was 14 years) underwent operation under local anesthesia, – so all these patients walked in and out of theatre without the need of stretchers, making the turnover quick and easy.
Pediatric surgery was performed using a combination with ketamine sedation and local anesthesia. The local Dr. Ini assisted brilliantly with ketamine, love, romantic music and good humour.
In between surgery we saw patients who requested screening for a variety of surgical/non -surgical diseases, and patients coming for check-up after surgery.
The patients were seen dressed in gowns ready for surgery in a room in front of the theatre where they were marked at the operation site, and informed about surgery, sitting ready for surgery when the first patient left the room. Peripheral venous access was established for children undergoing ketamine sedation before entering the operating room, facilitating the start of surgeries.
Cleaning between the shifts were swift and we developed a fast track way of washing, putting local anesthesia, and getting all ready for surgery.
Almost all patient went home the on the day of surgery and came for check up 2-3 days later in the outpatient department.
Our dear hosts: Sisters of Nativity
THE TEAM
The team consisted of three surgeons: Steve Lindley (UK), Alan Kravitz (Washington DC) and Thorbjorn Sommer (Team leader Denmark). Anesthetic Nurse Lene Scheffmann Gosvig (Denmark) assisted with the procedures together with the local nurses.
Two months before departure we had 2 virtual Zoom meetings, the first including our African colleagues, where we were introduced to each other, discussed the mission, the need of equipment and had a very good introduction by Dr. Austin and Dr.Ini (who actually took us on a virtual tour with his mobile on facetime around the Hospital – super nice !).
LOCAL STAFF
In the corridor nurse Benita made sure to list all the patient for each day, kept a very strict protocol ensuring a good overview of patient flow. She knew exactly where the patients were, when they should be operated and for what, which created a swift flow of patient and very short intervals between operations. Lead scrub nurse Rose was phenomenal, managing many different members of staff who came to help in theatre. The nurses, some of whom had limited theatre experience did a very good job assisting us, and we tried to share as much knowledge with them as we could – Steve didn’t let up in his teaching, with very rewarding results.
EQUIPMENT
Concerning Equipment, we brought two Diathermy Machines, drapes, gowns, sutures, meshes, gloves, masks, drains and surgical instruments (the latter was also left at the hospital for future use).
There was one monitor with a pulse oximeter and a blood pressure cuff, without an ECG, which were used when patients received Ketamine (kids).
The last days we used the local textile gowns and drapes which we found very usable. In future missions it seems more sustainable to bring new textile gowns and drapes which can be used after the mission, minimizing the amount of waste of single-use gowns and drapes.
ANESTHESIA
The operating room was equipped with oxygen supply and a ventilator which we did not use. We did not use any spinal anesthesia.
Ketamine was available at the hospital as well as Lignocaine. We used our own Marcaine with adrenaline the first days and Lignocaine for the last days and found either very affective when applied in steps of cutaneous, subcutaneous, and subfacial injection steps before washing and draping, making the effect of local anesthesia maximal before commencing surgery. That strategy made it possible also to do inguinoscrotal hernias as well under local anesthesia.
ASEPSIS AND SURGICAL MATERIAL
All patients had washed before arrival for surgery. At the hospital they were washed with appropriate antiseptics, hair was removed, the site of operation marked on the skin and local anesthesia was applied.
Basic surgical material boxes were available, however a lot of the instruments were not appropriate, so we had to sort out small instruments for the kids, and fortuitously, we brought a few appropriate sets of instruments, which were left for future use by the local staff.
ACCESSIBILITY FOR THE POPULATION
Before our arrival, the Hospital had conducted an information campaign with information about the possibility of hernia surgery. The patients paid what they could afford, some came a long way to be operated (7-8 hours of transportation).
The patients had preoperative pain killers (Paracetamol+NSAID) and postoperatively they were given a single dose of antibiotics. We recommend bringing NSAIDS , antibiotics and Paracetamol.
ACCOMODATION IN ABUJA
We stayed within the Sisters of Nativity Compound, where the Hospital was situated, a 1 hour drive from the international Airport. It was a perfect and very safe place to be located in. We were greeted with flowers, songs and dance and a nice meal when arriving. The sisters were amazing hosts, providing us with food and beverages, good company, love and smiling faces every day, – such an encouragement. The rooms were nice and spacious with a private bathroom. Laundry was offered as well.
Our routine included Breakfast at 7AM before starting surgery at 8-8.30 AM.
We had a lunch break at 2 PM, and finished the last surgery between 4 and 8 PM, depending on the number of cases scheduled.
On the first Sunday we were joined by Dr. Austin in Harvest mass at the Catholic Church and had Lunch with Leaders in the organization, – a memorable event to participate in.
The last evening the sisters had invited us to a Party in the Compound with dances, food, heartful moving speeches – and they dressed us in beautiful traditional Nigerian dress as a gift to bring home with us. We are so grateful for the opportunity to be a part of this, and we all expressed our mutual gratitude for the successful campaign.
The reason for this was first of all Dr. Austin Ella and the staff at the Hospital and Sisters of Nativity. They ensured that the logistics worked, they were prepared with patients on the line when we arrived and working together was a lifetime experience for all of us. We left a piece of our heart with them.
CONCLUSION
Strengths of this location:
The Hospital is close to the Airport, reducing time for transportation to a minimum. Patients came from far away, and the standard at the facility makes it easy to do high-volume Surgery with good quality in every aspect.
You can`t find a better host than Sisters of Nativity – they were everything from caring hosts, joyful company, incredibly good cooks taking care of our needs.
The Hospital is 30 steps from accommodation – so no time is wasted on transportation.
We had a very good collaboration with the staff in assisting us with everything.
There is a very good opportunity to continue and develop the work in this place with the local staff and contribute with surgical expertise.
We highly recommend Hernia Missions conducted on a regular basis to Sisters of Nativity in Abuja!
Things we might do differently:
Thinking sustainability from the start when doing the campaign, avoiding the heavy loads of single use gowns and drapes. Provide equipment that can be used further on.
Bringing more local anesthetics, antibiotics, painkillers and dressings.
We had to pay for registration to the Nigerian Medical Association which we hope can be negotiated at a reduced rate for future doctors.
We found (some of us) that diathermy was very useful and can recommend bringing it with you.
On behalf of the Team 2023
Yours sincerely,
Thorbjorn Sommer
Head of the Hernia International Mission to Abuja November 2023
General Surgeons: José Mª Guallar, Berta Lluch, María Dolores Periañez, Ainhoa Andrés, Enrique Colás
Paediatric Surgeon: Rocío Lizarraga
Anesthetists: Francisco Llácer, Inma Giménez
Nursing Team: Javier Madrazo, Esperanza Galarza, Míriam Martínez
Total: 11 volunteers
REPORT
Given that Dr. Eduardo Perea’s report from last year was very helpful, I am borrowing his structure and incorporating common aspects for future missions.
TECHNICAL REPORT:
DATES AND LOGISTICS DEPLOYED:
Campaign conducted from October 20 to October 29, 2023
ADULT PATIENTS: Hernias (inguinal, umbilical, ventral, and inguinoscrotal), hydroceles, supernumerary breasts, ganglions, condylomas, lipomas, and sebaceous cysts.
Total operated patients: 96 patients (including 33 paediatric patients, aged from 9 months to 11 years)
Patients seen in consultation: 161
Complications (within 7 days of our arrival):
– 2 seromas in inguinoscrotal hernias
– 1 seroma in supernumerary breast
– 1 folliculitis
– 2 cellulitis in pediatric umbilical/inguinal hernias
CAMPAIGN SUMMARY
THE LOCATION
Farafenni General Hospital was established in 1999 as part of the Gambian government’s effort to create a healthcare center of reference in the eastern part of the country. It is a well-equipped and organized large center with 250 beds, of which 175 are currently occupied, due to human resource limitations.
Farafenni is a small inland town strategically located next to the only bridge across the Gambia River, making it a transit point for local trade and travel between different parts of Senegal.
The population is approximately 25,000, providing services to both Gambian and Senegalese residents. While English is the official language, Wolof and Mandinka are the commonly spoken languages among the population.
The hospital is divided into an initial area for administrative offices and emergency care, and a nearby building for laboratory and testing, which connects to different wings for surgical patients, maternity, pediatrics, internal medicine, and dentistry, each with two floors.
In the surgical wing, there is a clean circuit with two large operating rooms, one dedicated to maternity and the other for general surgery. Each operating room is equipped with a basic ventilator capable of using halothane and an diathermy generator.
The operating rooms are equipped with split air conditioning, allowing comfortable work despite the high outdoor temperatures.
Obstetric material is not used due to the high number of emergency cesarean sections.
The surgery room can be configured to accommodate three tables simultaneously while allowing for easy patient entry and exit on stretchers.
THE TEAM
This time, we had a larger team than usual, consisting of five general surgeons, one pediatric surgeon, two anesthesiologists, and three nurses (you can find their names at the beginning. ( See Photo 2).
LOCAL STAFF
The hospital has a competent local staff that has been of great assistance. Thanks to our contact with a Cuban surgeon based there (Dr. Alain), we were able to operate on 16 patients on the first day (this would not have been possible without his prior patient selection).
Local nursing and auxiliary staff, including instrument specialists, anesthesia nurses, circulating nurses, orderlies, and cleaning staff, proved to be highly competent (see Photo 3).
The hospital also has a reception/recovery room where peripheral venous access is established before entering the operating room, facilitating the start of surgeries, especially for younger children.
EQUIPMENT
Given our larger team and the fact that it had been done in previous campaigns, we requested to work with three operating tables.
The hospital has one diathermy generator that can accommodate only one terminal. We brought various sutures from previous campaigns, but there were no meshes available.
There was only one monitor with a pulse oximeter and a blood pressure cuff, without an ECG.
ANESTHESIA
The operating room is equipped with a ventilator and two vaporizers for halothane and isoflurane, but only the first gas was available.
We primarily used the table where the ventilator was located for paediatric surgeries.
We could work with manual and controlled IPPV ventilation, although monitoring the method of ventilation was not easy, we could assess tidal volume and respiratory rate, but there was no capnography.
Additionally, there was an oxygen condenser that could be used with a Mapelson if two general anesthesias coincided.
They had normal saline, abocaths, spinal anesthesia needles, and bupivacaine with dextrose available.
ASEPSIS AND SURGICAL MATERIAL
Basic surgical material boxes were available, with sufficient but deteriorated instruments. There was a laparotomy kit with more equipment than was used during the campaign. Surgical gowns and cloth drapes were sterilized using an autoclave.
Because we had a large team and considering the advice from the previous team, we decided to bring two additional diathermy generators, which allowed us to work on three operating tables simultaneously, even for procedures requiring electrical devices.
Bringing complete surgical drapes, gowns, and other disposable surgical materials and medications was very useful.
ACCESSIBILITY FOR THE POPULATION
The hospital is affordable and accessible to the population, with a charge of 40 Euro cents for Gambian residents and 80 Euro cents for Senegalese residents upon admission. Imaging and laboratory tests are charged separately, but the fees are not excessively high, although some patients may have difficulty paying.
OUR LIFE IN FARAFENNI
We traveled via Barcelona-Casablanca-Banjul, arriving in the capital at 1:30 AM. Mr. Sainey Dibba, the hospital’s logistics officer who helped with hotels, meals, and transportation, was waiting for us at the airport, along with other hospital staff.
This made it much easier for us to clear customs and exit.
From there, we went to a nearby hotel (Lebato Hotel) to rest for a few hours before heading to Farafenni. The rooms had fans and allowed us to take a shower. They also had a beachfront view.
The following morning, we left for Farafenni with two cars. The journey took 3-4 hours on well-paved roads, but it was time-consuming due to traffic.
In Farafenni, we stayed at the Wallyman Hotel, which was a 10-minute walk from the hospital and had a pleasant garden leading to individual air-conditioned rooms (the cost was approximately 110 euros per person for the entire stay).
It’s worth noting the sounds of the nearby mosque with repeated prayers at 5 in the morning :).
Upon arrival on Saturday afternoon, we began unpacking our luggage, which included 22 bags of material and medication. Dr. Alain had already prepared a list of patients for us to assess, but it was mostly on Sunday that they arrived, allowing us to start surgeries on the same day at 9 AM.
Our routine in Farafenni included walking to the hospital in the mornings at 7:45 AM for breakfast before starting surgeries.
Once at the hospital, the surgeons made rounds with patients who had been operated on the previous day, while the anesthesia and nursing teams prepared the surgical tables.
Surgeries would begin, and they continued until 2 PM, when we stopped for lunch at the hospital.
Afterward, we resumed surgeries from 3 PM until 6-7 PM (although some days we finished later, it was not the norm). It was several days of very satisfying work alongside the competent local staff.
On the last day, we met with Dr. Kebba Manneh and the rest of the hospital staff for a debriefing session, where we expressed our mutual gratitude for the successful campaign.
We believe it was successful based on the number of patients operated on and the opportunity to operate on pediatric patients.
Our flight departed in the early hours of Sunday at 2:30 AM, so we traveled in two cars to Banjul after the hospital meeting, accompanied by Mr. Sainey.
We decided to rest for a few hours in a beachfront hotel with a pool. From there, at 10 PM, we headed to Banjul Airport, en route to Casablanca.
CONCLUSION
Strengths of this location:
– Strategic location with a significant population in need
– Presence of a Cuban community with which communication and patient follow-up is easy
– Strong collaboration from the local hospital and its staff in assisting us with transportation, accommodations, and other logistics
– A significant number of Spanish foundations and NGOs working in Banjul and other rural areas can help access the needy population (it would be important to contact them well in advance of the campaign)
Areas for Improvement:
– Difficulty in filling out and sending forms, data, photographs, and other documents in the months leading up to the campaign.
– Creating an inventory of all materials and medications with expiration dates, manufacturers, and quantities is a challenging task when you are carrying 400 kg of luggage like us.
– It is impractical to pay 400 euros for medical registration to work in the campaign (initially requested, but we were later granted scholarships, and it cost us only 30 euros with expenses).
– If possible, bring both an endocrine surgeon and a pediatric surgeon.
– Bring an additional source of energy (electrocautery or Ligasure for thyroidectomies). Note that there is only one available, and we can work on three surgical tables simultaneously.
– The hospital accommodates a large multidisciplinary team.
– Improve patient recruitment so that surgical schedules can be created in advance (in the final days of our campaign, we ran out of patients. We were informed that the best period to go is in the last two weeks of November or the first week of December due to the employment situation of the population).
