Author: akingsnorth

 Korogwe Hospital, Tanzania – May 2017

                                                The team and the mission

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

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

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

                                                                   The hospital

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

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

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

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

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

                                                           Day to day

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

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

                                                              Operative record

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

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

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

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

                                     Practical anaesthesia in a resource limited setting

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

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

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

                                                Shopping list for future missions

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

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

Surgical materials needed:

·        Gowns

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

·        Gloves

o   Will need plenty for the team and korogwe staff

·        Face masks and theatre caps

·        Mesh

o   Sterilised and of the mosquito brand

·        Sutures

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

·        Local anaesthetic

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

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

·        Diathermy plates

o   They have a metal plate which they re-use

o   Recommend disposable plates, which we reused.

·        Diathermy pencil tips

·        Drugs – Antibiotics, analgesia

·        Dressings, needles, syringes

Anaesthetics materials needed

·        Oxygen regulators

o   Only one available at present

·        CO2 absorber and breathing circuits

·        Laryngoscope

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

·        Intubation/airway equipment

·        Paediatric masks, airways and LMAs

·        IV cannulas

·        Nitrile gloves, tape and cleaning solution

·        Anaesthetic drugs

                                                                       General

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

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

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

Cost of the mission and accommodation

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

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

                                                       Many people to thank

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

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

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

Vernon Sivarajah

Benin, April 21-29, 2017

Cea-Cea Moller-team leader,

Richard Turner – surgeon and hardest worker

Christine Russell-surgeon and bold French speaker

Philip Gribble-anaesthetist and educator

Paul Scaife-surgeon and fastest runner

Clancy– teenage anaesthetic nurse student scribe scout interpreter!

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

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

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

Pre-arrival

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

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

Arrival

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

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

Accommodation

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

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

Food

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

Patient Preparation

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

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

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

Theatre

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

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

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

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

AdenosineAdrenalineAlbumen 20%AmiodaroneAmpicillinAtropineBupivacaineBuscopanCa ChlorideCalcitriol

CeftriaxoneClindamycinDiazepamEtomidateFentanylFlumazenilFrusemideGentamicinHaloperidolHydralazine

KetamineLignocaineMetaclopramideMetronidazoleMidazolamMorphineNaloxoneNeostigmineNitroprusside

OndansetronPolaraminePropofolRocuroniumSteroids (5 types)SuggamadexSuxamethoniumThiopentoneTranexamic Acid

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

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

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

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

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

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

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

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

Operations

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

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

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

Anaesthetics

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

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

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

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

Post-Op

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

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

Student Participation

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

Suggestions for next time

Surgical

         * Program 8 patients per day

         * Theatre nurse volunteer

         * Good scissors

         * Sterile gowns

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

         * Diathermy handles and blades

         * Scrotal supports

         * Gallipots

         * Self retaining retractors

         * Large sterile drapes that cover the whole patient

         * Local anaesthetic

         * 2^nd Mayo instrument trolley

Anaesthetic

         * Oximeter, BP, capnography

         * Small syringes for mixing

         * Large non-sterile gloves for Phil

         * Laryngoscope

         * Portable U/S

Other

         * Theatre snacks!

         * Room shelving for storeroom

         * Clear plastic organizing boxes

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

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

Cea-Cea Moller

Team Leader

Hernia International – mission report

International Hebron Hospital – Phnom Penh, Cambodia, 9 to 13 Jan 2017

Team members:

Dr. med. Jürgen Meyer

Prof. Markus Heiss

Dr. med. Andreas Hohn

Dr. med. Simone Seefeld

Nicole Daams (nurse)

Our German team (3 surgeons, 1 anaesthesiologist, and 1 scrub nurse) arrived at Phnom Penh on Saturday 7 Jan 2017, and the next day we were warmly welcomed by the hospital’s vice director Dr Chul Lee and his team. He gave us a brief introduction to Cambodia’s history and the story of the Hebron missionary hospital which is funded and operated by Korean Christian missionaries.

The Hebron hospital has three well equipped operating rooms available, all with AC, full monitoring, and anaesthesia machines. As cardiac surgery and ENT surgery is regularily performed by different international teams, most common drugs and standard airway management equipment is available at the Hebron.

On Monday we started on one table, but temporarily, we were able to run two tables concurrently, depending on the personnel resources and the particular complexity. Our Team was supported by a local surgical resident, several scrub nurses, and two anaesthetic nurses. During this week, we managed to do 28 hernia repairs. Among these twelve children were between 2-12 years old with inguinal hernia to a varying degree. All children were operated by using the technique of Ferguson.

Most of the adult patients showed large inguinal hernia, three-times on both sides and in five patients chronic incarcerated hernia were met and operated under spinal anaesthesia. Only one patient with an altered coagulation due to liver cirrhosis and one woman with a large abdominal incisional hernia needed general anaesthesia. All children received general anaesthesia and an additional caudal block for postoperative pain control.

In adult patients, the Lichtenstein technique with polypropylene mesh implantation was used. The abdominal incisional hernias were operated with sublay mesh implantation.The patients were clinically investigated by our team. Sonography was available and used occasionally. All patients came with a preoperative checklist and were all well prepared by the local team. Patients had received perioperative antibiotic prophylaxis. Laboratory tests and chest x-ray were done according to the local standards and further lab tests as HIV, HBV, and HCV were available on the very same day.

Patients were visited by the Hernia International team twice a day and no major postoperative problems, especially no signs of infection were found. Only one young patient with a large incarcerated scrotal hernia had a prolonged hospital stay due to a postoperative bowel dysfunction and abdominal distensions The ward nurses did an excellent and dedicated job and took care for the patients. The ward nurses were supported by two local GP residents.At our last day, a great celebration in the hospital´s main hall was performed with a warm acknowledgement for the performance of our team.

As accommodation we choose the Dragon hotel in Phnom Penh, which is a little hotel nearby the hospital with friendly service and clean rooms. In dependence of traffic it takes 10- 15 minutes with the tuk-tuk to the hospital and 15-20 minutes to the city center. After our mission we traveled for two days to Ankor wat und Siam Reap. The tour was well organized by the people from the hospital, so we had the opportunity to visit the temples from Ankor wat.At last we had a great time in Cambodia, we met a lot of nice people, which helps us a lot and finally we could help some patient…..   

Hernia International Report

Thirteenth Mission

Carpenter, Ghana, November 2016

Hernia International team, Canadian GRID team and Ghanaian organisers

Leighton (North West) Team: Magdi Hanafy, Sara Watson, Perry Board, Geraldine Burke, Ramona Maria Fetita, Emma Brown, Ambareen Kausar, Diane Dugdale, , Katherine O’Shea.

Northampton Team: Rob Hicks, Nichola Blunt,

Canadian Team: Tony Brown, Martin Stewart, Laurie Patry, Margie McGregor, Susan Simpson

German Team:           Antje Hopt.

Spanich Team:            Natacha Apentchenko

Ghanaian Team:         George, Colin, Noah, Mathew, Daniel, Mumuni, Eric, and many others.

Our surgical team this year comprised of 18 volunteers from the UK, Canada, Spain and Germany. Many of us had previous experience and some were newcomers. We travelled differently this year. After arriving in Accra with our 52 pieces of luggage, we were transferred to a hotel to rest overnight. The next day, rather than travelling to Carpenter by coach (an 11 hour trip) we took the plane to Kumasi, followed by a four hour drive to Carpenter. We arrived by lunch time and had time to unpack. This difference made our trip much easier. Although that incurred a cost it was well spent.

On the first day while we were arranging our theatres we received a patient with a strangulated hernia. He has been in this condition for four hours. The anaesthetists were not ready yet but managed to prepare themselves very quickly to put him to sleep. The operation went very well without the need for bowel resection. For the first time our first operation was an emergency.

While we were operating, I was seeing patients in the clinic and listing them for the same and subsequent days to fill up three theatres with general and local anaesthetic cases. On that day, and subsequent days, I saw and listed sixty patients and refused to operate on lipomas, ganglia, skin lesions or anything else other than hernias.

One patient listed for an inguinal hernia operation in two days’ time was admitted on the second morning with the same hernia strangulated. He was operated upon successfully.  In the evening after dinner another patient came with a small strangulated hernia. Two emergencies on the same day, three in 48hours, that was unbelievable. With the help of our anaesthetists’ sedation and pain control we managed to reduce the last hernia by gentle taxis. He was first on the next day’s list.

All children were screened for Malaria and 100% were positive. Each child required treatment for three days before the operation. The first children’s list was on Wednesday and the second was on Thursday of the second week.

This unpredictability of emergency admissions made me conscious not to overload the lists and tire our staff. Average 9-10 procedures a day per theatre, taking into account the complexity of the cases, was more than enough. The aim was to finish all cases, clean theatres and finish computer work before sunset (6:00 pm) every day. I successfully resisted my desire to get every hernia on the planet operated upon, and was content with that number per list per day.

By the end of our mission (nine days), we counted 268 hernias operated on (219 patients). We worked hard as well in a daily clinic on site to populate the lists and in the villages to populate the waiting list for 2017.

We were five surgeons (all consultant level) and one registrar paediatric surgeon. Seven experienced theatre nurses, two consultant anaesthetists (one full time and one part time), one experienced anaesthetic assistant nurse, and one ITU nurse for recovery and ward duties. Not to forget our Ghanaian helpers who organised admission, discharges, patient transfers, translation, consenting, meals, rooms, calling us if we were needed for a condition or a question. We were also supported by Collins, a community Ghanaian nurse who tested all patients for HIV and Malaria before their operation. He is the nurse who will take charge and care of our patients after we leave and he will communicate with us if there are any problems.

This year did not hide any surgical challenges more than the usual hernia operations. We had two wound infections, one deep and one superficial. Both treated by incision, drainage, antibiotics, pain killers and daily dressings in our facility followed by the community care with Collins. I had one of the most dreaded complications while doing a Stoppa repair for bilateral large inguinoscrotal hernias. I unintentionally entered the dome of the urinary bladder.  I catheterised the patient and repaired the bladder with two layers of interrupted Vicryl. I conferred with my surgeon colleague and we decided to continue with the repair of the hernias. A tense five postoperative days with IV antibiotics, Iron tablets, plenty of water to drink and urine observation for amount and colour. Seven days afterwards the urine was clear and the patient was eating and drinking and sitting out with the catheter and asking for a football. Nurse Collins will remove the catheter 10 days after the operation.

We operated on a Lumbar hernia the size of a small melon for the first time. We had a patient with a large Spigelian hernia on one side (shown above) and a large inguinoscrotal hernia on the other. We had a hernia going into the femoral sheath under the inguinal ligament. We had the appendix  inside the hernia sac (shown below), we had an aneurysm of the common femoral vein (Left alone). We had an epigastric hernia that turned out to be a large mobile mesenteric cyst or a tumour when examined with the patient lying down. She did not have an operation and was transferred for a scan. We had a lady with a huge abdominal mass occupying all the abdomen for the last three years. The mass was tense, dull, not tender. The patient was transferred to another hospital for a scan. ? Ovarian pathology. I saw a large inguino-scrotal hernia, which when reduced showed worms in the scrotal skin that kept dancing on touch,  each the width of a pencil and about 3-5 cm in length. Without a diagnosis we started the patient on intense anti-helminthic medications for five days.  I am looking forward to seeing him next year. We saw a patient with a “moderate” inguino scrotal hernia, who could not pass urine unless he squeezed his scrotal hernia. We concluded that the urinary bladder was atonic and relying on this manoeuvre to contract. Repairing this hernia would put the patient at a disadvantage.

Our Canadian colleagues kept helping us by supplying IV antibiotics and fluids, as well as antimalarial medications and test kits for HIV and Malaria. We took turns in joining them in the villages and short listed many more hernias for next year. We also helped with opening abscesses, diagnosing surgical conditions and recommending treatments. Our autoclaves this year were extremely hard working as we sterilised instruments for the dental team as well. Our Ghanaians helpers did, as usual, the most to care for the patients and kept us informed and helped us deliver the service at a high level. Collins screened every patient. Noah consented them and answered any questions. George translated for me in the clinic and made sure the wrist band belonged to the patient concerned.  Mumuni brought patients from outside the compound into the wards and allocated rooms for them, and discharged those who had operations the day before, booked minibuses for them and advised them regarding their take home medication. Mathew was a man who would not sleep, informed us of any problems, stayed up all night with the engineers to make sure the Air Conditioners were in place and working. He was the one who knew where we were and would come and let us know if a patient came with an emergency and stayed with us for translation. Everybody liked his dedication and personality.

Our Anaesthetists had Eric who is a qualified nurse anaesthetist from Bamboi. He took time off from his work to come and learn and help at the same time. He is a very good man who is willing to learn and help and never got tired. He is a good seed for the dream hospital we are going to build in the future. Nicky our ODP was described as having a battery attached to her as she never stopped working.

The way the team, from different countries and with different experience, gelled together and worked like a “well-oiled machine” was impressive.

 Sister Watson described the work as “seamless care, which is how it felt really, I am always amazed at how everyone pulls together and helps each other in the unique experience that is Carpenter.  Alongside the Ghanaian support team we laughed, worked tirelessly and became more culturally informed and enriched through shared conversations”.

The team worked hard and enjoyed what they were doing. The satisfaction in the face of each member of the team at the end of each day and on the last day of the trip was noticeable. Other than every day work, the packing and inventory on the last two days were made to perfection.

I would like to mention companies who worked hard to provide us with instruments and consumables needed for the trip. Medline supplied us with gowns, drapes, gloves and swabs enough to cover our mission. Eschmann supplied us with more sterilisers and diathermy machines to compensate for those which were destroyed last year by the electric power surge. KLM was kind enough to wave reasonable extra weights and accept extra luggage. ERS medical for transporting our luggage to the airports.  Our Local pharmacy in Knutsford supplied skin sterilisers without charging VAT. Many employees in Leighton and South Cheshire hospitals have made me aware of useful redundant instruments that I could take for the mission before they are disposed of.

Rob Hicks will take over the organisation of the missions from 2017 onwards. The mission is lucky to have him as a leader. He has a much calmer approach than me and he is liked by all the team. I shall still be a member and travel as a surgeon and help as much as I can in organisational matters.

See you all in Carpenter 2017.

Magdi Hanafy

Consultant Surgeon

Mid Cheshire Hospitals NHS foundation Trust

Volunteer in Hernia International group.

On behalf of Team Carpenter 2016 (UK-Ghana-Canada -Germany- Spain)

GOD BLESS YOU

Please make donations to:

Operation Hernia Leighton Branch.

Addressed to Mr Magdi Hanafy, Surgical Department, Leighton Hospital, Crewe, Cheshire, CW1 4QJ.

PS: all patients (and families of) were consented before photos were taken and published.

See you all in Carpenter 2017.

Magdi Hanafy

Consultant Surgeon

Mid Cheshire Hospitals NHS foundation Trust

Volunteer in Hernia International group.

On behalf of Team Carpenter 2016 (UK-Ghana-Canada -Germany- Spain)

GOD BLESS YOU

Please make donations to:

Operation Hernia Leighton Branch.

Addressed to Mr Magdi Hanafy, Surgical Department, Leighton Hospital, Crewe, Cheshire, CW1 4QJ

.

Ps: all patients (and families of) were consented before photos were taken and published.

The 7^th Mission in Ya Wilaya Hospital

Korogwe, Tanzania,

November 19th-26^th, 2016

The TeamTh

The Team

        Miss Zoe Vlamaki Surgeon, 2^nd trip to Korogwe

·        Dr Penny Howell anaesthetist.

·        Mr John Budd Surgeon with pediatric interest.

·        Mr. Alan Cameron Surgeon.

·         Mrs Anna Budd theatre nurse, Mr Budd’s wife

     Mrs Margaret Cameron NHS retired physiotherapist and Mr Cameron’s wife.

On a hot and sunny afternoon in Tanzanian’s dry season we have arrived at the busy Dar Es Salaam International Airport, the meeting point of the team.

Despite heavy traffic, a member from the hospital staff and the hospital driver, managed to pick us up at the airport waiting area, with a slight delay.

Familiar faces made the foreign country more familiar to meet new people. We had a warm welcome to the country and began the journey, loading the car with all the boxes and baggage.

To avoid driving to Korogwe in the night, we spend the first night at the Bagamoyo, two hours (depends on traffic )drive from Dar Es Salaam a resort  on the line of Indian Ocean. We had a very nice relaxing evening before our mission’s work and was a good time to get to know the team members.  The hotel in Bagamovo was good value for money and the hotel staff was helpful.

On following day Sunday, Omari drove us to Korogwa. The drive took more than 4h for us to reach our destination.  

Our first stop was at White Parrot Hotel where we were welcome by Avelina  a local Surgeon and the organizer of those mission trips, to Ya Wilaya Hospital.

We continued our journey with Avelina to our next stop the Ya Wilaya Hospital where we were welcomed by all hospital staff. The hospital has experience working with Hernia International Organization and we were the 7^th team who came to work with them .

Avelina took us to her office to brief on patients waiting list. At that moment over 100 patients were awaiting to be seen. The local staff had already made the screening for high risks cases. The ward was crowded with children and elderly placed together.

From start we did the usual practice, identifying patients who needed surgery and discharged home patience that didn’t required surgical intervention. Prior we did visit the operating rooms and meet closer the team to work with us in coming days. All our medical supplies were unloaded from car and we proudly notice our donations fulfill completely the storage space in the stocker site.

Our working week began as usual on Monday, but as tradition goes we had a meeting first with Chief Cancelor and the Mayor of Korogwa before commence our work.

Looking at the cases it was clear to us that some patients will need more than  local anesthetics. We put all pediatric surgery under general anesthetic and we allocated all pediatric cases to be performed in most equipped operating room 1. Operating room 2 had an air-condition and basic equipment for Spinal and LA. The operating room 3 was allocated for LA, unfortunately the room didn’t had an air-conditioner.

Hospital staff provided us with full assistance in all aspects of our work. Local doctors took part in provided training and assist us in all ongoing operations. Avelina only managed to join us on our last day, Friday. Her main duty kept her outside of the hospital for the most part of the week.

It is worth to mention the hospital driver Omari who was a great help through out our stay.

We did enjoyed the local food prepared for us every lunch, daily by the hospital.

We stayed at the White Parrot hotel. The rooms were clean, the service was good breakfast was included, the dinner was paid extra also quite good. Sadly, we were the last customers they had to accommodate. After our departure the place was closed down for unpaid tax.

In regards to our mission, we had 91 patients on a waiting list including children. Nevertheless, we managed to perform 97 surgical procedures. Where 27 patients were children, most of them under 5 years old, and 64 were adults.

Pediatric cases of : congenital inguinal hernias, umbilical hernias, undescended testicle, two cases of hypospadias, and hydrocele. All done under general anaesthetic.

 The adults operated were 64 patients,  of whom the 16 were female. Most of the cases were done under local anaesthetic. We worked  out the large scrotal hernias, non reducible inguinal hernias, incisional hernias, selected number for spinal anaesthetic.

We gave general anesthetic/Ketamin with the help of the experienced anesthetic local team in 3 cases with large hernias and one for incisional hernia. In one male case we had non response to any given analgesia and had to administrate general anesthetic with ketamine.

As per routine set, we performed usual postoperative assessment. Furthermore, the assessments were carried out with usual controls in place and we did final reviews for patients on discharge home.

We involve local doctors to participate in all stages of postoperative assessments and we have left necessary recommendations and instructions in place to follow on review assessments. Translated copy with postoperative care instructions was given to each patient on their discharge home.

In addition, we did daily ward rounds every morning reviewing each operated patient and run small daily clinic for new coming outpatients. It was noticeable that establishing good communication between our teams and hospital staff helped us to achieve good results in patients care.

It is important to mention that our medical supplies to the hospital prove yet again, to be an important part in our mission. Providentially, we have had an opportunity to organize our medical supply and it was vital in our work.

Our mission came to the end on Friday, some members of our team have organized a safari trip to finish their stay in Tanzania. I have decided to stay a little longer in the hospital and catch up with the staff, patients and local people. Working thorough the mission didn’t leave much time to do this and I am glad I’ve spent a bit more time with locals before returning back. Following morning I’ve travelled back to UK, after a short stop to Bagamoyo again. The split of the team made early good byes.

I would like to say our team has achieved very good results judging by responds we had from the hospital staff and the patients. Noticeable, the hospital had a rapid improvement with the changes we recommended and training we provide. We are happy to report hospital staff has in progress the implemented all given recommendations. For example: better ceiling in operational room 2, better air-conditioner in operational room 3 and an extra bottle of Oxygen supply, to keep always in stock.

Hospital surgical instruments stock contain large amount of unsuitable operational equipment. We advised hospital Metron to keep only instruments that are possible to use in surgeries, i.e. few selected hernia sets etc.

We understand hospital has a small affordable charge for the surgical procedures they performed; hopefully those funds will help hospital administration to improvements in place.

Considering constant demand for surgical intervention we hope the established improvements in the hospital will help other international teams to work in better settings.

I would like to mention Dr. Alexander Stanek, who helped to have donated new disthermy to hospital.  The donation was made  by Sister Carol Reid from Tyrone County Hospital and we all send a great Thank You*. Dr Stanek is planning his mission for May 2017.

Also, I would like to say, thank you, to each of you, on behalf of the hospital and myself to John and Ann Budd , Penny Howell, Alan and Margaret Cameron, who helped us to bring donated equipment all the way to the hospital and for the team work we have achieved.

Using this opportunity I also would like to say my gratitude to all my colleagues who helped me collect vital medical supplies for our mission. Especially, I would like to say “Thank You!” to: Dr. Nele Close who helped to cargo boxes of sutures; the staff at St Peter’s & Ashford and Crawley Hospitals NHS Trust for their support.

 Medical suppliers, companies Ansell and Swan & Morton who kindly provide supplies of sterile gloves and disposable scalpels.

In addition to above I would like to thank all my Greek friends and families who never stop donating and helping people either here, in UK, or in Greece or far overseas. Your help was absolutely fantastic! Moreover, I would like to say “Thank You” to our Greek Orthodox Church Arche-Bishop in UK, Mr Gregorios who always is happy and ready to support a good cause. 

A cordial Thanks You to all

Yours sincerely,

Miss Zoe Vlamaki MD FRCS, team leader.

Mission Report: Chittagong, Bangladesh from 23 to 28 November 2016

(Exterior of Nurture General Hospital)

Buried in the hustle and bustle of a sprawling seaport city, amongst paddy fields and a maze of roads filled with street peddlers and crazy tricycle ‘CNG’ taxis whizzing past, was the small 6 storey building that housed Mdm Nasreen Baqui’s Nurture General Hospital. Away from the chaos of the Chittaggonian roads, where no traffic lights or road rules hold true, our team from Singapore (comprising of 10 surgeons and 2 anesthetists) found our response in the operating theatres where we performed 70 operations in 69 patients -69 inguinal hernias and 1 hydrocele over a period of 3.5 days.

(Our team members: Top row – Rajesh, James, Darren, Zhongxi, Yexin.
Bottom row – Sing Ying, Chok, Shuhui, Norman, Yvonne, Jacklyn, Siok Yen)

We arrived on the evening of the first day, after an internal flight from Dhaka to Chittagong, and immediately started screening patients and planning out the workflow and logistics. All of the hernias were done under local anaesthesia or spinal anaesthesia for the larger ones, using the open Lichtenstein repair. Each day began with a ward round to review all the patients that were operated upon the day before, and discharge those who were well. Following which we would spend the day in theatre where we had 5 operating tables going on simultaneously, and then end in the evening by reviewing our post-ops and screening more patients for the following day.

  (Nisha, a local medical student, assisting our team in a surgery)

  (Our anesthesia team – Zhongxi and Jacklyn, ensured that our operations were carried out smoothly)

                                                                                     (Postop ward) 

Nasreen, her twin sons Yasir and Yamin, as well as her local support team were quintessential to the execution of this mission. They provided us with the most wonderful hospitality by accomodating us in a pleasant hotel, ensuring we had delicious warm meals and always going the extra mile to ensure all our needs and requests were met. We will never forget the smiles of gratitude on the faces of the patients, nor the enthusiasm of the local volunteers who were ever ready to help with translations. Everyone thoroughly enjoyed themselves on the mission and are looking forward to our trip back!

(One last group photo before we head home!)

1^ST SLOVENIAN “HERNIA INTERNATIONAL” EXPEDITION – GAMBIA 2016

(22^nd – 29^th October 2016)

India was our first choice of destination for an expedition in 2016. We put a lot of effort into it, however, due to poor communication from the Indian contacts we started looking for alternatives. We turned to Prof. Andrew Kingsnorth, who suggested Farafenni, The Gambia. It was a complete unknown, this tiny West African country, but with trust that our boss Andrew will not let us down, we started preparations with enthusiasm. First, we needed a team. There are quite a few Slovenian surgeons and other doctors, who are active in charity work in the third world. However, there has not been an entirely Slovenian “HERNIA INTERNATIONAL (HI)” mission up to now. Before taking the challenge to organize this expedition, I took part on missions in Mongolia, India, Ghana, Tanzania and elsewhere and gained a lot of experience and knowledge, which helped me bring together a national team. I brought together experienced doctors on one hand and enthusiastic youth on the other. The team members were Tomaž Benedik (consultant surgeon), his daughter Selena Benedik (medical student), Eva Pogacar (consultant anaesthesiologist), Urška Bricelj (resident of anaesthesiology), Luka Kovac (resident of obstetrics and gynaecology) and Jurij Gorjanc (consultant surgeon and team leader). Additionally, Alex Lupke (resident of anaesthesiology) from Grimma in Germany joined our team. He attended an expedition in Farafenni the previous year and helped us a lot with his previous experience. His practical skills in anaesthesiology and his information about the country, hospital and important details about the surgical team from Gambia were of great help.

 Team members – smiling with the lost luggage

The communication through e-mail-exchange, before the mission with the director of the AFPRC hospital (Armed Forces Provisional Ruling Council) Dr. Mamady Cham, PhD was excellent. He gave us the feeling that the team in his hospital was well organized, cooperative and appreciative of our help. The impression was strongly confirmed during and after the mission.

There were many possible ways to fly to Farafenni. We decided for a one-stop combination (Venice-Barcelona-Banjul), all other flights were two or more stop flights. A mistake! It was a low cost flight. Luggage was strictly weighed and any additional luggage had to be paid for. We tried to reserve extra luggage beforehand, but to no avail. Even worse, our extra luggage was lost and arrived at the hospital in Farafenni in the evening of our third operating day.

On our arrival to Banjul, we were highly honoured. We were welcomed to the country by Dr. Cham, the hospital director and the Gambian minister of health, the honourable Dr. Omar Sey. The embarrassment about the missing luggage at landing was reduced after Dr. Cham, again showed just how good a host he was. He gave provided materials from the hospital and medicine from the hospital pharmacy for our disposal. Without the help from the hospital, we would be limited just to a few surgeries until the fourth operating day.

  Meeting  honorable Omar Sey, Gambian Minister of Health

After spending one night in Banjul, we headed east on the south bank of the River Gambia and crossed it with the ferry just south of Farafenni. The journey in the hospital Taxi-van was pleasant as our Public Relations Officer Mr. Sainey Dibba explained many details about the country. Sainey was of great support during our whole mission.

Our accommodation was Eddy’s hotel, about a kilometre away from the hospital. After checking the operation theatres and the hospital gear, there was a lot of positive energy to start working the next morning. The AFPRC hospital is cleverly designed and strongly built entity. It is a renowned regional hospital with trained personnel. Essential persons for us were surgeon Dr. Lamin Jammeh (a very well educated and practically skilled young consultant), Dr. Francisco from Cuba (a perfectly trained and skilled anaesthesiologist) and Christiana, a skilled Anaesthesiology Nurse and great organizer in the operating theatre. Dr. Jammeh and Dr. Lupke did almost all the triaging and pre-operation preparations. This allowed the rest of the team to concentrate fully on surgery. We tried not to disappoint over a hundred carefully recruited Gambians with many diseases, because we wanted to stay focused on patients with hernias and hydrocoeles. Every day from Monday to Friday, we operated from 8.30 am to 8 pm, sometimes even longer. At the beginning the fast pace was not easy for the hospital staff but we all got used to it quickly (Friday was an exception, we finished early).

                 Postoperative transport of the small patients to the ward – personally by Eva and Urška

We performed operations on two tables, separated by screens. There was air-conditioning, so we only felt the 40^oC during lunch.

In 5 working days, we performed 63 procedures on 57 patients. There were no perioperative complications. 45 patients (80%) were male, 12 patients (20%) female. 19 patients (33%) were children. 36 patients (63%) had different inguinal hernias. Other hernias/diagnoses were 12 umbilical hernias (21%), 10 hydrocoeles (18%), 5 incisional and/or epigastric hernias (9%). One patient had a cystic scrotal tumour (orchiectomy) and two patients had symptomatic haemorrhoids (Milligan Morgan). Due to the excellent anaesthesiology team, almost 44% of all operations were performed in general anaesthesia, 46% in spinal and 10% in local anaesthesia. According to the statistics from the hospital administration, 82% of the patients were Gambians.

I was proud to lead a professional team: Tomaž, a very experienced consultant mastered even the most difficult hernia cases. His daughter Selena, a medical student, was assisting as a “real doctor” to her father up to 12 hours daily. Luka performed his first hernia repairs and showed talent for operations. Eva took a great deal of responsibility on her shoulders as the leading anaesthesiology consultant of the team, performing anaesthesias even in 1 year old babies. Her cooperation with Urška, who will make her consultant exam in 2017, was of great value for our success. So was Alex from Germany, as mentioned above.

We also provided education to the local surgeons and operating theatre staff on new techniques. Dr. Jammeh is now more skilled in Lichtenstein repair and Rives-Stoppa sublay procedure. However, there was also a lot that we learned from the Gambian team. Many details of the surgical procedures can be simplified without a risk to the patient and are less challenging for the operating team. Medicine in our home countries is definitely very sophisticated, which is good and necessary, but perhaps it is also too complicated in some ways?

 Education in the Op. theatre-dr. Jammeh performing Lichtenstein and Rives-Stoppa sublay repair

All the good work in Farafenni could not been done without good cooperation between the Hernia International team and local professionals at the AFPRC hospital. Therefore, on the last day of the mission in Farafenni, we did not have the impression that we just came there to operate on patients for one week, but that we cooperated with the local professionals in order to do something for the Gambian people. The centre of our interest was the well-being of the patients.

In the Bible, there is a saying: “If someone works well, he should also eat well.” (2 Thes., 3, 10). The excellent cook Jenaba Secka was taking care of our meals throughout the week. She provided us with local delicacies from grilled chicken to fresh fish from the River Gambia, not to mention the local fruit and vegetables. Without her food, we would not be able to stay in the hospital for 12 or more hours daily.

Who could forget our experience? Not just the good medicine of that week, but also new friendships, friendly Gambian people, social evenings in Eddy`s hotel garden with cicada songs and falling coconuts? What remains in the long term is our gratitude towards our Gambian hosts and our plans for future expeditions.

Jurij Gorjanc

REPORT CAMPAING CALCETA ECUADOR 2016

 The 2016 campaign of “Cirujanos en acción” and “Hernia International Foundation” has been successfully carried out from 2 to 12 October 2016 at the Ecuador Public Health Ministry Hospital of the San Agustín de Calceta province. The initial plan was to have carried out the mission in the amazon region of Ecuador in the San Francisco de Orellana Hospital between 2 and 14 October 2016. Owing to bureaucracy problems alien to our NGOs, that initial plan was postponed when we had already bought and organized all the flights and personal logistics, so that we had to work hard together in order to plan out our mission all over again. Since October 14^th was the day for the team to come back, and the 13^th is a local feast day in the city of Calceta the surgical mission was limited to 8 days. As a complement we were offered the possibility of working in the Mobile Surgical Unity of the Santo Domingo de los Tsáchilas Hospital, and so we worked there on 7^th and 8^th October 2016 with full success and satisfaction.

The working team members have been in order of age: Dr. Leopold Mitterger (Austrian retired general surgeon), Dr. Alejandro Unda (retired paediatric surgeon from Ecuador residing in Spain), Dr. Paul Wilkins (British anaesthetist residing in Australia), Dr. Francisco Gomez (infirmarian from Spain), Dr. Cesar Ramirez (General and digestive surgeon from Spain ), Dr. Ana Sepúlveda (anaesthetist from Spain), Dr. José Luis Guerrero (General and digestive surgery, from Ecuador residing in Spain), Dr. Olga Morató (Genera and digestive surgery, from Spain). The coordinator and responsible person for the organization of the mission was Dr. Cesar Ramirez.

 The Calceta Hospital is a public hospital belonging to the Public Health Ministry of Ecuador which has two operation theaters and a room for childbirth, plus about 90 beds with an average use of 90%. The city was affected by the earthquake of April 2016 and it has a high unemployment rate, so that offerings of health and social work are always welcome. This was the first time they hosted a mission from Cirujanos en Acción and Hernia International Foundation, and the organization on behalf of the medical hospital direction and the local health authorities has been excellent. They set up two marquees  for the reception and classification by two local doctors of Primary Attention sent by the District Office. Once the patients were seen to need surgery they were examined by our team in another marquee. Facilities for the analytic and preoperative study (which took place in 15% cases) have been high, as well as the organization of subaltern staff for shifting the patients. We’ve had a full operation theatre at our disposal every day, in which we worked simultaneously on two tables from 8 to 18 hours; the time was limited because of the need to coordinate with the timings of surgery staff of the hospital, since at least 3 nurses were always at our disposal. We had carried with us more than 100 Kg of medical and surgical material, including all the meshes and suture that have been used up, as well as syringes, needles, catheters, local anaestheticals, gauzes, compresses, surgical sterile operative fields, anesthetic medication, antibiotics and anaelgesicals, and finally three sets of surgical material entirely new for hernia surgery, two for adults and one for children. As the initial calculation was for 200 patients we gifted the remaining material fo the Calceta Hospital.

The collaboration from the part of all has been excellent, particularly from the District Director Dr. Julio Mejía, the Medical Director of the Hospital Dr. Don Christian García, and the Medical Directress of the Santo Domingo Hospital Dr. Kathia Tinizaray. I also would like to single out the great help of lady doctor Jennifer Zambrana, the queen of Calceta and all her family who have helped us in our getting places in the University Residence of Calceta and in our moves through the city at any time. Local media, radio and TV, have daily reported on our work, which has spread the news of our presence there so that we have been able to help a larger amount of patients.

On the whole 125 interventions have taken place in 8 working days, and our satisfaction to have achieved our aim is great. The collaboration of all the members has been very high, with a great team-work spirit, and I can say that the dynamics of personal relationship have been very good so that we have enjoyed ourselves and we have greatly enriched ourselves. The weekend on 8 and 9 October we visited the so called “World’s Half” and the city of Baños de Agua Santa with its spectacular geography: Río Bamba city, Pailón del Diablo and Chimborazo volcano.

I has been a great work and a good team, and we have worked in a place where there is real need and a great possibility for help. The great collaboration we have all received from all quarters and personal of the Hospital (so that a real feeling has gone beyond the purely professional activity) lead me to propose this hospital and its city for future missions of Cirujanos en Acción and Hernia International Foundation.

Hernia International Mission 2016: September 10-17

Luwero, Uganda

After the great success of last years ‘Hernia Camp’ a new team of enthusiastic volunteers embarked on another trip to Luwero, Uganda, once again led by Andy Pilcher along with consultant surgeons Tim Brown and Scott Caplin (Morriston Hospital, Swansea). The second collaboration between Hernia International and Care For Uganda saw the addition of consultant anaesthetist Dave Hepburn, trainees Edward Brown and Charlotte Brown and photographer/videographer/general enthusiast Dan Evans.

We arrived safely at the Care For Uganda Headquarters in Bbowa bright and early on Sunday morning. After a brief rest we made the journey to Bishop Caesar Asiili Hospital where we caught our first glimpse of where we would be working for the next week. We spent time exploring the theatre complex and making introductions with the local staff. It soon became apparent that much like last years trip, the main challenge would surely be the anaesthetic equipment (or rather lack of it)! Still, in Dave’s capable hands, and after the identification of some clean tubing for the anaesthetic machine we were raring to go. We unpacked the supplies we had brought and departed the hospital, eager to return the following morning. On Sunday afternoon we were offered the chance to see some of the other projects co-ordinated by Care For Uganda and meet some of the local children, a truly unforgettable experience.

Monday morning we began the work we came to Uganda for. On our arrival at the hospital there were already plenty of eager faces waiting patiently for us in the courtyard. We devised a makeshift theatre list and began seeing the patients in turn. On identification of a hernia suitable for repair we marked the patient and they were sent immediately to the ward for assessment. All patients had their HIV status checked prior to theatre and signed a consent form. We finished assessing all of the patients before getting started in theatre; a somewhat lengthy process at the Ugandan pace of life! It was a day filled with new experiences, from operating by torchlight to repairing large recurrent hernias venturing up the abdominal sidewall. We repaired 14 hernias on our first day of work, with plenty of inspiration for how to streamline the process in the days to come.

The days that followed just got better and better. We found ways to optimise our time at the hospital, for example being proactive with the autoclave to prevent long delays between cases, and dividing manpower between the clinic and theatre. We enjoyed the daily challenges that faced us and devising means of overcoming them. We took great pleasure in reviewing our post-operative cases and experiencing first-hand the difference we were helping to achieve. We also saw the darker side of such an effort; the swellings that weren’t hernias but most likely malignancy, and even an elderly patient with groin pain that transpired to be a fractured neck of femur. Turning away patients was undoubtedly the hardest part of the trip, especially at the end of the week when we physically couldn’t make theatre space for all those in need of our support.

By the end of 4.5 days of operating we had repaired 72 hernias on 65 patients. In addition we had strengthened relationships with staff at the Bishop Caesar Asiili Hospital and had the chance to take our operating skills back to basics as we performed surgeries using the most basic of equipment. Outside of the hospital the team shared a wonderful week in Uganda, cared for by the fantastic staff employed by Care For Uganda.

For me personally I was delighted to be offered the opportunity to join the Hernia International/Care For Uganda trip to Uganda last September. The skills I developed and experience I gained were invaluable and have already provided great benefit to me as I progress through my surgical training.

Charlotte Brown

ST4 General Surgery

Mission report

Mongolia- Dalanzadgad, Ulan Bator 2016

Mongolia is amazing country bordered by China and Russia with a population of just over 3 million people. The local surgeons where graceful in having the combined Australian/UK team back in 2016 following an amazing mission in 2015 that further enhanced the collegial relationship that is longstanding between Hernia International and Mongolia.

The team travelled the first week of the mission from the capital of Ulan Bator and made the journey to Dalanzadgad, the capital of the Omnogovi Aimag. Dalanzadgad was where the team examined and operated on over 40 patients with the case mix ranging from paediatric herniotomies through to complex incisional hernia repairs. The team enjoyed the local hospitality in the evenings and were treated to various displays of the stunning local culture and food.

Team Members: Trent Cross (Team leader), Shambhu Yadav, Rob Bohmer, John Copp, Vesselin Petrov, Prafull Bohra, Usha Bohra

The second week at the Second general hospital in Ulan Bator was a return to our familiar surrounds and to old friends. The local surgeons are a well trained and enthusiastic team and this year a wide variety of case mix allowed building on the hernia techniques training of previous missions. This year some 20 large complex cases where undertaken demonstrating component separation, advanced laparoscopic repairs of TEPP and Hiatal hernia repair.

The whole mission was coordinated by Enkhee, who not only organised all logistics support but also went above and beyond to take care of the whole team. Once again thank- you Enkhee.

Hernia International is looking forward to 2017 and the continued relationship with Mongolia.     

Trent Cross Oct 2016