Author: akingsnorth

Hernia International visits Trinidad in the West Indies

Whilst at an Intercollegiate Specialty Board Examination in the UK I was asked about groin hernia repairs using mosquito net mesh. The thoughtful surgeon (Prof Vijay Naraynsingh) later asked me to demonstrate its ‘value’ in the West Indies. I was honored and found the invitation hard to turn down! I gathered another volunteer (not too difficult!) but eventually traveled to this friendly region as a single surgeon team.

Trinidad, which lies outside of the Caribbean hurricane belt, is known for its Carnival and is the birthplace of steelpan, limbo, the music styles of calypso and rum (which I was engaged to try on numerous occasions). It is recognized as a high-income economy in the Americas by virtue of its petrochemicals industry. Indeed, I had not realized that many countries around the globe, irrespective of their ‘GDP spending on health’ still had difficulty in persuading patients that groin hernia repairs under local anaesthesia are safe and cost-effective. This was later to prove to be the ‘goal’ of this mission. 

After some obligatory paperwork (registration with the Medical Board) I travelled with my wife to be welcomed with open arms but set to work within 36 hours of arrival. At 7am daily I was transported to three different hospitals (Port of Spain General, Mount Hope and San Fernando) on the island, introduced to the patients and asked to choose the most appropriate cases. All the theatres were modern and had temporary AV connections installed so that I could teach the Islands’ audience of medical students, residents and interested surgeons (state employed and in private practice). There was still concern with regards to using EO sterilised mosquito mesh and, as was the case in the first mission of Operation Hernia (2005), I used commercially available mesh. I took my time and explained the steps required of a safe and comfortable repair under a local. None of the hernias were as large as those we see when neglect/delay has taken its toll.

Every night my wife and I were whisked off to various venues to give dinner lectures to an audience of surgical residents and surgeons numbering 40 or so. I spoke about the ethos of Hernia International, Preventing parastomal herniation, Emergency repairs of groin hernias and other topics (7 lectures in total). On the last night I was quizzed by the junior staff on various difficult colorectal problems and realized they too had as many unanswered questions as we do here. After four long days I relaxed on the nearby island of Tobago with my patient wife where we hiked through tropical rain forests.

The Trinidadian medical fraternity proved to be exceptionally welcoming and inquisitive and their patients most grateful (so I have since heard). I hope that I have managed to persuade all concerned as to the value of groin hernia repair under local anaesthesia.

Brian M Stephenson

Inguinal Hernia Workshops

                                                                        23^rd – 25^th February 2015

This workshop was initiated by Professor Vijay Naraynsingh who met Mr Stephenson at the Royal College of Surgeons examination in September 2014. It was held over three (3) days which comprised of interactive live surgery sessions and a dinner lecture per day.

Mr Brian Stephenson is a Consultant Colorectal Surgeon with special interest in inguinal hernia repair. He is a founding member of the British Hernia Society and has done a considerable amount of work through this affiliation. This includes travel to developing countries where he teaches and proctors the science and art of inguinal hernia repair. The majority of these are done under local anaesthesia.

General Hospital Port of Spain

The University of the West Indies in collaboration with the North West Regional Health Authority (NWRHA) conducted a Workshop in Open Hernia Repair under Local Anaesthesia on February 23. 2015.

Dr Andy Bhagwandass, Chairman of the NWRHA Board, opened the workshop and applauded the efforts of the local organizing team. Dr Bhagwandass affirmed the NWHRA’s support for these educational initiatives. He noted that Trinidad and Tobago was taking a ;ead role to advance surgical practice across the Caribbean.

Professor Vijay Naraynsingh, Head of Surgery at the University, reiterated his intention to strengthen the existing partnership with the NWRHA to ultimately benefit the people of Trinidad and Tobago. The University has undertaken to host two surgical workshops each year at the General Hospital Port of Spain.

Local workshop director, Shamir Cawich, was pleased at the success of the workshop reporting that over fifty (50) surgeons and residents from across the Caribbean participated, including representatives from Grenada and Bahamas.

Mr Brian Stephenson did repair of inguinal hernia under local anaesthesia. Patients were able to return home the same afternoon. The dinner lecture, on hernia repair, was done by Dr Brain Stephenson. It was held at the Tanmak Thai restaurant it was well attended by about fifty (50) doctors.

Eric Williams Medical Sciences Complex: Open Herniorrhaphy Workshop.

This was of great value for us as limited operating time with high trauma and oncological volume has led to a substantial waiting list for inguinal hernias. This workshop, as part of a wider workshop with San Fernando General and Port of Spain General, allowed surgeons in training the opportunity to learn about inguinal hernia repair under local anaesthesia; as a same day/outpatient procedure.

This workshop, coordinated by Dr Ravi Maharaj, Lecturer in Surgery, took place on Tuesday 24^th February and commenced with opening remarks from Dr Andy Bhagwandass, Medical Chief of Staff, Mr Kumar Boodram, Chief Executive Officer of the North Central Regional Health Authority and Prof Vijay Naraynsingh, Head of the Department of Clinical Surgical Sciences. Three hernia repairs were performed by UK Visiting Surgeon. All hernias were safely performed under local anaesthesia, the first two (2) with onlay mesh and the third with the plug and patch technique. Case presentations and literature review by the residents during the turn over time as well as thought provoking moderation by fellow consultants made this event a success.  

The workshop culminated with a Dinner Lecture at the Radisson’s Hotel, Port of Spain under the sponsorship of the Ministry of Health and patronized by the Honourable Minister Dr Fuad Khan. The feature speaker Mr Stephenson edified the audience on parastomal hernias. Minister Khan brought greeting from the Ministry of Health and encouraged our surgeons to perform these hernias under local anaesthesia.

General Hospital, San Fernando

The third day was hosted by the General Hospital, San Fernando. The live surgeries were well attended by the residents in training and also visiting residents from the Bahamas. The residents had the opportunity to clarify any doubts regarding the relevant anatomy and steps of the procedure. A mesh plug was demonstrated and most significantly the procedures were done under local anaesthesia. The patients did well and were allowed home the same day in minimal pain.

The workshop culminated in a dinner lecture at the Priveé Restaurant. This was well attended by residents and Senior Surgeons from the four main hospitals in Trinidad. The residents presented three challenging cases of colorectal cancer. Each case generated important discussions and allowed Mr. Stephenson to impart more of his knowledge and experience on the subject. The evening was chaired by Mr Patrick Harnarayan FRCS. Professor Naraynsingh presented the University tie and pin to Mr Stephenson as a token of appreciation for his work.

Hernia International Mission, Santo Domingo, Ecuador; January 2015

Team from UK: Mr John Chester (Consultant Surgeon), Mr Nicholas Markham (Consultant Surgeon), Mr Paul Houghton (Consultant Surgeon), Dr Jasmin Lucas (Consultant Anaesthetist), Miss Hina Bhutta (ST4 General Surgery).

Our journey began on the road from Quito to the Province of Santo Domingo de las Tsachilas- a 3 hour drive along the ‘Avenue of Volcanoes’ and a tortuous descent from the dizzying altitude of the Capital to the country’s 3^rd largest city. The spiraling road can be combined with dense fog and all manner of vehicles hurtling past at breakneck speed making this a road best travelled with an empty stomach and in the cold light of day!

On arriving in Santo Domingo we were taken straight to the Santo Domingo public hospital where we were acquainted with our tiny (14 x 8 foot) but entirely functional operating theatre in a ‘Unidad mobil Cirugica’ i.e. mobile operating unit, and introduced to the handful of lovely staff with whom we would have the pleasure of working during our short time there.

The next day, business began at 8am promptly. Ecuadorians had traveled from up to 200km away after hearing about the free service through a public campaign by the Ministry of Health and were triaged by the resident Cuban anaesthetist recently recruited to the hospital. Each morning we were shown a rapid-fire sequence of potential patients selected by our Cuban colleague (who spoke Spanish as machine gun fast as he presented patients!) and would select as many as we thought we could manage in a 12 hour shift.

There were challenges throughout our mission. Few Ecuadorians spoke English making communication/ informed consent etc. the first issue. We had arrived anticipating 2 operating tables for our British team of 4 surgeons (3 Consultants, 1 trainee) and 1 anaesthetist (Consultant) but unfortunately were met with only one, limiting the number of procedures we were able to complete. Technical issues also slowed us down such as intermittent loss of water in the mobile unit preventing scrubbing up and breakdown of the autoclave which could be detected by the slightly alarming whiff of singeing filling the little unit! Perhaps one of the most irksome technical challenges was not having a self-retaining retractor, proving to be the bane of one Consultant’s existence (you know who you are JC!).

On a more compassionate level, we all felt sadness and frustration when we had to ask patients to return another day, regardless of how far they had traveled, as we simply could not operate on them all in one day, and for example when patients were presented as having a hernia but clearly has some other diagnosis- including one gentleman with weight loss and a large hard testicular mass, and another gentleman with a 1 year history of flank pain. Turning these patients away without being able to assist further with investigations or appropriate re-referral was a sobering aspect of the mission.

During our time our British team, with the invaluable assistance of Noel the resident anaesthetist and Marlene our adorable Ecuadorian nurse, completed 35 procedures in 29 patients. Broken down, these procedures consisted of 19 inguinal hernias, 2 recurrent inguinal hernias, 10 paraumbilical hernias, 2 epigastric hernias, 1 recurrent incisional hernia and 1 sebaceous cyst. 23 procedures were carried out by the trainee under supervision. All operations were undertaken under spinal anaesthesia. 1 patient with an inguinal hernia repair returned to theatre with minor bleeding.

Despite challenges, the mission was rewarded by virtue of the immense gratitude we received from all of our patients. Without this service, many would continue living with their hernias or have to endure a long wait to receive surgery. Private hernia surgery at a cost of up to $3000 is simply not an option for most of these patients who earn on average only slightly more than this per annum. It was also humbling to be assisted by Marlene and Noel who were not paid overtime for all the extra hours in which they tirelessly aided us and who never stopped smiling. As a trainee, this was an incomparable experience on many levels. I was privileged to have 3 wonderful and patient Consultant surgeons supervising me, and the chance to finally understand the anatomy of hernias (!) and increase my confidence as the operating surgeon.

Thank you to Professor Kingsnorth for this invaluable opportunity and to Kathia Tinizaray Mera, Sandra Ocampo and Teresa Butron for making this mission possible.

Team members: Andrew Kingsnorth, Antonella De Rosa, John Hack, David Earle, Angleo Sorge, Alberto Meyer, Artur Seabra, Elaine Marinho, Luiz Alfredo, Sidney Chalub, Flavio Malcher.

Brazil is the fifth largest economy in the world, and is the world’s fifth most populous country, with an estimated population of 202,768,562 in 2014. The Brazilian health system consists of public and private components. The public subsector (the Unified Health System; Sistema Único de Saúde, SUS) was established in 1988 based on the principles of ‘health as a citizen’s right and the state’s duty.’ Since the creation of SUS access to health care has substantially improved, however regional disparities in healthcare still exist and are unacceptably large; the remote and poor regions of the north and northeast have reduced life expectancy compared to the south region, where life expectancy approaches that of rich countries.

The 2014 mission to Brazil was to the Amazonas state, in the northwest region. Most of the state is tropical rainforest with cities clustered along major waterways, accessible only by boat or plane. Manaus is the capital and the largest city, home to 45% of the states population.

The following three government hospitals were visited:

Hospital Geral de Manacapuru. The city of Manacapuru is located 80km west of Manaus with an estimated population of 92,996 in 2014. The hospital has three operating theatres but only performs emergency surgery. There are no elective surgical lists because of the lack of surgical expertise.

Hospital Universitário Getúlio Vargas, Universidade Federal do Amazonas. This is the University Teaching Hospital in Manaus, which is a busy, public hospital with five operating theaters. The hospital has the facilities and equiptment to perform laparoscopic surgery including laparoscopic hernia repair.

Hospital Regional Dr. Hamilton Cidade, Manicoré. Manicoré is a small town located in the south-east of the Amazonas state with a population of 52,200 in 2014. The hospital is well equipped with three operating theatres however no emergency or elective surgery is performed because of a lack of surgical expertise. At the time of our visit there were no doctors working in the hospital, which was run solely by nursing staff.

Eighty-nine hernias were repaired in 74 patients (female = 22, male = 52) with a median age of 44 years (range 2 – 83 years). Nine patients underwent more than one type of hernia repair, and there were 9 laparoscopic inguinal and ventral incisional hernia repairs. Local doctors were trained in hernia repair techniques, and an International Hernia Symposium was held at the University of the State of Amazonas, Manaus.

The humanitarian mission provided hernia surgery to the underserved population of Brazil and training to local doctors, building local sustainability. Practicing hernia surgeons from the host nation and the international surgeons were able to share ideas and learn from each other, a rewarding and invaluable experience for all team members.

Antonella De Rosa. September 2014

Phnom Penh, Cambodia, July/August 2014

Team Members: Trent Cross, Dominique Robert, Sarika Sharma, Almudena Ceballos Ruano, Cea-Cea Moller, Mohan Jayasundera

Cambodia is an amazing country that has suffered enormous tragedy during the reign of the Khmer Rouge in the mid to late 70’s. Genocide of over 3 million of its 15 million population and countless other atrocities have resulted in unimaginable suffering for the surviving population. The country has been in a state of rebuilding since 1980, with still a long way to go with over 20% still living below the poverty line. Few hospitals exist and those that do are largely private in nature expecting significant payment from the very poor population.

Hebron Medical Centre was the base for our team of 6, which included 4 surgeons, an anaesthetist and a theatre nurse. Hebron Medical Centre is an amazing hospital which started as a small house in 2007 and has progressed to a 70 bed hospital which has 3 operating theatres and sees over 40 visiting teams per year. It is a Korean missionary hospital and has many missionaries that stay on the grounds for years dedicating themselves to the people of Cambodia. The team worked well with the local staff and managed to treat over 60 patients performing 70 hernia operations on mostly children; some under 1 year of age. Other interesting cases included some recurrences in children and a complex re do inguinal hernia in an older gentleman which had previously been operated on 5 times. Both the patients and parents of the children where very happy and we left Phnom Penh planning to return in the near future. All patients we treated were well at the follow up clinic as arranged by our local coordinator Stephen Kim.

Socially we enjoyed very pleasant accommodation and were well taken care of by Hebron Medical Centre with our transport to and from the Hospital daily.  We had an amazing dinner with the hospital staff on the last night and tasted alot of the local cuisine. Most team members had planned a few days either side of the mission to see Phnom Penh, visit Ankgor Wat at Siem Reap and pay their respects at the Genocide Museum and mass burial site from during the reign of the Khmer Rouge.

Hernia International and I would personally like to thank Menaka Thomas from Samaana Yoga, Australia, and others who personally donated $1000 to support the mission. It was greatly appreciated and very generous. Hernia International is excited and dedicated to its long-term commitment to the Hebron Medical Centre and the Cambodian people.

Trent Cross August 2014

We are just back from our last mission of Hernia International Foundation and Surgeon in Action Foundation in Mongolia. The team was made up by Martin Kriz (surgeon) and Christian Andersson (urologist) from Sweden, Hugh McGregor (surgeon) from Australia, J. A. Pascual and T. Butrón (surgeons) and Faustino Santisteban (business) from Spain. This was the fifth mission in Mongolia.

 We all arrived on different flights on 14 and 15 June. Martin and Christian remained in Ulaan Bataar during the two weeks the mission lasted, as they went to the prison hospital. The rest of the group flew to the city of Khovd in the Northwest of Mongolia on Monday 16. We were met by the driver of the hospital where we were going to operate on the following days. We loaded all our equipment on a Russian van (the hospital ambulance) and we went to the city of Bayan Olgii 200 km north. The road went through the steppe and over some rivers, and we arrived after more than five hours and some incident as when the van stopped in the middle of a river we were crossing. We waited expectantly, and the driver could finally get us through.

 We had a picnic in the steppe with all that we had bought in the supermarket. Along the way we saw herds of sheep, goats yaks, camels, horses, cows and some yurta (Mongol tent). All that in the midst of a treeless landscape, pure steppe with mountains on the horizon. On arrival, we went to the hospital where we were introduced to the staff and then we saw the ten patients we would be operating the next day as well as the operating theatres. We ended our day with supper with the hospital director, two residents (Bota and Satu) and Sanchin in a Turkish restaurant.

Next day we started operating. We were able to get more instruments and so we could place two operating tables in one of the theatres. Thus we operated 12 patients. We had lunch and dinner at the hospital. Every day we did the rounds in the wards, and then we operated on three different tables. At the end of the day we saw the patients to be operated the next day. We were daily helped by the surgeons and residents of the hospital, and on Friday evening we gave two lectures.

On Saturday we went for an outing with some of the surgeons and anaesthiologists of the hospital. We went to a valley surrounded by mountains where the Mongols spend their summer. In the midst of that impressive landscape we were invited for dinner inside a Mongol tent. On Sunday morning Hugh operated on the last child. We then went round the city and had lunch with some surgeons and doctors of the hospital. Then we took our leave.

We came back again to Ulaan Bataar where we spent our second week. We arrived on Monday evening and we went to the hospital where we saw the patients we would be operating next day. The following days we followed the same pattern as in Bayan Olgii. At the end of the week we had operated more than one hundred patients.

In the evenings we walked around the city, we went to see a show of Mongolian folklore, and we had dinner in a Mongol restaurant. We hardly realized when the last day arrived. We had had a TV interview. Our mission was over, and we had come up to all our own expectations: 20 patients operated in the prison hospital, 52 patients in Bayan Olgii, and 29 in the second hospital of Ulaan Bataar. (101 patients, 29 of them children.)

Teresa Butron

Puente Piedre Hospital, Lima, Peru. June 2014

Team members: Dr Arun Baskara (Team Leader, surgeon from USA), Dr Ramon Soliva (surgeon from Spain), Mr Magdi Hanafy (surgeon from UK), Mr Michael Kelly (ST5 registrar from UK), Mr Shahab Khan (ST6 registrar from UK).

The Hernia International trip to Peru was wonderful and it was quite a humbling experience. We (Dr Ramon and myself) were received by Dr Jaime Herrera (who had made all the local arrangements to host the team) late in the night (or early morning) and his hospitality was amazing. We went to his home the next day and spent time with his family. It was so sweet when Dr Herrera’s little kid gave me and Dr Ramon a Father’s day card; I didn’t miss my daughters  on that day.

Our stay at the hostel was comfortable. We were assigned to stay at the 5^th floor. Though there were no elevators, the hotel personnel helped us to get the baggage to our rooms. They were very courteous and helpful. They brought breakfast to our rooms and it was a different experience.

We all were received at the Puente Piedra Hospital by the hospital Chief of Surgery, their CEO, and the surgeons working at the hospital. Every one of them were kind and again their hospitality was immaculate. The cases for the day were on a list and our team divided the cases among us on daily basis. The OR staff were kind, helpful and their enthusiasm in helping us amazed me. I wish I could have learnt more Spanish before landing in Peru. The flow of cases was good and I got the opportunity to teach the Surgical Residents. I could see that they are well ahead of the curve when it comes to hands on while doing the cases. Some of the cases were complex but doable. The lunch at the cafeteria was great and the hospital was kind to provide us lunch free of cost. The Chief of Surgery was there every day with us during lunch hours and made sure we were fed well.

Two weeks flew by in the blink of an eye. I felt a lump in the throat on the last day of our surgery when the thoughts of leaving that place crossed the mind. I appreciate Dr Herrera, Dr Miguel & Miguel (Two Surgeons), the Chief of Surgery and all other Surgeons, Staff, Students, Residents, hotel personnel for all their help and hospitality  which made our stay a pleasant and humbling experience; and thanks to our team as well.

I am looking forward to do more work in Peru during the coming years.

Thanks for arranging this trip, Hernia International.

Arun Baskara

Hernia International in Pakistan, March 2014

Team Members: Andrew Kingsnorth, Alan Cameron, Shambhu Yadav, Vernon Sivarajah, and Penny Howell (anaesthetist)

 As a destination for Hernia International, Pakistan’s reputation for terrorism, corruption, poverty, overpopulation and illiteracy did not seem promising. However my fears were allayed after attendance at a fundraising gala in Birmingham to support the Bewal International Hospital (BIH) in the Punjab – our host hospital. BIH is an extraordinary venture and based on £2m donations from Overseas Pakistanis mostly originating from the Bewal area. A modern, well-equipped facility has been built on the Pothohar plateau on which Bewal is situated. The plateau is fertile being situated between the Jhelum and Indus rivers which spread their muddy waters over the terrain in the monsoons. Wheat, barley and sorghum are grown in abundance. At this time of year the fields are a  green patchwork of terraced plots, which will be ready for harvest (manually) in just one month’s time. Shortly after the harvest the temperatures will rise to 40 degrees until the monsoons arrive in August. 

Our mission was meticulously organised by Atiq Rehman, an ex-patriot Pakistani who had relocated from Bewal about 30 years previously and who currently practices as a vascular surgeon in Dudley. Atiq had been largely responsible for the design, building, equipping and staffing of BIH during the last 3 years, and its coming on-stream as a community hospital, but with 2 operating theatres ready for use when the opportunity arose – enter Hernia International for a 5-day mission during 1-9 March!  

Bewal town is a typically chaotic, unplanned Asian town where street traders line the extravagantly potholed and undrained, metalled road on which traffic rules are absent and the main form of travel is tut-tut or a motorbike-for- four. In early March the mornings are bright and fresh (temperature about 5 degrees) and the atmosphere is bracing. We were housed in Atiq’s uncle’s spacious and vacant house about a mile from BIH. We had the luxury of a cook and housekeeper to energise us for the 10-hour working days. We had the choice of an invigorating walk to the hospital either through fields and past villagers’ houses and livestock, or through the town as it awakened and struggled to work, and children strolled happily to school.

Local members of staff supporting us included a theatre tech (Ashiq), and several nurses and a gynaecologist who doubled up as ward, OR and recovery staff. Surgeons doubled up as operator, scrub nurse and assistant. An exotic mix of supplies was brought by the team and provided by the hospital, all of which proved to be more than adequate for the 59 patients (with 66 hernias) that were treated. Several junior registrars from Rawalpindi Medical College attended during the week for hands-on tuition. Andrew lectured at the College and performed an operation on the Mother-of -all-hernias (4 hour job) at the Benazir Bhutto hospital.

The week was rounded off with a day spent in the capital city of Islamabad – a scenic, green and calm city planned and built in the 1960s, with a backdrop of the Margalla Hills National Park. After visiting the vast Faisal Mosque, we had lunch in a restaurant overlooking the panorama of the city below, before a tour of the Pakistan Monument at its imposing best, at dusk.

It was a great adventure, and no doubt we will be back.

Andrew Kingsnorth