REPORT  BISHOP MURRAY MEDICAL CENTER, MAKURDI, NIGERIA

DATE 09-05/18-05 2025

Contents

1. TECHNICAL REPORT: 1

2. CAMPAIGN REPORT 1

3.             CONCLUSION 2

4.             BUDGET: (small breakdown of expenditure) 2

5.             SIGNATURES 2

1.    TECHNICAL REPORT:

1.1 DATES AND LOGISTICS DEPLOYED:

We started the trip on the morning of 09/05. 2 members of the group left from Vigo, 2 from Gran Canaria, 1 from Granada and we met up in Madrid with another 4 members of the team to take the flight to Doha. There we meet up with the last 2 members of the team, who leave from Barcelona. In total 11 people take the next flight to Abuja.

We buy the plane tickets through Angelis, an agent of Halcon Viajes.

To enter the country it is necessary to obtain a visa, which has been a terribly complicated procedure and has caused us a lot of problems. First you have to fill in an online form and pay 258 dollars. Then you have to bring to the embassy in Madrid your passports, proof of payment, 2 photos of each of you, an individual letter of invitation from the bishop of the diocese of Makurdi and a copy of the bishop’s passport. It should be taken into account for future missions, if any of the members of the group have a trip for which they need the passport in the weeks prior to the campaign (as happened this time with 2 members of the group), as you know when you hand in the passports, but not when they will be returned to you. We were fortunate to have the help of Yaili, a contact who helped us in the previous mission, to get these passports in time. Thanks to Damian and his great patience, as he went to the embassy 6 times and spent the whole morning there, we got the last visa 1 week before departure. We also had to pay for one of the visas twice, due to a logistical problem, apparently impossible to solve without filling in a new online form.

This campaign is carried out in collaboration with Hernia International, although in this case all the participants are volunteers from Surgeons in Action (Cirujanos en Acción). The campaign was coordinated with Dr Austin Ella, Associate Director Program Management at the Catholic Caritas Foundation Building and Dr Thaddeus Aende, a physician at Bishop Murray Medical Center.

1.1    ADULT PATIENTS:

Number of patients: 89

Mostly abdominal wall pathology, goitres, hydroceles and large lipomas were operated on.

1.2   PAEDIATRIC PATIENTS:

Number of patients: 20

Inguinal hernias, umbilical hernias and hydroceles were operated on.

1.3   Total procedures

135 procedures + 3 caesarean sections in which anaesthesia was performed.

 Adults: 106 procedures

Goitres: 8 total thyroidectomies, 23 haemithyroidectomies, 1 thyroglossal cyst.

Inguinal hernia: 35 unilateral, 6 bilateral. All were repaired with the Lichtenstein technique

Epigastric hernia: 6

Umbilical hernia: 4

Femoral hernia: 3

Hydrocele: 2

Lipomas: 8

Incisional hernia: 1

Testicular tumour: 1

Reinterventions: 2

 Children: 29 procedures

                 Unilateral inguinal hernia: 11; bilateral: 3

                 Umbilical hernia: 9

Hydroceles: 2

Epigastric hernia: 1

1.4   Total patients

109 patients

1.5   COMPLICATIONS:

As complications, 2 patients required immediate postoperative reoperation: 1 haematoma in an inguinoscrotal hernia and 1 bleeding in the immediate postoperative period of a total thyroidectomy. All complications resolved without further incident.

To date, one month after our return, we have not been informed of any incident.

2.    REPORT OF THE CAMP

2.1. THE PLACE

The hospital has a large operating theatre with 3 tables, which allows 3 patients to be operated on at the same time, with a screen between each table. The room is air-conditioned, which is appreciated in view of the high temperatures during the day. There are lamps on each of the tables, but they are insufficient for the surgeries, so it is essential to bring a front light. We had some power cuts, but not for long.

Next to the surgical room is the sterilisation room. On the other side is a small room where we did the recovery of patients under general anaesthesia.

There are several separate rooms for men, women and children. They are large rooms with many beds, where the heat during the day is very intense. In addition, in one wing of the hospital, there are single rooms with air-conditioning, very comfortable for patients who can afford them, but with the disadvantage that they are not adequately monitored by the staff.

They have a laboratory where they do tests, microbiology cultures and even have a small blood bank.

The accommodation is about 15 minutes away by car. It is a residence of the diocese where we stayed free of charge. The rooms are simple, with a big bed and a bathroom with WC, washbasin and a shower (with buckets of water). There is air-conditioning, but at night they turn off the generator around 12 o’clock, until 7 o’clock. There is no wifi in the residence. In the hospital there is wifi in the dining room area, although not very powerful. Some of the team members used e-sim, although not all of them worked properly. Dr Thaddeus got us some Nigerian sim cards which also worked irregularly, but it was enough for us to communicate with our families without problems. These cards are also available at Abuja airport.

2.2. THE TEAM

 General Surgeons:

                 Ana María Gay Fernández

                 David Fernández Luengas

                 Cristina Roque Castellanos

                 Natalia Afonso Luis

                 Salifou Hankouraou

Urologist: Francisco Enrique Valle García de la Guardia

Anaesthetists:

                 Rocío Díez Munar

                 Adrián Martínez López

                 Irene Macía Tejada

Nurses:

                 Nuria Agulló Sánchez

                 Paula Salgueiro Alonso

                 Guadalupe Martí Farre

2.3.  LOCAL STAFF

Dr Thaddeus Aende, a doctor with surgical training, screened patients prior to our arrival, and during our stay we had his assistance in some surgeries.

Benedicta, an anaesthesia technician, was with us throughout the campaign, helping and showing a lot of interest in learning.

We had the help of Lawrence, Nicholas, Jacob and Slim among others, for patient transfer and organisation.

Charity and Agnes, tireless workers, took care of sterilisation and cleaning of equipment.

Father Peter, the health coordinator for the area, looked after us throughout the campaign.

2.4.  EQUIPMENT

The operating theatre is equipped with:

– 2 diathemy generators donated by Hernia International and Bisturí Solidario, which work properly. We took with us 1 Ligasure generator with diathermy genertor from the foundation and another diathemy generator that was not necessary to use.

– Autoclave for sterilisation.

– Dragger ventilator model Atlan 300 with Philips monitor, donated by the César Ramírez Foundation (Bisturí Solidario) in the previous campaign, which is still in good condition.

– Surgical material: there is some surgical material there, although it is scarce and deficient, so we take several boxes of instruments from the foundation.

– Sterile clothing: they have gowns and cloth cloths, which we have not used, as the surgical rhythm of the campaign requires priority to be given to the sterilisation of material.

2.5. ANAESTHESIA

The facility has 1 Drager ventilator, model Atlan 300 with Philips monitor. The ventilator has the capacity to ventilate in Manual, VM, PC and PS, as well as an external flow system where a Mapelson can be adapted for both adults and children. It has a Cal soda system, which does not change colour and is changed by emptying and refilling the same canister; the hospital has a system to do this. The monitoring of the respiratory system consists of flows, volumes and most importantly, Capnography and inhaled and exhaled gases. The Philips monitor has EKG, PANI, Respiratory Rate and optional Temperature. There are 3 sizes of blood pressure cuff.

The ventilator is plugged into the wall with oxygen and medical air intakes, because the 2 bottles on the back of the building are for oxygen, so you only ventilate with 02 at 100%, but at very low flows. If you remove the Cal soda, this ventilator has the ability to take ambient air and mix it with your oxygen, lowering the FiO2 you give to the patient.

The ventilator also has 1 Sevorane and 1 Isoflorane vaporiser, both from Baxter.

For the other 2 OR tables there is no monitor available, but there is another oxygen bullet and a concentrator in poor condition.

We used the anaesthesia machine for the thyroidectomies, which we performed with Propofol in continuous perfusion (we carried a pump). Four of the 30 patients were intubated with a video laryngoscope, although without major complications. It should be noted that there was no laryngoscope, both the Macintosht and the airtraq were carried by us.

On one table, only spinal anaesthesia for hernias and 2 large lipomas were performed with local anaesthesia and sedation. It should be noted that on this table 3 caesarean sections were also performed by the hospital team, but with our collaboration in the spinal anaesthesia and monitoring. The pulse oximeter and the PANI were ours.

The third table combined adult rachis with paediatric general anaesthesia. For this purpose we mounted a Sevorane vaporiser connected to an oxygen bullet on one side and a Mapelson on the other. All children, except one 9 year old and one 10 year old who underwent a rachis with sedation, were done with laryngeal mask spontaneously, without complications. These patients only had a pulse oximeter for monitoring.

We set up a small ‘Awakening’ in the exit corridor for thyroidectomies and children.

We did not have any serious episodes of note.

We have left medication and material with the anaesthesia technician in charge, Benedicta. This 47 year old nurse is very well trained, very interested and helpful.

On the last day we didn’t have enough fentanyl and she got it for us from the pharmacy. I think that given the circumstances and knowing that you can get it there, you should not bring it from Spain.

The patients do NOT come to the operating theatre with a needle and the serums available there are mainly saline and Dextrose 5%. We managed to get several boxes of Ringer’s after protesting, but not enough.

Despite what it may seem, we worked well, comfortably and quite safely.

2.6.  ASEPSIS AND SURGICAL  SUPPLIES

They have an autoclave, and 2-3 people dedicated exclusively to the washing and sterilisation of material, which is very efficient, so except for the odd moment, we had no lack of material at any time.

2.7. OUR LIFE IN MAKURDI

We landed in Abuja on Saturday 10 May at 6am. We were held up at customs on arrival because of the equipment, which was quickly sorted out as soon as Dr Thaddeus arrived, which was delayed by about 1.5 hours.

We started the journey to Makurdi in 2 vans, one for the material and one for us, with a security guard. The trip is really uncomfortable, as the van is too small for the 13 people in it. It takes a little over 6 hours to reach Makurdi. There a big welcome awaits us with local songs and dances. They have also prepared a big welcome poster for us. Afterwards we have lunch in the hospital dining room and then we start unpacking the equipment to prepare the operating theatre for the next day..

Dr Thaddeus did the pre-selection of patients and prepared the surgeries for the 3 tables on the following days. The patient selection was very good, but not the planning, as he planned many goitre surgeries and few surgeries for children and adults with abdominal wall pathology, despite having made the indications beforehand. Fortunately, in the following days more patients appeared and we were able to complete a few days. We also found it somewhat difficult to make them understand that the order of the surgeries should be from the most complicated to the least complicated throughout the day, and not randomly as planned. In addition we found more complex patients in the last 2 days, so for future missions it would be good to warn that patients with hernias and giant goitres should be operated on the first days because of the complications that may arise.

On Sunday 11th, we were joined by Dr Salifou Hankouraou, a doctor with surgical training, who had travelled 3 long days from Niger. Salifou worked hard throughout the campaign, always trying to learn as much as possible with us.

Every day we start with breakfast at 7:00 a.m. at the nursing home. We then travel to the hospital in two cars. Two or three members of the team handle the rounds and the corresponding discharges. Others are responsible for seeing patients undergoing surgery during the day and organizing the order of surgeries on the three operating tables.

We operated like this without many incidents for five and a half days, stopping for lunch, finishing the shift between 9 and 11 p.m. Every day before leaving for the hotel, the team that finished first made a round of the rooms to check on the patients’ condition.

Lunch is prepared at the hospital, in a cafeteria in the office area. We ate very well and with a variety of food throughout the week. We have to thank the cook for the special gluten-free menu she prepared for Nuria and me every day.

Dinner is served at the residence, not as good or varied as the one at the hospital, but quite acceptable.

One evening, the Bishop of Makurdi, Wilfred Chikpa Anagbe, visited us. They hosted a large outdoor dinner, gave us each a gift, and we all ended up dancing.

On the last day, Friday the 16th, we operated on the remaining patients, collected everything we needed to take home, and before lunch, we were taken to a nearby market where we were able to buy some souvenirs.

We began the return trip, another nearly six hours to the Caritas residence in Abuja, where we stayed to catch the plane the next morning.

We returned home with very good feelings about this place and its people. Despite all the difficulties we encountered along the way, as always, it was worth it. Many thanks to all the extraordinary people who were part of this team of volunteers, for all the effort they put in with such humor and good vibes.

3.    CONCLUSION

3.1 STRENGTHS OF THIS PLACE:

The hospital has a good infrastructure for this type of mission, with plenty of space and very cooperative staff. The donated materials are well cared for.

Dr. Thaddeus is cooperative and carefully selects patients. The entire staff is deeply involved in the campaign and is very pleasant and caring.

3.2. Improvement objetives:

Although patient selection was good, daily surgical planning needs to be improved to optimize time and resources.

More monitors should be obtained and a room adapted for general anesthesia recovery.

Undoubtedly, the biggest challenge for this campaign is obtaining visas, which has nothing to do with the destination hospital, but it is something to keep in mind when coordinating this mission. Above all, it is important to consider that it is almost essential to have someone on the team who can go to the embassy in person.

4. BUDGET:

4.1. COST PER PARTICIPANT:

Approximate cost per participant: €1.479,75 (± depending on the place of origin)

4.2. TOTAL COST OF THE CAMP:

Flight tickets Vigo/Gran Canaria/Granada-Madrid: €1,347.48

Flight tickets Madrid-Abuja: 9 flights: €8,632.56

Flight tickets Barcelona-Abuja: 2 flights: €2,159.68

Cancellation insurance: €449.46

Transportation Abuja-Makurdi round trip: €600

Visas: €2,838

Hotel Abuja: €250

 TOTAL COST OF THE CAMP: €16.277,18

5. SIGNATURE

                                                                                                                           Signed: Ana María Gay Fernández

                                                                                                                                         Team leader of the camp

Cirujanos en Acción

Hernia International Mongolia May 2025

The team consisted of 3 volunteers from Australia (Rob Bohmer, Andrew Zhang, Hairul Ahmad) and 1 from Bulgaria (Dragomir Daranov), from 26 May to 6 June 2025.  The first week was in Darkhan, a provincial town of about 100 000 population, the second largest in Mongolia. The second week In Ulaanbaatar Second General Hospital.  The trip was well organised locally by Dr Enkhee and Dr Sonor, who sorted all out paperwork, registration, transport and hotel bookings (WhatsApp the preferred method of communication). 

The work experience

In Darkhan, the team conducted 22 operations, mainly incisional and inguinal herniae but cancelled 11 patients. The cancellations were due to poor optimisation/selection (cirrhotic patients, patients on blood thinners, asymptomatic patients, smokers, overweight patients or frailty). There were 2 available theatres but not well utilised, starting often at 930am and long change over times. With 4 visiting surgeons, local surgeons and 2 theatres, there was a lot of waiting around. A new laparoscopic stack arrived while we were there, providing excellent vision however the sutures and scalpel blades were poor quality and some of the hand instruments need replacing. The surgeons were keen to learn and generally were excellent technically but need to work on pre-op selection and optimisation of the patients. A harmonic scalpel was available! There is an ICU but staffed at times by the anaesthetist on call who had to do 2 jobs at the same time. Case selection in terms of safety needs to be considered, although liver resections are now being offered there. We provided all the mesh used, all other equipment was locally provided.

In Ulaanbaartar the team conducted 20 operations, again mainly incisional and inguinal hernia, some large and complicated from liver surgery. Again 13 were cancelled mainly due to poor selection and optimisation. An attempt was made to get the local surgeons to operate on all cases and see the patients with us pre-op (the latter more difficult to organise but should be a priority for future missions). The laparoscopic equipment was good as most surgery is performed this way including lap gastrectomies and lap liver live transplant harvesting has just started in the hospital! The surgeons are technically excellent, however pre-op selection and optimisation could be improved. “Time out” and sharps handling could be improved especially with a high incidence of hepatitis. Post-op care seemed good but we only saw the patients on day 1 or 2 post-op and have not been involved in longer term complications such as mesh infection. We provided all the mesh used. Component separation and TAR release was often required for the complex herniae.

The visitor experience

The local surgeons, residents and staff involved with our visits were amazingly friendly and hospitable and we thank them, often they teach us more than we teach them. Inter-country work is a privilege and contributes to surgery in so many ways apart the technical side of surgery. Thanks especially to Drs Naraa and Sonor, residents “George” and “Jenni” who interpreted for us.

Most surgeons understand some English but are shy to speak it. We were hosted very well in both places, taken to dinners, treated to a local music show and taken to the country to experience farm life in rural Mongolia. Vodka and beers flowed at times!  Both hotels we stayed at were of high standard. 

Recommendations for future teams

Mongolia has made a huge advancement in laparoscopic surgery since I was there 7 years ago and in Ulaanbaartar, do mainly laparoscopic work including inguinal herniae. They are keen to progress their skills which means Hernia International should select surgeons with advanced abdominal wall reconstruction experience. The local surgeons need to clearly state what they need from visiting surgeons to allow for the best experience for them and the visiting team. Saying that, the local surgeons really appreciate any input from visiting surgeons to ensure they are up to date with world standards. Although the local surgeons are skilled and keen to learn new techniques, equipment can be difficult to get hold of and may not be in the best working order (including lap needle holders and limited suture options). Mesh is now available more readily but patients seem to have to contribute to the costs. Mesh for the visit was provided by the visiting team. Botox is not available. Visiting surgeons need to be adaptable and weigh the balance between teaching new techniques and being aware of safety issues this can raise. Pre-op assessment and patient optimisation should be a key teaching issue. “Time out” posters are in theatres but not often practised, promulgating this would be another way visiting teams could improve safety in surgery in Mongolia. Sharps precautions should be worked on. The junior staff work long unsafe hours. The surgeons have a government stipulation that any “urgent” surgery needs to be done within 2 hours, supporting the local surgeons to change this so appendicectomies and cholecystectomies do not usually need to be done after midnight would be useful and improve patient safety. 

Patients were seen in rooms with multiple people popping in and out, privacy not an issue! It would be best to insist on seeing patients with a surgeon present rather than a resident only, to talk about the decision process. The theatre lists frequently changed without the visiting team being notified. There is a significant time spent sitting around as only 2 theatres were available in both hospitals, 4 visiting surgeons and emergency cases bump hernia lists. 

We would suggest, the first morning should be set aside for a talk about the weeks plan and who is going to operate each day, discuss operation plans and the types of mesh available, basic anatomy and pre-op optimisation rather than leave it to the end of the week lecture. Maybe Ulaanbaatar should be the first week, with the first morning teleconference shared with the country hospital and visit the country hospital second week. We would suggest a local surgeon coordinates theatre flow and the Hernia International surgeons role for each case and ensuring sufficient mesh supplies for each case. Where possible a local surgeon rather than resident should interpret to improve decision making. Overall a very rewarding experience and thanks to all the local surgeons and people involved. 

Rob Bohmer 

Campaign District Hospital Kwimba-Ngudu. Tanzania

Dates:  Saturday 29th March to Sunday 6th April 2025.

1.    TECHNICAL REPORT:

1.1   DATES AND LOGISTIC DEPLOYED:

The team of cooperants began training in early November 2024, coordinated by Santiago García del Valle and assisted by Dr. Teresa Butrón, director of the non-governmental organization Cirujanos en Acción, and under the umbrella and collaboration of the Hernia International Foundation. A team of 12 people was formed, including pediatric and adult surgery, anesthesiology, and nursing. This was the first campaign that Cirujanos en Acción has organized at the Kwimba District Hospital. The team of volunteers was responsible for collecting all the consumables needed for the campaign, including surgical gowns, sheets, sterile surgical drapes, sutures, meshes of different types and sizes, urinary catheters, sterile and non-sterile gloves, as well as a large quantity of drugs (general anesthetics, local anesthetics, muscle relaxants, antibiotics, opioids, analgesics, etc.) and disposable anesthetic material, including spinal and regional anesthesia needles, laryngeal masks, and other necessary materials.

Dr. Violeta Heras brought a portable ultrasound device that was very useful for performing regional block techniques for postoperative pain. Dr. Lourdes Delgado provided a significant amount of oral medications for postoperative analgesia in pediatrics.

The plane tickets were obtained through Angelis, who works as a “free agent” for the Halcón Viajes agency. The tickets were purchased from Turkish Airlines, which allowed the transport of one 30-kilogram bag per person plus carry-on luggage up to a total of 10 kg. However, we didn’t encounter any problems at the Madrid airport when we exceeded this amount. In fact, Turkish Airlines donated medical supplies they had on their premises. The journey included stops in Istanbul and Dar Es Salaam, from where a local flight took us to Mwanza. We were greeted by staff from Kwimba Hospital (Dra Mogassa). After loading our equipment into two cars, we were taken to our accommodation in Ngudu after a two-hour journey. It is worth highlighting the fact that the planes that operate local flights from Dar Es Salaam to Mwanza are small and have limited cargo capacity, so half of the equipment had to be transferred on a later flight and collected at the airport.

Our initial contact in Tanzania was Dr. Marco James, although in the last month he was transferred to another health district and Dr. Elizabeth Mogassa was our reference person. This contingency made the final communication somewhat difficult and slowed down some of the necessary procedures for the development of the campaign.

There was no difficulty in obtaining the necessary visas and permits to carry out our task. The Tanzanian customs authorities request a certificate of donation of the material to be moved, as well as a list with the approximate estimated value of each product and the estimated expiration date. We forwarded these documents to Dr. Mogassa. At customs, after some discussions, we were allowed to pass all the material with the help of an individual letter of invitation from the Kwimba Local Government authorities

1.2   ADULT PATIENTS:

The following procedures were performed in adults:

– 15 inguinal hernioplasties

– 1 umbilical hernioplasty   

– 2 supraumbilical or epigastric hernioplasties

– 1 paraincisional hernia

– 14 large lipomas

– 1 fibroid

– 2 giant ovarian cysts

– 1 emergency hysterectomy

– 2 cesarean sections

– 1 epididymal cyst

– 1 hemorrhoidectomy

– 1 Axillary abscess evacuation

– 1 excision of multiple perineal condylomata

1.3   PAEDIATRIC PATIENTS:

In the pediatric population, the following procedures were performed:

– 3 umbilical hernias (2 hernioplasties and 1 herniorrhaphy).

– 3 inguinal herniorrhaphy

– 1 Removal of supernumerary finger of hand

1.4   TOTAL PROCEDURES:

A total of 50 surgical procedures were performed

1.5   TOTAL PATIENTS:

A total of 45 patients were operated on.

1.6   COMPLICATIONS:

A patient, pregnant at term, came to the emergency department with a retained dead fetus and had to undergo fetal extraction and urgent total hysterectomy with the help of local staff. She died hours after the operation due to incoercible haemorrhage and puerperal sepsis.

A wall hematoma occurred after hernioplasty. She did not require more than surveillance and compressive bandaging.

There were no other major complications during our hospital stay nor were there any other complications 15 days after our departure from Ngudu.

2.    REPORT OF THE CAMPAIGN

2.1. THE PLACE

Kwimba is one of the seven districts of the Mwanza region and its most important population center is Ngudu. It is located in the northwest of Tanzania and the nearest airport, two hours away by road, is the one in Mwanza, on the shore of Lake Victoria, although it does not receive international flights. It is a very rural area, with very small urban centers, including Ngudu, being agriculture the main occupation of the population, generally carried out on small family plots. Agricultural work is carried out from December to May and this fact was definitive in explaining the little surgical activity performed, as many potential patients were unwilling and unable to leave their livelihood until harvesting the year’s crop, thus foregoing surgery at that time.

The District Kwimba Hospital is located about 7 kilometres from Ngudu and, as we were informed, serves a population of about 70,000 people living in isolated houses or small rural villages in an area that stretches for many kilometres with difficult transportation and therefore difficult and costly access to the hospital for a large part of the population. It is a single-story building, located in the countryside. It is spacious, with a very rational layout and has emergency, hospitalization, pediatrics and gynecology wards, with very little surgical activity except for cesarean sections.

2.2. THE TEAM

Paediatric surgery  

Lourdes Delgado Cotán.

Adults General surgery

José Manuel Hernández González.

Patricia Maldonado Valdivieso.

César Lévano Linares.

María Savoie Hontoria.

Irene Ferrer Vilela.

Anesthesiology

Violeta Heras Hernando

Susana Rodríguez Giménez

Santiago García del Valle (Team leader)

Nursing

Yolanda Gómez Pérez

Elena Iñiguez Mentxaca

Mónica Pérez Ortiz

2.3. LOCAL STAFF

In the absence of Dr Marco James due to relocation, Dr Elizabeth Mogassa was our local contact and put us in touch with the hotel and the catering company.

In the hospital there are 3-4 general practitioners (General Practitioners) dedicated to surgical activity, led by Dr Haruna Elias who perform caesarean sections as they arise. The anesthesia of these patients, almost exclusively spinal, is performed by nurses who perform the technique well but lack the necessary knowledge to deal with possible complications

2.4. EQUIPMENT

The hospital has two adjacent operating rooms of small size, insufficient to be able to install two tables in one of them. In addition, they use one of the two operating rooms for cesarean sections, generally urgent, a situation that happened to us between 2 and 3 times a day which meant pausing our surgical activity. In addition, there is a small room in the emergency room that can be used for minor surgery or wound care under local anesthesia. Although we bring instruments from Spain, they have enough material and sterilization systems. They have some drugs (Propofol, local anesthetics, ephedrine, oxytocin, etc.) but no narcotics or muscle relaxants. There are no diathermy generators so we had to transfer two sets of equipment from Spain.

There is a small resuscitation room with space for 2-3 patients with an SpO₂ monitor

2.5. ANAESTHESIA

Most procedures in adults were performed under spinal anesthesia supplemented later with ultrasound-guided blocks (ilio-inguinal or transverse abdominal plane block). In children they were performed under general anesthesia with laryngeal mask and always supplemented with regional block for postoperative anesthesia.

In each of the operating rooms there is an anesthesia machine, old but perfectly operative, with Halothane and Isoflurane as anesthetic agents. There is monitoring of basic operative parameters in each operating room. There is no centralized gas (Air, Oxygen, N2O), only large capacity oxygen cylinders connected to the anesthesia machines. There are oxygen concentrators and suction devices but of low power.

It has the capacity to cross (whole) blood and transfuse, an aspect that we were able to verify since a patient undergoing an emergent obstetric hysterectomy required units of whole blood

2.6. ASEPSIS AND SURGICAL MATERIAL

It has the capacity to sterilize surgical instruments and surgical linen equipment.

In the same way, it has a good amount of surgical instruments that we complement with material donated by Dr. César Lévano

2.7. OUR LIFE IN NGUDU.

We stayed at the PAM Lodge Hotel in Ngudu. Single rooms, clean and spacious. There is no hot water. The night, accommodation only, cost about US$10 per day. The hotel is adjacent to a bar or discotheque and on party days the music would go on late into the night making it difficult to rest.

All the catering was contracted with a small company formed by local women who prepared breakfast and lunch in the hospital itself and dinner was served in a dining room of the hotel.

At 7:00 am we were picked up at the hotel and transferred to the hospital where we had breakfast with the rest of the operating room staff. The first two days of the campaign was the Tanzanian National Holiday so there was almost no activity at the hospital. Although Dr. Mogassa assured us that an appeal was made in the weeks prior, there were very few patients ready to be evaluated, most of them showed up at the hospital during the days we stayed in Ngudu. As the days went by we were able to operate on a greater number of patients, but always fewer than we would have wished.

At 14:00-14:30 our food was brought to us: various types of vegetables, salads, rice, chicken, fruit, always hot and generally well prepared. In the afternoon we continued to operate until finishing around 19:00-20:00 in the evening. Dinner was served in a room of the hotel around 21:30.

As the surgical activity was not very intense, we visited some schools and talked to the teachers informing them about the possibility of assessing children and young people with hernias or other medical problems.

The group of volonteers returning directly from Kwimba had to suffer the cancellation of their flight from Dar Es Salaam to Istanbul. Although they were able to be reassigned to another flight, they suffered the inconvenience of a long waiting time in Istanbul. Although they complained to Turkish Airlines, to date, they have not received the requested financial compensation.

A group of the team extended their stay in Tanzania to visit some national parks near Mwanza (Ngorongoro, Tarangire, etc)

3.    CONCLUSION

3.1 STRENGTHS OF THIS PLACE:

1.- The local staff, both doctors, nurses and auxiliary staff, are very involved and actively participated with us, helping in all tasks.

2.- Very acceptable facilities

3.2. IMPROVEMENT OBJETIVES:

1.- Prior recruitment of patients. This task was practically not carried out and made our work very difficult. Improve the previous information of the campaign to the population.

2.- Since there are many transfers and local flights in small planes, it is advisable to adjust the displaced material to the scheduled activity, which is linked to the previous point.

3.- Adjust the dates of the campaign. Schedule it outside the agricultural work season, ideally between May 20 and June 30.

4.- To be able to have a local generator (they had two units but none of them worked) would facilitate our work.

5.- The trip to Ngudu was very long and with several long stopovers and road transfers. I suppose it will not be easy to optimize the times, but it is important to have the dates well in advance and the teams formed to ensure that the stopovers will be of the shortest possible duration.

4.    BUDGET:

4.1. COST PER PARTICIPANT:

VISA: 80 euros

Flights: 850 euros

Accommodation and meals: 160 euros

4.2. CAMPAIGN TOTAL COST:

12.900 euros

5.    FIRMAS

                                                                                                                                            Fdo:    Santiago García del Valle

Responsable of the campaign

Cirujanos en Acción

CAMPAIGN AT CD DUNBAR HOSPITAL, GBARNA CITY, BONG COUNTY, LIBERIA

APRIL 1-9, 2025.

Cirujanos en Acción campaign with Hernia International at CD Dunbar Hospital, in the town of Gbargna, Bong County, which serves a population of nearly half a million people in central Liberia.

-TEAM

The surgical team was composed of 12 volunteers, members of the Spanish NGO Cirujanos en Acción (Surgeons in Action), collaborating with Hernia International.

Francho Blasco Blasco. Anesthesiology, Mallorca.

Estefanía Fernández Fernández. General Surgery, Lugo.

Elena Fernández Segovia. General Surgery, Málaga.

Leonor Gómez Garrido. Nurse. Seville.

Cristina Martínez Insua. General Surgery, Burela (Lugo)

Mónica Mogollón González. General Surgery, Granada.

Guadalupe Moreno Sánchez. General Surgery, Ibiza.

Pilar Murga Pascual. Anesthesiology. Badajoz.

Mª Jesús Nieto Berrocal. Nurse. Badajoz.

Mª Carmen Perdigones Fernández. Nurse. Seville

Alberto Rando Pérez. Anesthesiology. Mallorca.

Antonio Mª Satorras Fioretti. General Surgery. Burela (Lugo). Team leader.

Four volunteers already had experience; for the remaining eight, it was their first campaign.

The local coordination was carried out, as on previous occasions, by surgeon Dr. Peter George, currently president of the Liberian Medical Association and a member of the NGO Liberian Physicians and Surgeons Without Borders. He, along with two other local volunteer surgeons, Michael and Gloria, accompanied us to perform pediatric surgeries and other procedures for the population.

The visa for the trip was obtained directly at the Liberian Embassy in Paris, as there is currently no Consulate in Madrid. To do so, the passports, requested documents, and the cash payment had to be sent by mail along with a prepaid envelope for return. Suspecting excessive delays, and thanks to the intervention of the local coordinator and Senator Prince Moye, a collaborator living in Paris picked them up by hand and brought them directly to Spain.

– MATERIALS

A total of twenty-four suitcases of supplies and medication collected by the volunteers, weighing 550 kg (two of 23 kg per volunteer) werner donated.

The Public Hospital of Mariña in Lugo donated the total of 40 kg of medication, at a cost of €1,200.

INDA company donated 380 sterile gowns and 200 surgical pijamas.

The supplies included two electrosurgical generators provided by Cirujanos en Acción, as well as four boxes of surgical instruments.

Hernia International sent 100 mosquito nets, to which were added others donated by volunteers.

– TRANSPORTATION

The flight departed on Tuesday, April 1st, at 8:10 PM from Madrid, with Royal Air Maroc, on a stopover in Casablanca and arriving in Monrovia, with a two-hour time difference, at 4:35 AM on Wednesday, April 2nd. There,  the loss of a suitcase of equipment was discovered which we were unable to recover until the last day, and which we donated to the local team.

After processing the claim, we began the journey aboard two vans, stopping at the Club Hollywood Hotel in Monrovia. There, we were invited to breakfast and offered rooms for a shower and a short rest. We then met with the Ministers of Health and Finance, Senator Moye (the campaign’s driving force), and other local authorities, after which we set off for our destination, a three-hour drive along well-maintained roads without incident. After arriving at the hospital, we unloaded our equipment and prepared for the next day’s start.

– ACCOMMODATION

* HOTEL

The Passion-1 Hotel has good facilities by the usual standards for African campaigns. Spacious single rooms with showers, air conditioning, television, WiFi that worked irregularly, and were clean.

The price was over budget, but the local organization covered part of the cost, so we paid $45 per person per night, including breakfast.

The electrical plugs were compatible with European ones, so no power adapters were needed.

* MEALS

Breakfast was served at the hotel, with very spicy local dishes, fruit, and supplies from our packaged goods stock.

At midday, light meals like meat empanadas, fruit, and drinks were brought to the operating room, along with water, which was consumed constantly.

We had dinner at the end of the day on the porch of Geeta’s Bar, a restaurant near the hospital, with a limited but varied menu. The most common dish was chicken with rice, with varying degrees of spiciness, from moderate to extreme. We took the opportunity to unwind there after the intense work days.

The first night, our Liberian colleagues invited us to dinner, and the next day we went to Senator Moye’s residence, where we were also treated to local dishes.

*INTERNET

Connection with a local router provided by the coordinator we had with us. Network outages were common, but we could use it every day.

-HOSPITAL

CD Dunba Hospital is a typical African center, consisting of one floor and several wards. Overcrowded, poorly ventilated, and with poor hygienic conditions.

In the inpatient unit, there are several rooms with multiple beds, an indefinited number of more than 100.

There are two operating rooms with four tables, one of which was used by the cooperating Liberian surgeons. We work in three teams of two surgeons, an anesthesiologist, and a nurse, with the collaboration of local staff, especially the anesthesia nurse Lorba, who acts as supervisor, and nurses Hawa, Jacob, and Emmanuel.

The overhead and portable lamps don’t work, so the use of headlamps is necessary. Several of the existing electric scalpel generators don’t work either, so we used the two we had brought; and the local ones needed a different plug than the standard one we brought. Frequent power outages.

Old tables, with limited mobility. Very poor restraint systems and armrests.

Air conditioning in both operating rooms was operating erratically, which often led to extreme temperatures and humidity, especially in the afternoon.

The operating rooms have ventilation systems, but they are not working, so general anesthesia cannot be performed. There were no problems with the oxygen tank supply.

There are autoclaves and personnel to operate them, who worked continuously. We brought sterilization bags to facilitate the task, despite which the instruments in the different boxes were randomly mixed and had to be reorganized at the end of the campaign.

The disposable gowns and drapes we brought were used, as we did not have the re-sterilizable cloth ones.

There are several rooms where boxes of medical supplies, likely used in other campaigns, were piled up in an unorganized and uncontrolled manner, accumulating dust without anyone caring for or using them. In these, we arranged and organized the materials and medications.

-DAILY ACTIVITY

Breakfast at the hotel and transfer to the hospital (a five-minute drive or a twenty-minute walk), arriving at 8:00 AM. The theaters were prepared, the patients previously selected by the local teams were assessed, and surgical activity began, which was about 9:30 or 10:00 AM. Starting on the second day, post-operative patients were visited, dressings were performed, and patients were discharged with pain medication for each one.

A morning surgical session with three tables followed by a short break for a drink, which continued into the afternoon. The session ended at 8:00 PM. If there were new patients, they were assessed for the following day. Afterward, transfer to Guetta’s for dinner and return to the hotel around 11:00 PM.

Due to gastrointestinal issues, two volunteers were unable to work one morning each, requiring intravenous treatment at the hotel in one case, although the situation was resolved without major consequences. A couple of minimal punctures were also performed during the procedures, so the patients underwent HIV serology tests, with negative results.

-SURGICAL ACTIVITY

A total of 111 patients underwent surgery, with 131 procedures, 92  men and 19 women, ranging in age from 14 to 80 years.

The most common pathology was inguinal hernia, with 98 cases (64 right, 9 left, and 15 bilateral); all underwent Lichtenstein mesh hernioplasty, except for one Marcy procedure in an adolescent. Most were primary, with six recurrents (all without mesh).

The midline hernias, 9 epigastric and 4 umbilical, were treated with mesh, except for 3 herniorrhaphies for small defects.

Six hydroceles (one bilateral) were treated with vaginal eversion, and a testicular tumor in a young man was treated with orchiectomy. This case had been agreed upon with the local team, and the specimen was sent for pathological examination.

Ultimately, 13 soft tissue tumors (lipomas and cysts) underwent excision.

Most procedures were performed under spinal anesthesia; 10 with local anesthesia and sedation, and only 2 with local anesthesia. No significant anesthetic complications occurred.

The only major complication was ischemic orchitis in a patient who had undergone surgery for a hernia and hydrocele, which required a subsequent urgent orchiectomy.

Two patients with drains remained hospitalized for several days until they were removed.

Operating room capacity exceeded 8 procedures (8.6) per table per day, with an average of 4 in the morning and four in the afternoon for each team.

-RETURN

The operation took place over five days, from Thursday the 3rd to Monday the 8th. An attempt was made to add some patients on Tuesday morning,  but the local coordinator rejected it, so that day the material was collected and the return trip began, with a visit to the Benson Hospital.l, an old center being renovated for its launch, an unexpected and completely unnecessary activity, but one that wasted our time.

A stop for lunch at the A la Lagune Hotel in Monrovia, followed by a transfer to the airport, an hour and a half away.

On the day of our return, due to an oversight by the local coordinator, we didn’t have a hotel near the airport, as the two existing ones are high-end but expensive. Despite everything, we managed to negotiate the use of shared rooms for $50 per person, including a swim in the pool, to rest for a few hours.

The return flight was at 5:45 AM., which, with a four-hour stopover in Casablanca and a two-hour time difference, landed in Madrid at 7:10 PM on Wednesday the 9th. There, the generators and equipment were returned, we said our goodbyes, and began the return journey home

-EXPENSES

-Medical Supplies: ………………………………………………………….…, Donation

-Medication:………………………..…………………………..………($1,200) Donation

-Visas: $100 per person……………………………………………………………$1,200

-Airfare Madrid/Monrovia/Madrid

$1,000 ticket + $40 insurance: $1,040 per person………………….…..…..…$12,480

-Accommodation

*Gbarna: $45 per person per night (6) with breakfast………………..….……   $ 3,240

*Monrovia: $50 per person……………….………………………………..…….…..$ 600

-Food

*Gbarna: 5 lunch + 4 dinner……………………………………………………..……$670

*Lunch Monrovia: …………………………………………………………….…..……$265

-Internet:…………………………………………………………………….……………$150

-Transportation: $200 per person………………………………………….………. $2,400

______________________________________________________________________

TOTAL……………………………………………………………………….………. $ 21,005

EXPENSE PER VOLUNTEER: $1,750

Of the initially proposed budget for lodging and food ($50 + $35 per person per day), due to a change of destination to an area with higher prices, the local organization covered part of the costs.

-PROPOSAL FOR UPCOMING CAMPAIGNS

The CD Dunbar Hospital is a well-equipped center for conducting surgical campaigns for simple wall pathologies. There is a good patient selection and the facilities are appropriate. Local staff collaborate well, with adequate sterilization.

For future interventions, teams should take certain considerations into account.

-The use of headlamps is essential.

-Lack of gowns and cloth drapes. Need to provide sterile disposable drapes and gowns.

-Shortage of instruments. Boxes must be brought.

-There is no good availability of approved electrosurgical generators, so they must be brought. Furthermore, existing ones do not allow connection with standard plate electrode cables.

-No general anesthesia equipment is available; if pediatric or major interventions are planned, intra- or postoperative mechanical ventilation cannot be considered.

-Loss of luggage on the outbound flight with Royal Air Maroc. Distribute materials/medications to minimize the consequences of loss.

-Need for postoperative oral analgesia, as nothing else is available.

MISSION REPORT IN GATUNDU. KENYA

SPANISH TEAM

NOVEMBER 2024

On this occasion, our team has carried out a new cooperation mission in Kenya. Specifically at the Level Five Hospital.

The Gatundu District Hospital is classified as a District Hospital. It is a Public Hospital owned by the Ministry of Health. It is located in the Gatundu constituency, Gatundu South division, Gatundu sub-county in Kiambu County in Kenya.

Our team this year consists of a total of 12 people: 6 general surgeons, 3 anesthesiologists and 3 nurses. All of us with extensive surgical experience and some of the veterans with more than 10 cooperation missions previously. Two of the surgeons are pediatric surgeons, given the previous indication by Dr. Mwitta (local surgeon), that he had enough child patients to operate on.

The mission took place between November 9 and 16, 2024.

We arrived at Nairobi airport on Sunday 17 at 03:15h, coming from Madrid and Barcelona, ​​via Istanbul on flights without incident.

At Nairobi airport we had the first and important incident: the customs agents at the airport blocked the 23 boxes of clinical material and medicines, claiming that they had no knowledge of the list of material or authorization for entry into the country, so they blocked all the boxes. After endless negotiations on the night of Saturday to Sunday, the material was left in storage at the airport until Monday. The human team went to the hotel, leaving one of us at the airport waiting for events, which never happened. On Sunday morning it was impossible to solve the problem, due to the absence of a responsible official to sign the import document.

This circumstance, which was delayed until Monday morning, meant that it was practically impossible to begin surgical activity until Monday afternoon. On Monday morning we triaged the patients until all the clinical material arrived at the airport. The intervention of the hospital director was necessary, who went to the airport with Dr. Marsal and after a lot of paperwork, a lot of posturing and little collaboration on the part of the officials, they signed the long-awaited paper, after paying some fees, which the hospital management took care of.

In principle, we brought material and human equipment to be able to work on 3 simultaneous surgical tables. Because there are only 2 operating rooms available, an operating room with two surgical tables was set up.

The hospital has only 2 anesthesia machines and non-centralized O2, so one of the operating rooms was dedicated exclusively to pediatric surgery with general anesthesia, and the other operating room (double table) was used from Tuesday for adult surgery, with locoregional or general anesthesia.

In total, 56 patients were operated on and a total of 67 surgical procedures were performed from Tuesday to Thursday. There was only one early complication, consisting of a hematoma of the surgical wound in an adult, which was reoperated on the next day after the patient was visited, and was resolved.

Most of the patients spent the night in the hospital, and except for some patients operated on for hernias who stayed one or two days for pain control, and eventrations, all the others, including the children, went home the day after surgery. So far and according to the information given to us by Dr. Mwitta, there have been no incidents or complications in the medium term for any patient.

On Friday 15th, no surgeries were performed due to lack of patients, so our activity that day was to visit all the patients from the previous day and verify the absence of early complications and discharge the patients.

Thanks to the good work of our colleague Dr. Marsal, we were able to acquire an electric scalpel, which was donated to the hospital (they only had 2), and an autoclave, which arrived at the hospital on the last day of the mission. When we arrived, the autoclave was broken and it was necessary to take instruments and consumables to another hospital, which delayed and hindered the fluidity of the surgical activity. Photos of both are shown, and a video of thanks from Dr. Mwitta

Our stay at the hospital ended on Friday at 12 noon local time, and the team left for the capital Nairobi where we stayed in a hotel. The next day part of the team left for the return trip to Barcelona, ​​and 8 of us went to the Amboselli National Park, for a few days of rest and enjoyment of the wonderful natural reserve at the foot of Mount Kilimanjaro.

Comments of interest for future missions:

Level 5 Hospital is a regional hospital with many years of antiquity and poor maintenance. The surgical area is suitable for this type of mission, but the infrastructure is scarce. The consumables are poorly organized and much of the material is expired and wasted. They did not have adequate sterile mesh.

The incident at the airport delayed the start of the activity by 24 hours. Therefore, it is essential that, prior to carrying out any mission, the hospital (Dr. Mwitta or the hospital management, have a copy of all the clinical consumables and medications and anesthetic drugs) that the team is going to carry, including their expiration date if they have one. It is highly probable that if they arrive in Nairobi on Saturday or Sunday, there will not be customs officials with the capacity to make decisions and resolve the problem, with all the problems that this entails.

The other major problem that we detected is the lack of patients. Dr. Mwitta, as he told us, carried out an information campaign about the mission in public schools, markets and the hospital itself, since he found out several months before the mission was to take place, but in the end he was only able to recruit fewer than 60 patients. The efficiency of missions with few patients must be assessed, which make the personal and economic effort of each volunteer worthwhile.

We must thank the personal effort of Dr. Mwitta, a local surgeon, who with only one local assistant surgeon, carries out all the care of the patients and the urgent and scheduled surgery that arises, but it is difficult for him alone to also organize missions and recruit patients. This is a situation to be assessed in the future.

For the team’s stay in Gatundu, the team stayed in a hotel (Maxland Hotel) near Nairobi (45 minutes by van), comfortable, in single or double rooms and with breakfast included, at a very reasonable price. Local logistics, hotel reservations and transfers from the airport to the hotel and vice versa, and daily transfers from the hotel to the hospital (35 minutes) were organized by Dr. Mwitta and the hospital at no cost to the team.

The hotel is located in a shopping center at the foot of the highway where there are several fast food and local restaurants and a well-stocked supermarket. It is the best accommodation option for future missions.

Our recommendations for future missions would be:

1.- Send Dr. Mwita a list of all the clinic material, medicaments and anesthetics drugs that you are going to take well in advance, so that he can manage their authorization by the customs officials (Highly unlikely due to local idiosyncrasies).

2.- Take plenty of surgical gowns, surgical gloves and surgical drapes. As we took few due to their volume and weight, we had to buy from a local supplier, since the hospital did not have enough units and they were reserved for emergency cases. We spent 500 dollars and in the end there were not enough units.

3.- Bring a supply of mesh for hernia repair. Our team brought 200 units of LDPE mesh, provided by Dr. Kingsnorth, already sterile and individually packaged. We left about 50 units at the hospital for future missions. It makes no sense to leave more because their sterilization date expires and they do not have gas sterilization, which is essential for mesh.

4.- The surgical instruments are abundant, but they are sequestered, and very disorganized. They always have to ask Dr. Mwitta for permission to use them, and the first two days we worked very precariously. This is an issue that needs to be improved directly, indicating the needs to Dr. Mwitta, so he has them ready.

5.- The drugs and anesthetic material are scarce, so we advise future teams to be well supplied with them, according to the preferences of each anesthesia team. The two pieces of equipment are basic but work without problems. There was only one problem one day due to a power cut, which took a while to resolve (it required the intervention of the local electrician and a me who indicated where the problem could be).

6.- Patient recruitment must be done well in advance, by the surgeons and hospital staff, otherwise there will not be enough patients to be able to operate on the 5 days.

7.- The team’s accommodation has been comfortable throughout the week and the transfer to and from the hospital well resolved from the hospital and at no cost to the team.

8.- Excellent collaboration and help from Dr. Mwitta and his local assistant, and adequate from the auxiliary staff, although after 8:00 p.m., it is convenient to finish the activity, because they start to get impatient….

Daily we started at 9 a.m. and finished at approximately 8 p.m. The hospital provided breakfast, coffee, tea and some pastries mid-morning and lunch at about 2 p.m.

I hope that this information and reflections will be helpful for the organization and execution of future missions. I am sending you some photographs. See you later.

Enrique Navarrete de Cárcer

Spanish team Hernia International, team lider

KANIFING HOSPITAL CAMPAIGN. SEREKUNDA. GAMBIA

DATE: November 9-17, 2024

1. TECHNICAL REPORT:

a.        DATES AND LOGISTICS DEPLOYED:

Departure from Madrid on Saturday, November 9, 2024 at 6:00 pm with stopover in Lisbon and arrival in Banjul on the 10th at 1:05 am. Return with departure from Banjul on November 17, 2024 at 2:05 h with stopover in Lisbon and arrival in Madrid at 11:20 h.

b.        ADULT PATIENTS: Most of the patients have been adult patients although we have also included a small number of children, ranging in age from 9 to 85 years, of which 32 are female and 85 male. A total of 20 thyroid surgeries including goiters, thyroid nodules and thyroglossal cysts. We have also performed abdominal wall surgeries including inguinal hernias, umbilical, epigastric and incisional hernias and soft tissue tumors of various types, mainly lipomas and epidermal cysts. All patients operated on for inguinal, umbilical or incisional hernias have been operated on under spinal anesthesia while patients undergoing thyroid surgery are operated on under general anesthesia. Extirpations of soft tissue tumors were performed under local anesthesia with or without associated sedation depending on the size of the lesions.

All patients have been previously selected by the local hospital staff and subsequently have been assessed by us in medical consultation with the support of local health personnel, indicating the type of surgical intervention and providing them with specific informed consent in English. All admitted patients have been assessed in the hospital ward prior to medical discharge, providing them with medical indications and the corresponding discharge report.

Total procedures performed: 131

Total patients operated: 117

Thyroid surgeries: 20

Inguinal hernias: 70

Incisional, umbilical, epigastric, Spiegel’s and diastasis hernias:           

17

Soft tissue tumors: 25

c.        ADDITIONAL COLLABORATIONS: In addition to our work in the operating room we have participated in other activities in an extraordinary way both in the surgical area and in the emergency area. In total 19 procedures outside the scheduled surgical work: Two cures for water burns in infant and 3 year old, cure of oil burn in infant, suture of lower limb for incised wound, assessment and care of malnourished infant, participation in resuscitation of at least three neonates after complicated deliveries, Participation and collaboration with the local staff in anesthetic procedures of at least two surgical interventions, facial and oral sutures in assaulted patient, facial wound healing, 2 ulcer healing in lower limbs, finger suture, three scalp sutures. In total 19 extra procedures outside our planned surgical activity.

d.        COMPLICATIONS: At our departure, only one acute retention of urine in an 80 year old patient with correction of a bilateral inguinal hernia, which required the placement of a bladder catheter.

2. MEMORY OF THE CAMPAIGN

   The Gambian government is the largest healthcare provider in the country. Public and private healthcare facilities can be found in The Gambia although there is no public healthcare at zero cost.

The public health system is composed of three levels:

 Tertiary level, consisting of six government-operated referral hospitals.

 Secondary level with 38 health centers.

 Primary level, 492 medical posts distributed throughout the country. The private system provides 34 clinics.

   The Gambia has one doctor per 1,000 inhabitants and many communities still rely on local healers first. Although health has been identified as a priority area by the Government, data from the latest United Nations Development Program (UNDP) report shows that access to healthcare is still one of the greatest deprivations of the population and varies according to geographical location and age. It also has the Medical Research Council which is funded by the UK Government. There are also a number of private clinics and some health NGOs operating in The Gambia.

  Serekunda is the most populous city in The Gambia. It is located in the province of Kanifing and is situated thirteen kilometers southwest of Banjul, the capital of the country. It has an estimated population of 348,000 inhabitants. The population it serves is indifferently Gambian or Senegalese due to a migration crisis. The languages spoken by the population are mainly Wolof and Mandinka.

   The Kanifing General Hospital was established in 2010 in a government commitment to respond to the growing demand of an expanding metropolitan area near Banjul. It is a 500-bed facility that provides secondary medical services to a population of more than 300,000 people. The hospital employs more than 540 staff, most of whom are physicians (nurses and midwives) and other personnel. The hospital has typical African architecture. It consists of several pavilions. At its center is a large courtyard surrounded by several one- and two-story buildings housing the hospitalization and surgical areas. At the entrance of the hospital complex you can find the administration area and an administrative building where patients are registered before any procedure to be performed in the hospital complex, also in that initial part you can find the emergency care area and a nearby laboratory and testing building from where walkways are divided to other wards for surgical patients, maternity, infant, internal medicine and dentistry, all of them two floors.

   The operating room block is located in a two-story but independent building. In the surgical area there are two large operating rooms, one for maternity and the other for general surgery.  Each operating room is equipped with a basic respirator with halothane capacity and an electric scalpel. The operating rooms are equipped with split air conditioning, which allows comfortable working for many hours despite the high outside temperatures. The obstetrics material cannot be used due to the large number of urgent cesarean sections. In this area there is a room adjacent to the general operating room that is used for pre-surgical preparation and also for post-anesthetic recovery, and two other rooms near the obstetric operating room, one used for the recovery of women after cesarean sections and other surgeries performed in that operating room and another one recently enabled for surgical interventions if needed. This same building has a sterilization area with an autoclave and various shelves for material, where local personnel sterilize all types of material. On this floor there are also changing rooms for women and men, a restroom and a staff lounge. Upstairs there is a large terrace, a room for the gynecology and anesthesia guard, a bathroom and a large area that is used as a storage area for leftover material from other campaigns and for the volunteers to eat.

a.        We used the operating room for surgery to perform two simultaneous operations and, since we had another operating room near the obstetric operating room with an electric scalpel available, we used it as a second operating room for the third table, so that we could work more comfortably to perform three simultaneous operations.

b.        The team consisted of three surgeons, Arturo Cruz, Victor Vaello and Ana Moreno, a fourth year surgical resident, Adriana Aviles, two anesthesiologists, Javier Mora and Salvatore Catania, and three nurses, Ana Carrascosa, Miriam Llorente and Manuela Dorado, a total of 9 members, four surgeons, two anesthesiologists and three nurses.

c.        Local staff.

Hospital with a large team of staff available, to highlight the Cuban staff that thanks to our cultural and language ties, have provided us with advice and support. Among them there is an anesthesiologist, Luis, a general surgeon and a urologist. In addition, Dr. Sanyang, who thanks to his knowledge of the Spanish language was a determining factor in the development of the campaign, was also present in consultations and in the surgical area,

Local nursing students, nurses and several assistants who were in the ward were working with us from time to time. For the transfer of patients from the operating table to the transport stretcher there were 2-3 assistants/celerators in charge of this activity.

Cleaning personnel

Sterilization personnel

Nursing staff dedicated to wound care and suturing of emergency patients.

d.        Equipment: The surgical area of the Hospital has a room on the upper floor with a large amount of stored and poorly organized material, mainly from previous campaigns. Among other things, there are boxes with abundant instruments, sterile gloves and consumables, some surgical drapes, gowns and even some sutures.

e.        ANESTHESIA: All the anesthesia used in the campaign was provided by the anesthesiologist members of the group. Anesthetic drugs are available at the center and are mainly used for anesthesia in cesarean sections, urgent interventions and very few programmed interventions of local surgeons’ patients.

f.         ASEPSIS OF SURGICAL MATERIALS: There is a sterilization area with an autoclave sterilizer available that works adequately. The local staff in charge of sterilization has regular training so that they frequently mix instruments from several different boxes or packages, we have also found deficits in the packaging of the material, so that specific attention has been needed in sterilization procedures for later use.

g.        OUR LIFE: Regarding the trip until our arrival in Banjul, we must highlight the excellent combination Madrid-Lisbon-Banjul by TAP airline. Minimum waits and flights adjusted in time as they were not long distances to be traveled.

   The arrival at the airport was smooth and everything was facilitated from the beginning by Jose Maria Bereguiain, representative of ASEDA, who was waiting for us at the airport and facilitated the payment of the airport security fee as well as the management of the customs clearance of our luggage. There we were also met by local staff that Jose Maria had arranged for the transportation of luggage and material, as well as our own transportation to the hotel we had hired.

   The hotel where we stayed was the Seaview. It was a reasonably priced hotel, simple and correct in terms of hygiene, service and breakfast, although there was a small conflict regarding the punctuality of the breakfast time to allow us to leave at the stipulated time, which was solved without incident. It has a swimming pool that allowed us to relax at the end of the day. On the other hand, the location of the Hotel was excellent, about 20-25 minutes from the Hospital by van, in a tourist area that allowed versatility for the choice of different options for dinner.

   The first day after arrival, Sunday, was dedicated to the organization of material, cleaning of the operating rooms and a meeting with the medical direction of the Hospital, in which we were clearly explained the expectations with the group in order not to incur in problems that could occur previously. We also spent the first consultations for the programming of the next day.

From the second day our surgical activity began in full, which would last from Monday morning, November 11, until Saturday, November 16, at noon. In total 5 days and a half of work in which we performed all the activity previously described. The days started around 8-8:30 am and lasted until approximately 8:00 pm. Lunch as well as water and other drinks were provided by ASEDA thanks to the invaluable work of José María Bereguiain, who was always aware of any problems that might arise and the needs of the group.

3.        CONCLUSION

   Undoubtedly the participation of ASEDA members and especially of José María Bereguiain in the organization, logistics, mediation with local authorities and the hospital, has been a determining factor for the success of the campaign.

Strengths of this place:

The collaboration of ASEDA.

The security of the country

The collaboration of the local staff

The availability of material and facilities, to a certain extent, acceptable.

Easy accessibility to the country.

Objectives for improvement:

The operating room-sterilization circuit in which the local personnel many times do not have clear objectives can be improved.

The fact of maintaining fixed and frequent campaigns in the future could provide the possibility of establishing collaboration links from the training point of view for the local personnel. I think it is feasible to open a stable training line with local staff (doctors, nurses, assistants, etc…) with a view to improving health care through lectures, workshops, participation in our operating rooms, etc…

BUDGET:

COST approx/person Accommodation: 450 Euros.

COST approx/person Flights: 525 Euros

COST travel insurance: 45 Euros

LUNCHES COST (Contributed by ASEDA): 0 Euros

COST TRANSPORTATION (Provided by ASEDA): 0 Euros

COST OF DINNERS approx: 150 Euros

TOTAL COST OF THE CAMPAIGN per person: Approx.          

1170 Euros

TOTAL COST approx. for the 9 team members: 

10530 Euros

Fdo: Arturo Cruz Cidoncha

Campaign Coordinator

Surgeons in Action

REPORT

SIERRA LEONE CAMPAIGN November 2024

POLICE HOSPITAL.

TECHNICAL REPORT

Dates and logistics deployed

The team of collaborators began to be formed in the first days of July 2024 under the coordination of Santiago García del Valle and the help of Dr. Teresa Butrón, director of the non-governmental organisation Cirujanos en Acción and under the umbrella and collaboration of the Hernia International Foundation.  A team of 13 people was formed, including surgery, paediatric and adult surgery, anaesthesiology, paediatrics and nursing.

The team of volunteers was in charge of collecting all the consumables needed for the campaign including surgical gowns, sheets, sterile surgical drapes, sutures, different types and sizes of mesh, urinary catheters, sterile and non-sterile gloves and sterile and non-sterile gloves, sterile and non-sterile gloves as well as a large quantity of drugs (general anaesthetics, local anaesthetics, muscle relaxants, antibiotics, opioids, analgesics, etc.) and disposable anaesthetic material, including spinal anaesthetic needles, laryngeal masks, endotracheal tubes and other necessary material.

The Hospital Universitario 12 de Octubre in Madrid made a donation of a large amount of medication including anaesthetics, analgesics, antibiotics and vasoactive drugs through the anaesthesiologist of that hospital, Dr. Ana Hermira.

The Ramón y Cajal Hospital in Madrid made an important donation of drugs through Patricia Arenas. 

Johannes Mühlbacher of Bartholomäus Apotheke in Vienna, Austria, made a donation of drugs through Dr Valéry Solari.

 The airline tickets were obtained through Angelis, who works as a ‘Free Agent’ for the agency Halcón Viajes. The tickets were purchased with Maroc Airlines, which allowed the transport of 2 bags of 23 kg per person plus cabin baggage up to a total of 10 kg.

Our contact in Sierra Leone was Dr John Mumuneh Konteh, an endocrinologist, Deputy Director & Medical Superintendent of the Kingtom Police Hospital and he was the person with whom we maintained continuous email communication on all aspects of the preparation process. He was always readily available for any queries or additional information.

• Documentation. Dr Konteh provided us with the necessary forms to obtain a temporary licence to practice medicine in Sierra Leone, a simple procedure to follow.
• VISA. There is no difficulty in obtaining a VISA as the process is simple and easy and takes less than 5 days. The cost is about 80$.

The group of volunteers, based in various cities in Spain, as well as Vienna and Bucharest, met at Madrid airport from where they left on Thursday 21 November at 19:00 for Freetown with a stopover in Casablanca where we met Dr Alejandro Unda from Malaga.  Dr Alina Costache went directly to Freetown from Bucharest and we met her at Freetown airport on Friday 22 November at 3:00 am.  

The campaign ended on Saturday 30 November 2024 and the team arrived in Spain on Sunday 1 December at 12:00.

PATIENTS.  A total of 170 procedures were performed on 141 patients during the seven-day campaign.

ADULTS PATIENTS: A total of 105 surgical procedures were performed in 86 patients, 77 men and 9 women. Patients ranged in age from 18 to 65 years (median 43; interquartile range 35-55). The following procedures were performed:

Lichtenstein:  74 procedures

Nyhus: 11 procedures

Hernioplasty: 1 procedure

Ligation hernial sac: 1 procedure

Excision lipomas / desmoid tumour: 12 procedures

Hydrocelectomy: 4 procedures

Onlay: 1 procedure

Evacuation + drainage of postoperative haematoma: 1 procedure

Most cases were performed under spinal anaesthesia (78 patients) and the rest under local anaesthesia. In all cases with sedation according to the patient’s needs. It is worth noting the high number of patients with large and long-standing hernias, which led to long surgical times..

PAEDIATRICS PATIENTS. Sixty-five procedures were performed in 55 patients, 8 girls and 47 boys.  Patients ranged in age from 1 to 17 years (median 11; interquartile range 8-14). The following procedures were performed:

Herniotomy: 46 procedures

Herniorrhaphy: 10 procedures

Orchidopexy: 5 procedures

Excision lipomas / queloids: 4 procedures.

COMPLICATIONS: A postoperative haemorrhage occurred after removal of a lipoma on the thigh in an adult patient requiring surgical exploration and evacuation and a good outcome. We were subsequently informed that there were no complications following our departure from Freetown.  

Two volunteers were pricked and the HIV rapid test was negative in both sources, so no preventive measures were necessary.

CAMPAIGN REPORT

THE PLACE.

                     The Republic of Sierra Leone is located in the Gulf of Guinea area between Liberia and Guinea Conakry. The country ranks 181 out of 191 in terms of the Welfare Index (HDI). The current population is about 8.7 million. Life expectancy at birth is 60 years, and only 43% of the population is literate. The official language is English, although the rural population speaks other languages such as Creole, Men or Krio and sometimes requires a translator to understand them. Since the end of the war in 2000, there has been steady economic progress, interrupted only by the Ebola epidemic of 2014, although there are no universally established social structures. The political situation in the country is stable with some tension induced by the rivalry between the two major political parties. The last democratic elections were held in June 2023. We were always accompanied by a security officer and driver, both from the Sierra Leone Police.

THE TEAM was composed of a total of 13 volunteers:

• General &Abdominal Surgery: Teresa Butrón Vila. Juan Pablo Alarcón Caballero. Beatriz Castro Andrés.
• Paediatric Surgery. Alejandro Unda Freire. Valéry Solari.  
• Neurosurgery:  Alina Costache.
• Paediatrics: Emilia María Tallo Martínez.
• Aneshesiology: Ana Hermira Anchuelo. Irene Merino Martín. Santiago García del Valle (team leader).
• Nursing: Patricia Arenas Suárez. Nuria Guardiola Morales. Mª Carmen Ibáñez Santamaría.  

HOSPITAL. The Police hospital is a construction with two two-storey buildings separated by a small avenue that serves as access for patients and workers. Initially intended for the medical care of police personnel and their families, it has now been extended to the civilian population. 

                     It has General Medicine, Obstetrics, Paediatrics and Preventive Medicine services, as well as a basic laboratory. It has the support of the Freetown University Hospital for tissue analysis and complementary examinations (radiology, ultrasound, etc). It has two operating theatres, but no basic monitors or anaesthesia machines, although it is worth celebrating that on the day of our departure a technician was setting up a new anaesthesia machine (Dräger Atlan™) in the largest operating theatre with Isoflurane and Sevoflurane vaporisers, a machine donated by the NGO Bisturí Solidario, which is already operational according to what I have been informed.
 

There is no laboratory service, although rapid tests for HIV and malaria are available. There are no permanent, permanent doctors in the hospital, although during the first few days we had the presence of a doctor in training in anaesthesia, Tamba James Jabba, who had to be absent due to a family problem. There is a very efficient nursing staff for pre- and post-operative tasks, as well as cleaning, orderlies and sterilisation, all under the coordination of Mr Unisa Sesay Incharge, who is in charge of solving and channelling all our requests. There are two operating theatres available, both equipped with air conditioning and separated by the sterilisation room. In the larger one we placed a second operating table (always of suboptimal quality) to perform adult surgery, while the other was intended for the paediatric population. We work with our own pulse oximeters and PANI equipment as there is no monitor. They have two oxygen concentrators and the only suction system is very weak, ineffective in case of having to aspirate blood or fluids in moderate or high quantity.

Although we carried quite a lot of specific surgical instruments, it was not necessary to use them except on a very ad hoc basis. It was organised by boxes on the first day and sterilised in a high-pressure steam cooker. It was complemented by the paediatric surgical material that Dr Solari and Dr Unda brought with them. We transferred two diathermy generators from Spain and the hospital itself had another two, but when we started to use them on the patients, two of them broke down and we were unable to work on more than two surgical tables for the first two days, which meant that we were unable to operate on all the patients initially scheduled. Surgical lights are scarce and of very low intensity and difficult or impossible to handle, making it necessary for Surgery to use photophores

We were provided with sterile tissue gowns and surgical drapes because, due to an error on our part, we moved an insufficient amount of these materials.

They have a very limited amount of drugs. They had a sufficient quantity of sera for the patients they treated.

ANAESTHESIA. The lack of an anaesthesia machine forces almost all procedures to be performed under spinal anaesthesia (many surgeries lasting more than 2 hours) combined with sedation or even general anaesthesia under spontaneous breathing. Fortunately, future missions will be able to count on at least one modern anaesthesia machine.

OUR DAILY LIFE

We arrived at Freetown International Airport on Friday at 2:30 am and there were no difficulties with customs formalities. Dr John Konteh was waiting for us with Abu Marrah of the Sierra Leone Police who would be our companion throughout the campaign activities. From the airport we transferred to the ferry, which took about 40 minutes and cost $45 per person (one way) to get to Freetown and we also paid for the two local people who accompanied us. We arrived at the port of Freetown and loaded all our luggage onto a police bus which took us to the Jam Lodge Hotel, centrally located and with good facilities, including security. The price was $85 with breakfast. In general, despite being a poor country, hospitality is not cheap, even by European standards.

After a few hours rest, we went to the Police Hospital (10 minutes drive) where we unpacked and organised the equipment and did the patient screening and pre-anaesthetic assessment in all patients scheduled.

Trabajamos durante 7 jornadas (de sábado a viernes inclusive).

As a general rule we started our surgical activity at 8:30 and finished around 22:00 with a short break for lunch in a room adjoining the operating theatre. Although it was possible to order prepared food from outside, we were satisfied with the good fruit that was brought in every day: grapes, tangerines, bananas, pears and avocados.

After the day’s work we had dinner at the hotel, a menu that we had previously ordered in the morning (rice, chicken, pasta, fish, etc.). After dinner, it is necessary to order breakfast the next day (fresh juices, omelette, fried eggs, toast and coffee). The rooms are comfortable, spacious, with mosquito nets on the windows, shower and air conditioning (remember to bring an English plug).

On Monday 25 November we were received by the Inspector General of Police, Mr William Fayia Sellu, who presented us with the individual Temporary Licence to practice medicine in Sierra Leone.

Saturday 30 November was spent visiting the local market in Freetown and the Tacugama chimpanzee reserve, some 20 kilometres from the capital. We then had lunch at a resort on a nearby beach.

Later that evening, before leaving for the airport, we were invited to a dinner with all the Police Hospital staff who worked with us.

The group left Freetown at 2:30 am and arrived in Madrid on Sunday 1 December at 12:30 without incident. 

CONCLUSION

                  Site’s strengths: There is probably a large population that would benefit from CeA surgery as the population has large and very advanced hernias. The people were very warm to us and continually expressed their gratitude. The nursing team is very efficient although they are not able to assist with surgical tasks. Staff were very interested in learning the basics of anaesthesia

                  Improvement objetives: It is desirable to improve both the lamps and the operating tables, as they should be of adequate size and have the capacity to vary their height and change the position of the patients during surgery. Most of the adult patients operated on were male, which may simply be a biological problem or a certain gender bias in the selection of patients, an aspect that is difficult to verify. It would be interesting to carry out training processes for nurses in the operating theatre.

BUDGET

COST PER PEOPLE: Flight tickets between €1000 and €1100. Hotel and meals about €650. VISA 80€.  Total amount around €1700-€1800 per volunteer.

Signed on behalf of the whole team of volunteers:

      Santiago García del Valle

HERNIA INTERNATIONAL MISSION NYANDARUA COUNTY, KENYA.

NOVEMBER 22-30, 2024.           

STATUS: COMPLETED

Coordinator: Dr. Gachara Boniface (Kenya), coordinator Samuel Wainaina (Kenya), Medical Superintended Beatrice Mugure (Kenya), Team leader Thorbjorn Sommer (Denmark).

The International Team: Hugh Warren, (UK), Emma Sanchez (Spain), Thorbjorn Sommer (Denmark), assistant John Warren, Nurse anesthetists Lene Scheffmann Gosvig  (Denmark).

Total: 5 volunteers

TECHNICAL REPORT

DATES AND LOGISTICS DEPLOYED:

Campaign conducted November 22-30, 2024.

ADULT PATIENTS: Hernias (inguinal, umbilical, ventral, inguinoscrotal), lipomas, hydroceles.

PEDIATRIC PATIENTS: Hydroceles, umbilical hernias, inguinal hernia.

CONSULTATION AND SURGERY PERFORMED:

Total procedures: 153

Total operated patients: 140 patients (of which 61 were pediatric patients, aged from 1 months to 14 years)

Patients seen in consultation: 160

Complications (within 7 days of our arrival):

Acute:  one scrotal hematoma evacuated post OP day 1.

After 1 week: one incisional hernia had an infection and one scrotal swelling, both managed conservatively.

CAMPAIGN SUMMARY

JM Kariuki Memorial County Referral Hospital

The Hospital is a major referral center for 700.000 people living in Nyandarua County.

It is located 2,5 hours’ drive north of Nairobi. The Hospital is under constant development with new departments and development of various health projects.

The hospital consists of different departments: Surgical department, emergency department, Intensive care (4 beds), medical care, vaccinations center, facilities for child-mother care, maternity, laboratory and testing etc, CT and Ultrasound scanning facilities.

Concerning the surgical department there were two operation theatres, with two tables each of which three was used for the current Hernia mission, the other was used for acute surgery, primarily caesarean sections. Other types of surgery (like ortopedics) were directed to other hospital during the Hernia mission. As such it was possible to perform 3 operations simultaneously, which we found very efficient, also making it possible to collaborate with each other with difficult cases.

The operating theatres were well equipped with air conditioning, allowing for a comfortable work environment. Power cuts were rare and did not affect our work.

The hospital was equipped with three diathermy machines, and we brought an extra new one donated by Medtronic Healthcare Denmark.

The Team members brought each what was possible to collect of up-to-date equipment (gowns, sutures, scalpels, drapes, dressings, meshes etc.)

We had a terrific anesthetic service from anesthesiologists George, Esau and Daniel and Karaoke making it possible to do surgery under general or spinal anesthesia. Local anesthesia was used in selected cases. Lene Scheffmann Gosvig enjoyed this cooperation very much.

The General Surgeon at the Hospital Jyrus Ochieng was a very hard working and skilled general surgeon, and we had a very inspiring and joyful time together discussing treatment options in individual patients, indications for surgery and of course also technical aspects of Hernia surgery.

We did ward rounds every morning to see the patients who had undergone surgery the previous days before discharging them.

In between surgery we saw patients who requested screening for a variety of surgical/non -surgical diseases, and patients coming for check-up after surgery.

The patients were seen dressed in gowns ready for surgery in a room in front of the theatre where they were marked by the operating surgeon before the operation, they were informed about surgery, written information about the surgery, operative procedure, risks etc. and consent of the operation was ensured.

Cleaning between the shifts were swift, making it possible to do fast track surgery

Patients were schedules to stay in the ward to the following day, where they were seen before discharge.

THE TEAM

The team consisted of three surgeons: Hugh Warren (UK), Emma Sanchez  (Spain) and Thorbjorn Sommer (Team leader Denmark). Anesthetic Nurse Lene Scheffmann Gosvig (Denmark) and John Warren (son of Hugh) assisted with the procedures together with the local staff. Two months before departure we had 2 virtual Zoom meetings, with participation of our Kenyan colleagues, where we were introduced to each other, discussed the mission, the need of equipment and had a very good introduction by Dr. Gachara, Samuel and Beatrice (medical superintended) from the Hospital.

TRAVEL/VISA/PERMITS

Travel to Kenya is easy since there are a lot of departures to Nairobi. eVISA must be obtained (online) before departure. Samuel did a terrific job securing Temporary Surgical License to the surgeons operating before arrival.

SCHEDULE

Our routine included Breakfast at 7.30 AM before starting surgery at 8-8.30 AM.

We had a lunch break at 2 PM, and finished the last surgery between 4 and 9 PM, depending on the number of cases scheduled. We had visit of the local health authorities, the bishop and representatives of the governor, showing a lot of support for the Camp. Thursday night a party was arranged at the Hotel together with all the staff, local organization and everybody involved in the Hernia Camp with tasty food, a lot of good talks and the team members were granted with gifts (Masai Blankets and a very nice sculpture), which we all are very thankful for.

LOCAL STAFF

The local staff had done a significant job in recruiting patients using various channels such as posters, newspapers and radio advertising, ensuring we had a lot of patients. In fact, some patients unfortunately had to be turned down and await further missions due to the limited time of the camp. Some patients had waited +8 years for hernia surgery – so the camp was really needed. Arriving in the Hospital all patients were carefully registered and prepared before being seen by a surgeon prior to surgery, with evaluation and marking of the hernia.

It was an important and primary focus of all staff to ensure patient safety from the first step. Doctor Aisha and nurse Lucy were phenomenal to arrange everything logistically, kept the files in place, knew were the next patient was and where the previous should go. The Medical Superintended Beatrice Mugure did a terrific job with competent overview of the organization. Extra personnel had been called in, so we were well equipped with competent staff from anesthesia, surgical and ward assistance, making it possible to upscale the number of procedures substantially. Working together with the local staff was a very positive experience for all of us, sharing expertise, skills, technical tips and ways to go forward in the care of hernia patients.

EQUIPMENT

The Hospital was well equipped, and the Team brought what was possible for each member to collect from their home Hospitals of new equipment. Medtronic Denmark had donated a Diathermy Machine.

ANESTHESIA

The Theatres were equipped with ventilators and at each operative table, there was monitor with a pulse oximeter and a blood pressure cuff, and ECG.  Anesthesia was obtained using Ketamine, Halothane and Desflurane, spinal or local anesthesia. The majority of patients received local blockage with Marcaine as post operative pain treatment together with Paracetamol and Ibuprofene.

ASEPSIS AND SURGICAL MATERIAL

All patients had washed before arrival for surgery. At the hospital they were washed with appropriate antiseptics, hair was removed, the site of operation was preoperatively marked on the skin and local anesthesia was applied. All patients received a single dose of Ceftriaxone as SSI profylaxis. The local staff practiced aseptic procedures making it easy to secure clean procedures. Sufficient surgical material boxes were available, we also brought supplementary instruments for future use by the local staff.

ACCESSIBILITY FOR THE POPULATION

Before our arrival, the Hospital had conducted a major information campaign with information about the possibility of hernia surgery. The patients paid a small fee, what they could afford, some came a long way to be operated (many hours of transportation).

ACCOMODATION IN NUANDARUA

We stayed at the nice 818 Hotel situated 1 km from the Hospital, making a short morning walk possible. In some days after dark transportation was promptly provided, making sure none of the team were eaten by hyenas on the way back. The Hotel had a very nice staff, nice spacious rooms with aircon, clean bathrooms, a nice restaurant with a variety of local and international meals. However, the best was a Tusker Beer after long working hours.

CONCLUSION

Strengths:

The Hospital is not too far away from Nairobi Airport, reducing time for transportation to a minimum. Transportation is swift and well organized. Patients came from far away, and the standard at the facility made it easy to do high-volume Surgery with good quality in every aspect. Accommodation is nearby so no time is wasted on transportation.

The staff is very well educated and a tremendous help in assisting us with everything. They have the capacity to raise awareness of Hernia surgery, planning a comprehensive surgical camp and secure patient safety in a high-volume setting. It is highly recommended to further develop Hernia Camps in Nyandarua, since all capacities for further hernia surgery is present. There is also a wish to do laparoscopic hernia surgery in the future, and if it would be possible to provide laparoscopic equipment it would definitely be the place to do it.

Things we might do differently:

We found it very useful to divide patients in groups according to hernia type, adult/pediatric and male/female, since competence of different hernia also varies among surgeons. We did that the last days and in future missions it will be useful with this strategy from the start.

Bringing more local anesthetic will be helpful.

In Conclusion we highly recommend Hernia Missions conducted on an annual basis in Nyandarua, and I would be grateful to do a mission there again next Year.

On behalf of the Team 2024

Yours sincerely,

Thorbjorn Sommer

Head of the Hernia International Mission to Nyandarua November 2024

Report on Hernia International Expedition to Bomi County, Tubmanburg, Liberia

Dates: 1st December 2024 to 8th December 2024

Team Members

   •     Ajaiya Mull: UK Anaesthetist

   •     Ernesto Blas: ODP

   •     Mahesh Pai: UK Surgeon

   •     Daniel Pastor: Spanish Surgeon

   •     Dr Peter George: Local Liaison and Medical Officer at Bopolu

Dr Peter George, a seasoned organiser of similar trips, facilitated our work seamlessly. Having worked with him in Ganta city Nimba County in 2019, it was a pleasure to collaborate again. The local surgeon at Tubmanburg was Dr Shariff.

Summary of Work

We operated on 80 patients, performing 95 procedures:

   •     74 inguinal hernias (8 bilateral)

   •     5 hydroceles

   •     3 lipomas

   •     7 other abdominal wall hernias

   •     6 gynaecological operations (including myomectomies)

During the period we were there we had no complications.

Location and Logistics

Tubmanburg is a small town approximately 60 km from Monrovia, the capital. Due to the quality of the roads it is a 2-3 hour drive.

   •     Arrival:

We landed in Monrovia on Saturday night, stayed overnight, and drove to Tubmanburg the following day. Daniel arrived on Monday.

   •     Work Schedule:

• Started on Monday with 10 cases.
• From Tuesday onward, we operated at full capacity, completing 17–18 cases daily.
• Dr George handled paediatric cases, while Daniel and I focused on adult cases. Dr Shariff performed gynaecological procedures, including myomectomies.

• Dr Mull administered spinal anaesthesia for the vast majority of cases. Ernesto was excellent is providing general support in theatre and ensuring smooth flow throughout along with the local staff.

Facilities

The hospital in Tubmanburg had two operating theatres:

   •     A smaller theatre (one table) used for paediatric and gynaecological cases.

   •     A larger theatre with four tables, where 2–3 patients were operated on simultaneously.

While the operating rooms had air-conditioning, conditions were still hot and sweaty. Local staff assisted with scrubbing. The theatres were clean. There was only one theatre light. We used head torches for operating lights.
The local team saw the patients and sent them to theatre. We would review them before surgery, mark them and check the consent. Of note they did not use the WHO checklist. We implemented it for the cases we did. It would need a culture change and local leadership to put this into practice.
Most of the patients came from fair distances and hence were kept in overnight. We prescribed them one dose of antibiotic. They were reviewed the following day by the local team and ourselves.

Accommodation and Meals

   •     We stayed in a basic but clean hotel with air-conditioned rooms.

   •     Dr George provided breakfast daily, and we dined out in the evenings at a good local restaurant.

   •     On the last day, we stayed at a comfortable hotel near the airport, which was convenient for our late-night flight.

Costs

   •     The trip cost approximately $1,000, excluding flights.

   •     Carry additional funds for emergencies.

Key Recommendations

     1. Supplies:

      • Bring sufficient medical supplies, including drapes, surgical gowns, sutures, and gloves.

      • Anaesthetists should carry essential drugs, especially local anaesthetics for spinals.

      • Be prepared for lost luggage by dividing critical items across team members.

     2. Health and Safety:

      • Ensure your Yellow Fever vaccination booklet is ready for airport checks.

      • Stick to bottled water to avoid illness.

      • Stay hydrated as the heat and perspiration levels are high.

     3. Travel Tips:

      • Roads are in poor condition; bring motion sickness medication if needed.

      • Consider staying at an airport hotel for convenience on the final day.

This trip was highly successful, achieving significant clinical outcomes despite logistical challenges. The collaboration between the international team and local staff ensured smooth operations and high-quality patient care.

The Hernia International Meru camp was conducted over two weeks from November 4-15. This was a quickly organized trip that was coordinated with the help of Peter Karanje of Nairobi, Kenya with the support of the Ministry of Foreign and Diaspora Affairs that came together at the last minute.

The Team consisted of surgeons from the USA and Australia and an anesthetist from Australia. We collaborated with the Ambassador and staff from the Ministry of Foreign and Diaspora Affairs as well as local administrators and staff at the Meru Teaching and Referral Hospital.

• Heidi Miller – MIS/Hernia Surgeon – USA
• Cea-Cea Moller – General/Trauma Surgeon – Australia
• Chandra Hassan – Bariatric/General Surgeon – USA
• Dominique Roberts – Retired General Surgeon – Australia/France
• LiLin Hong – Anesthetist – Australia
• Peter Karanje – Businessman/Logistics coordinator – Kenya

There was very minimal pre-mission planning with the hospital which made for a slow start in our clinical activities, but this ramped up nicely. We were met at the hotel in Nairobi by Peter and the representatives of the Diaspora who provided our transportation for the two weeks of the camp.  The trip from Nairobi to Meru is approximately 5 hours by bus and passes around Mount Kenya which was hidden in the rainy season cloud cover our entire trip. On arrival we settled into the Meru Slopes hotel, which was comfortable and walking distance to the hospital.  The first morning we were met by the administrators, surgeons and surgical trainees and given a tour of the beautiful and clean grounds of the Meru Teaching and Referral Hospital. The hospital has a working ICU and dialysis unit as well as a maternity ward and theater.  The Casualty is set up with Xray and a theatre, but it was not functioning due to staffing issues.  The radiology unit consisted of ultrasound, CT and MRI although the latter two were both nonfunctional during our visit.  In the case of a required CT scan for an incarcerated complex recurrent incisional hernia, the patient was transported to a private hospital and paid out of pocket to have this done.

The patients were evaluated by the surgical trainees and admitted the day prior to their surgery dates. Our OR lists were completed the day before and we operated Thursday and Friday the first week and Monday through Thursday the second week.  We used a combination of pure local, local with sedation, spinal and general anesthesia.  Dr Hong oversaw a lot of the anesthesia care, but this was also supported by local providers.  We cared for a total of 35 patients aged between 2 and 78.  We fixed 17 inguinal, 8 umbilical, 12 epigastric and 2 recurrent incisional hernias.  We also saw 12 patients in consultation during a Tuesday clinic afternoon. The patients were kept for a night post operatively and seen in the wards prior to discharge. We worked with surgical trainees as well as a local pediatric surgeon and urologist to collaborate on some of the cases. We also assisted the local surgeons with some emergency cases including a splenectomy, amputation, and trauma laparotomy.  There were no complications and the surgical trainees have been asked to keep us informed of any developments.

OR staffing was limited and often consisted of learners or students without any real guidance or oversight.  The physical ORs were in decent condition with electricity, battery powered lights and anesthesia machines in three rooms. The upstairs ORs had been renovated and decorated by KidsOR and the fourth OR was in the process of being equipped and stocked.  There is laparoscopic equipment available and interest by the surgeons in future laparoscopic camps.  The OR provided drapes, gowns, and sterile instruments although gowns and drapes were at times the limiting factors for being able to get through a full day’s list.

The Ministry provided transportation support as well as tea and lunch every day for the team and the entire OR staff.  We had our fill of Kenyan tea and delicious local food.  The Ministry also came with higher level support during the second week for a ceremony and tree planting at the hospital.  Our donated supplies were also presented at this time. We left the mosquito net meshes that were not used for the hospital as well as donations of Duramesh.

Social Activities:

Our evenings were spent walking from the hospital, resting, and enjoying local restaurants and libations.  Over the weekend Peter was gracious to come to Meru from Nairobi and played Tour Guide.  On Saturday we went to Ngare Ndare Forest Park where we did some off-road driving, hiking to waterfalls which were brown in the rainy season but usually are a beautiful clear turquois, and walked across a canopy walk. On the way home we drove through the Lewa Wildlife Conservancy where we saw Zebra, ostrich, rhino, elephants, and a giraffe amongst other local animals. On Sunday we drove a bit further to get to Meru National Park, the least visited Park in Kenya, and went for a six-hour game drive with some good showings but no cats.

Advice for future teams:

There is good opportunity for collaboration in Meru.  The hospital is well run, and the surgeons are friendly and competent but obviously lacking time and resources to do much outside of emergency cases. I believe many of them also have private practices in other hospitals. The trainees are used to a level of autonomy that is not the norm in US hospitals, so although they were interested in learning they were not used to our level of supervision.  Planning with the hospital and OR staff will help to ensure a patient load that keeps the Hernia International Surgeons busy but doesn’t overwhelm the hospital capacity.  There is room for improvement or growth in the patient recruitment as well as in the use of local and spinal anesthetics and early discharge home.  The operating theater could be better optimized in its efficiency of use and its sterilization and hygiene practices. Having additional nursing staff with the team would be helpful as well.

** For supplies being brought into country, we came across some difficulty with customs even with the supplies marked as donations for humanitarian use.  They are sensitive to medical supplies and expired supplies.  If working with Peter Karanje or the ministry, send him a list of supplies and you may be able to avoid this with a letter of support. **

Heid Miller, MD MPH

Maine, USA