Author: akingsnorth

KAMUTUR SURGICAL CAMPAIGN. BUKEDEA DISTRICT. UGANDA. SEPTEMBER 20th-30th 2019

SURGEONS IN ACTION FOUNDATION

1.TECHNICAL REPORT:

a.   DATE AND LOGISTICS:

A team of 12 people: 4 general surgeons, 1 pediatric surgeon, 3 anesthesiologists, 1 radiologist,
two surgical nurses and a professional photographer.18 packages with a total of about 400kg ofsurgical equipment and medicines.

 Departure from Madrid on Friday 20/9 at night and arrival in Madrid on Monday 30/9 in the morning.
This time we traveled with Ethiopian Airlines. A success, because the journey, with stopover in
Addis Ababba, is shorter, and also allows us to carry 2 23kg packages per person.
Saturday 21/9: A long bus journey, which we already  know  from  other  campaigns, heavy due to
long distance and what it means to travel on the road through Africa: traffic jams, pavement in bad
condition, dirt tracks.., until reaching Kamutur, a village in a rural setting in the Bukedea district.

 Sunday 21 to Friday 27/9: Surgical interventions, from 8:00h to 20h, in 3 simultaneous operating rooms.
b.   ADULT PATIENTS:

68 procedures have been operated on in 62 adults.

 More complex procedures have been performed than in previous campaigns, thanks to improvements made
in the new surgical ward. To highlight some procedures:
-19 inguinal hernioplasties, with PLP meshes provided by the volunteers.
-1  infraumbilical  laparotomy  for  removal  of  right  ovarian  cystic  mass,  previously
diagnosed by ultrasound by our radiologist.
-1 xyphopubic laparotomy for massive splenectomy.

-8 hemitiroidectomies by unilateral giant goiters.

-1 total thyroidectomy per giant bilateral goiter.
-3 large submandibular pleomorphic adenomas.
-1 large left inguinal tumor with extension to the thigh, about 20cm, Schwannoma said by pathology
report.
-1 large incisional hernia, with retromuscular PLP mesh (Rives)
-The  rest  of  procedures  have  included  umbilical  hernias,  anal  pathology,  soft-tissue

tumors (some of them very large) and removal of complex keloid scars.

c. PEDIATRIC PATIENTS:

35 procedures have been operated on in 25 paediatric patients, from 1 to 16 years of age. As most
noteworthy:
-7 inguinal hernias-4 hydroceles
-1 retrorectal teratoma.
-1 patient of 16th with multiple neurofibromas in left face, of great complexity, who had been
abandoned in the hospital.
-1 distal hypospadias.
-All other procedures include umbilical hernias, cures and soft-tissue tumors.

We have had to reject some paediatric patients, because of high complexity, such as a large facial
tumor, stoma closures or tonsil surgery.
It should be noted that, due to the location of the hospital in a rural environment, away from any
urban core of a certain entity, the recruitment of patients is quite complicated. Firstly, because
of the campaign’s publicity difficulties (advertinsingsare placed on local radio stations and phone
messages are sent) and secondly because of the patient’s difficulties in getting to the hospital.
This is especially sensitive for paediatric patients.
Total procedures: 103

Total patients: 87c.    COMPLICATIONS:
So far as to leave Kamutur on Saturday 28/9 in the early morning, it is worth highlighting only two
re-interventions by post-surgical hematomas, one  in total thyroidectomy, which was successfully
resolved, and another after removal of a pleomorphal adenoma submandibular, equally resolved  with  
drainage.  We  haven’t had any phonatory complications in any thyroidectomy. The patient who had
splenectomy was pending post-splenectomy vaccination,and has evolved successfully following our
departure. The pediatric patient with face  neurofibromas  has successfully evolved with healing of
the surgical wound, keeping important palpebral oedema that evolves more slowly (one of the removed
neurofibromas was in retroorbital location). The rest of the patients have had no complications.
We have received reports of Pathological Anatomy from Mbale Hospital, of the cases we consider most
necessary. For subsequent campaigns, always  assessing  the difficulties and cost of this, let it
be known that this study can be carried out in the samples deemed appropriate.

2. CAMPAIGN REPORT
a.   THE PLACE:
Uganda is an East African country, bordering Kenya, South Sudan, Congo, Rwanda and Tanzania. It is
an independent country, belonging to the Commonwealth, since 1962. He has had a very convulsive
recent past, and currently maintains a relative socio- political calm, with presidential regime led
by Museweni, who has ruled since 1986. It is divided into 111 districts and a capital city,
Kampala. More than 80% of the population is Christian. Each woman has an average of more than 6
children. Life expectancy is estimated to be around 52 years. The Bukedea district, where Kamutur
is located, is a district with about 120. 000 hab, in a rural environment, and with 80% of itspopulation below the poverty line.

The Holy Innocents Health Center (HIHC) has improved a lot since our last visit. It currently has
care for gestation and delivery, hospitalization  area,  laboratory  with basic diagnostic tests,
and a surgical pavilion already completed, and a new surgical hospitalization building connected to
the surgical pavilion, in a very advanced phase of construction, with a ward for women and another
for men.
Regarding the surgical pavilion, it is a building that has 3 operating  rooms,  whose current
endowment is:
-1 operating room with electro-surgery generator, an anesthesia tower and a monitor.
-1 operating room with an electro-surgery generator, a monitor and an oxygen concentrator.
-1 operating room without electro-scalpel.
All three operating rooms have a new and very functional operating table. There are legs. Each has
ceiling light and a floor lamp, although it is advisable  to bring front spotlights.
There is no running water yet available, although it appears that the external pipeline from Mbale
will be completed in the coming months.
In addition to operating rooms, the pavilion has toilets for men and women, a post- anesthetic
recovery  room, a cleaning room, an instrument and sterilization room, a warehouse, a staff room
and a waiting area for patients.
It has a system of solar panels and rechargeable batteries to support electric power.
Unfortunately, it is still not enough to meet the needs of the pavilion when it is operating at
full capacity more than two days, because the rate of charge of the batteries is lower than the
consumption rate, so it is necessary, to this day, to complement the energy input with a diesel
generator. This situation is likely to change with improvements that are pending, one is the
increase in battery capacity, and the other is the arrival of power supply  that is planned for theend of this year.

 The hospital center is clean and tidy. A more than acceptable asepsis-antisepsis circuit is
maintained, using a pressure autoclave using a gas-heated pot (there is an autoclave, which
consumes too much electrical energy and cannot be used at the moment) and organizing the instrument
in small kits, aided by all the single-use sterilized material we carry with us. We have
collaborated with 3 very efficient and willing local nurses, to which we appreciate their great
capacity and willingness to work.
With regard to the admission process, two aspects should be highlighted:
-The admission process in the hospital includes the payment of between 10,000 and 50,000 Ugandan
shillings, which is equivalent to a maximum of 12 euros, and the completion of a small medical
history by local doctors, usually in the days before our arrival.
-The medical team of the campaign consulted in the consultation area all the selected patients, to
decide the indication and order of surgery.
It should be noted that any surgical intervention in Mbale Hospital, especially in the case of more
complex patients such as thyroidectomies, can account for  between several hundred thousand and
several million Ugandan shillings.  Apart  from  some cases where the indication of surgicalintervention by the surgeons responsible is not accepted.

b.   THE TEAM
On September 20, Friday night, we left Madrid a team of 12 people:
-Carlos de la Torre Ramos, pediatricsurgeon,
-Sebastián Fernández Arias, general surgeon,
-Ana Gay Fernández, general surgeon,
-Julio Calvete Chornet, general surgeon,
-Beatriz Revuelta Alonso, anesthesiologist,
-Miguel Angel Pereira Loureiro, anesthesiologist,
-Astrid Alvarez Fernández, anaesthetologist in training (R4)
-Nieves Alegre Bernal, radiologist,
-Nuria Agulló Marin, nurse,
-Gustavo Sánchez Bravo, nurse,
-Sergio Sánchez Agulló, photographer,

-David Fernández Luengas, general surgeon.
This campaign has been carried out by a team from the Surgeons in Action Foundation. Together with
the medical team, on this occasion a professional photographer has participated in the campaign,
with the aim of collecting audiovisual material to make a documentary montage about this place, its
reality, its needs, and the task that the Fundación Action takes place here.
c.    LOCAL STAFF
There are currently two doctors at the hospital. For our work, we have had 2 nurses in the
operating room (Esther and Rose), who did circulating work together  with  our nurses, and cleaning
and sterilization. In addition, we work with hospital nurses, who assist all hospitalized patients
24 hours a day, and two wardens who  take  care  of patient transport and other tasks. It is right
to acknowledge to all of them the enormous effort made and the joy with which they have shared the
work with us. We were very pleased to note upon our arrival the cleanliness of the facilities,
which we were able to check how it was maintained day after day by the cleaning team.
We have also collaborated with local doctors (Viktor and Kenneth), who have helped us with the
prior selection of patients, and have participated in surgical interventions. During the last day
in Kamutur, there was a great celebration, on the occasion of the official  opening  of  the  
surgical  pavilion.  More  than  100  people  attended,  with  the presence of Ugandan Senate
authorities, representatives of the Ministry of Health, and the Bishop of Mbale. A mass was
officiated and the pavilion was officially opened. The authorities present were able to check the
enormous effort made to equip the hospital with the necessary means to perform surgical interventions safely.

 d.   THE EQUIPMENT
In addition to the surgical ward, it is worth noting:
-Surgical instruments, there is a basic reserve of instruments in the hospital, but we have carried
instrumentals to make about 6 basic kits, which have allowed us to work fluently, relying on
constant cleaning and sterilization in the autoclave by local nurses.
-Regarding consumable material and operating room clothing, the needs are enormous.We have used
much of the material we have worn,  among  gauze, compresses, gloves, dressings, disposable sterile
cloths, disposable sterile gowns, anesthetic medication iv, iv antibiotics for prophylaxis,  
mosquito  meshes  and antiseptic solutions for surgical wash, among other things. Without this  
material, posing such a campaign to this place is impossible. The next teams must be very aware of
the need to provide all this material, although it is true that, thanks to the material left over
from previous campaigns, material is gradually stored in the pavilion (current inventory of the
warehouse is attached).
-Regarding the work of our radiologist, she has been able to use a simple ultrasound, acquired by
the hospital, which has a single low frequency convex probe for abdominal cavity examination, and
does not have Doppler. With it she has carried out two different tasks:
1.- Diagnostic studies to the patients we have required.
2.- Basic training plan in the use of the ultrasound for doctors and local midwives, for use in
basic diagnostic studies and for gestation control.
-Another task that we have done during the campaign is the training of local staff in basic  
cardiopulmonary  resuscitation  maneuvers,  with  a  CPR  mannequin  donated  by the company Ambú, and which we have left there so that in future campaigns you can continue to use
it for training.

e. ANESTESIA, ASEPSIA AND QUIRURGIC MATERIAL

1. Anesthesia: The hospital has an anesthesia machine and an oxygen concentrator. The anesthesia
machine functions as an oxygen concentrator, i.e. it collects ambient air and concentrates it to
get Fi02 of approximately 80-90%. It could be connected to an oxygen bullet or a wall oxygen
delivery system, but the pavilion lacks these systems. Yes there are a couple of oxygen bullets,
but the connections are not compatible and their use would leave the hospital without them, so the
bullets were nearby to use only in case of urgency. The respirator has an internal battery that
lasts about  30 minutes, to take into account in case of failure with generators or solar panels.
The oxygen concentrator continues to function perfectly, so we were able to perform general
anesthesia in two of the operating rooms simultaneously.
In the third operating room, most surgeries were performed under local anesthesia and many with
locorregional anesthesia, without incidents.
In this campaign, thyroid surgery was done for the first time, with everything surrounding these
types of interventions. In addition to the laryngoscopes, we had fasteners and we carried airtraq
of different sizes. We used them in a timely manner, but all the orotracheal intubations were
successful, without any incident. Although if such interventions are to continue, we must be prepared for possible difficulties.

In addition to all the medication usually carried in these campaigns, the Hospital was insisted on
the provision of halothane (there is only one halothane vaporizer, it is not possible to use
another type of gases), to be able to perform the maximum number of surgeries with the lowest cost
in inductors, and some kind of muscle relaxant. In previous campaigns there was no fridge to store
the medication. Now there is a fridge in the surgical pavilion, and we got succinylcholine  and  
cisatracurium  in  Kampala, albeit at a very high price. Halothane is almost impossible to obtain
in European countries, and in Uganda they can take care of buying it. The relaxants should take
them, so in future campaigns it would be possible to carry what each anaesthetist considers, well
protected in cold during the trip, since there they can be  stored without problem.
With regard to the material they have in their warehouse, there is a significant surplus in face
masks, guedel, spinal needles of different sizes, local anesthetics (hiperbara and and isobara
bupivacaine), electrodes, nasal oxygen masks. All other medications and fungibles need to be
provided in each mission. Important mention of any drug we anticipate needing in thyroid surgeries.
For this campaign we have carried calcium gluconate iv, calcium+calcitriol oral, levothyrosine, as
well as material for eventual realization of tracheostomies.
Surgery was performed in adults (abdominal wall, thyroid, skin tumors…) and in children
(abdominal wall, urological, sacrocoxygeal, facial tumor…) without any incidenceof any kind.
2. Asepsis: Basically, they have a “sterilization” room where they store the packages with the
sterile material, and where a “express pot” autoclave is placed on gas fire, with pressure  meter.
The  system itself  is  rudimentary, but effective  for  getting the material sterilized. I
recommend the following teams to carry sterilization bags and witnesses, very useful there.
Surgical clothing is very scarce, with very few cotton gowns and re-sterilizable cloths. We use a
lot of disposable cloths that we carry from Spain, as well as disposable robes. We have been
particularly concerned that all our adult patients with indication of antibiotic prophylaxis
receive a dose of cephazoline 2gr iv or similar in anesthetic induction, which we have taken. In
the hospital there is a pharmacy with some medications, but in general, it is advisable to take all
the medicines that are deemed to be used.
3. With regard to surgical equipment, we carried a lot of material that is essential that other
missions also carry, from gauze and compresses to sterile gloves, drains, dressings, steri-streaps,
sutures, elastic bandages, etc…
The surgical instruments there are useful, although generally somewhat rudimentary. We have
preferably used our own instrumental divided into small kits.
f.    OUR LIFE IN KAMUTUR
The alarm clock rings at 7:00am. It’s time to get up, grab a big bucket and approach the hospital
well, in the middle of the central square to fill it with water. There’s enough hustle at that
time, and you always find some kid in the well that gladly applies to the pot’s crank to get the
bucket filled. Then there is going through the kitchens to add enough hot water, for tastes, and
approach our “shower”: a stay with walls of approx. 1.5m high, outdoors, where we could perfect the
technique of the bucket shower. The mornings are fresh, about 20 degrees max. The rest of the day
during this time of year is warm, up to 30 degrees, and with relatively frequent rain showers. As
far as the bathroom is concerned, we have improved from last year. It is no longer necessary to go
to the latrine “communal”, because we have a bathroom in the area of the bedrooms and two others in
the surgical pavilion. As there is no running water, it is necessary to pour a good bucket of water
for flushing the toilet.
All meals were made on the covered terrace, with a menu basically the same every day, clean, cooked
there, and enough to feed, without great difficulties.
Our life in this place is very simple. We have always felt very well treated and very accompanied.
Apart from hospital life, which occupied much of the day, our social life was limited to
conversations around the table. Especially in the evenings, when, after dinner, we enjoyed one (or
two) wonderful bottles (75cl) of Nile beer, with an entertaining conversation.
Regarding the rooms, we have lived in relatively cozy cabins, two for the  6boys, another for the 4
girls, and a room for Nuria and for me. They are quite basic, with the beds as only furniture, but
clean and comfortable enough to spend a week.We paid around $70 each for the room and food, for the
whole week.
Communication with the outside world can only be done through the Ugandan telephone network, via
SMS or calls at an international rate.
Our trip back to Entebbe we did it in two days of car of about 4.5h each day, taking the time to
rest on Saturday in a hotel in Jinja, where we could enjoy a boat ride on Lake Victoria, visiting
the famous source of the river Nile.

3. CONCLUSION:
In short, we consider that this campaign has been a success, both for the number and complexity of
patients that we have been able to operate, with little complications, and for the satisfaction of
the team for the great treatment received by the authorities and local staff. This year, thanks to
the functioning of the pavilion, we have been able to perform, for the first time in Kamutur, surgical interventions of greater complexity, with general anesthesia, such as thyroidectomies and abdominal surgery.
Strengths of this place:
– Moses Aisia, true hospital engine. Its ability to launch, from nothing, this center, is amazing.
– The hospital itself, a true center of hope for this place, with a much-needed population, mired
in poverty.
– The treatment we have received and the willingness of the staff to work with us.
– The works carried out, with the surgical pavilion already functioning, and the new
hospitalization ward in the very advanced phase of construction.
Improvement objectives:
– Improve the process of recruiting patients for campaigns. This is a goal that should be
considered paramount, to make the most of campaigns. Among the measures that can be implemented,
there are two that would probably be very profitable:
-Get a means of transport that would collect patients in nearby villages in the days leading up to
the campaign.
-Make a visit to Kamutur Elementary School, which has 681 students censed today, to perform a
medical checkfor surgical pathology, which is likely to be going unnoticed to their parents.
– Ensure complete energy independence in the surgical pavilion.
– Medical material: Today, any campaign must have the need, already explained, to carry with all
necessary medical material. Our recommendation is maintained  to supply the hospital with this
material, by the management of the center.
– Complete the channelling of running water and electricity, by the  Ugandan government.
– Complete the start-up of the blood bank, currently in the manning phase, according to the rules
of the control protocol required by the Mbale Blood Bank.

4. BUDGET:
For informational purposes, and without going into excessive detail, it must be said that the
campaign  in Kamutur is more affordable for the surgical team than  other locations. This is due to
two fundamental reasons. One, the cost of the plane ticket, not especially expensive. Another, the
costs of accommodation and  maintenance, which have been almost non-existent (70$ for the entire
stay of 6 days), in addition to road transport, about 450 dollars round trip all the equipment. The
budget has not accounted for the cost of all the material we have contributed, in total about
400kg.
COST PER PARTICIPANT: Approx. 900€
TOTAL COST OF THE CAMPAIGN: Approx. 10,800€, paid for by the volunteers and with partial funding
thanks to the Spanish Surgical Association grant of 3500€.

Fdo.: David Fernández Luengas Responsible for the campaign
Surgeons in Action

Belohorizonte Mission Report

5-10 August 2019
The Brazilian mission took place in Belo Horizonte ( 1,5 million people), capital of the State of Mina Gerais, one of the wealthiest states in Brazil. It was organised by Gustavo Soares and Christiano Claus and well prepared with the participation of 12 local surgeons and one overseas surgeon (myself).

Operations were done free of charge place on 4 sites : University Hospital, a large up to date place were all type of surgery can be performed, Sao Francisco Hospital : a non for profit organisation which let us use their facilities, Santa Monica Hospital in Divinopolis a private hospital which opened free of charge a theatre room for several patients every day, sessions also took place at Ouro Preto Hospital, the previous state capital city. In the 2 largest hospital we had 4/5 theatre rooms for us all day long. There is a lot of controls and security at each hospital entrance which makes it a bit difficult to enter the hospital if you are not accompanied by one of the locals.

 Theatres are usually well equipped, theatre lights are good, instruments quality depends on the hospital, the scrub nurse is usually an (unpaid) surgical registrar in his first year of training who is always very keen on closing all wounds and craving to do more surgery. One senior registrar was excellent at laparoscopic inguinal hernia repair. There is a good balance between male and female trainees which is promising as all senior surgeons were male. Communication was a bit of an issue as few people speak English, it is worth wile to speak some Portuguese if only to make sure you operate on the correct patient, correct side and could ask for assistance when needed. Check lists are not performed before and after surgery. Rooms are very well cleaned after each operation by a team of 2 cleaners. Anaesthetist perform usually a spinal anaesthesia and are good at it, nurses are well trained and efficient. No child to operate on. There is nothing to bring as meshes and sutures are provided by the local pharmaceutical companies. Of note, everything is kept in a safe room where an attendant only releases the products on demand from the theatre room for a given patient and this is recorded to avoid stealing which seems to be a serious issue even in the private hospital!

 There was a good balance of hernia types, inguinal, mid lines, para stomal, large incisional hernias and numerous umbilical of all sizes and shapes, some patients seemed to have been waiting for more than a year before they could access surgery. The Brazilian surgeons are keen and good at performing laparoscopic repair of these and are not using too much single use equipment. Mesh usage was the routine for most hernias. 250 repairs were performed over the week, follow up is organised by the juniors, we had private and public surgeons coming every day from various other hospitals.

Accommodation was in a good hotel in the town centre although with the local traffic it always takes time to go to and return from the hospitals, early morning start at 06H30, return when the job is finished. Pleasant evenings in restaurants and bars with the Brazilian teams, we had 2 sponsored meals on Monday and Thursday night. One interesting teaching session Friday afternoon with a packed amphitheatre.  Ambiance is Brazilian, work hard and have fun after.

 This hernia mission in Brazil is great, never boring, be careful however, this is a hard working week with no moment to relax. Have your vaccinations including yellow fever up to date.

Dominique Robert for Hernia International

dominiquerobert@bigpond.com

VENTANILLA – International Humanitarian Hernia Mission. June 2019.

Ventanilla, Callao. Perú. 

 On the 8th of June 2019 a mission of the project Hernia International arrived into Lima Perú. The mission intended to visit for two weeks the Ventanilla District General Hospital.  Ventanilla District is a densely populated community located at two hours drive from the city of Lima and belongs to the Province of El Callao. The population of Ventanilla is about 300.000 inhabitants.

The mission Ventanilla 2019 was sponsored by Fundación Cirujanos en Acción, www.cirujanosenaccion.com and Hernia International,  www.herniainternational.org.uk

Volunteers of the Ventanilla Mission June 2019: The mission was composed of nine volunteers; five consultant surgeons, two consultant anaesthetists, and two theatre nurses.

 – Rafael Chavez – Surgeon, UK

 – Dominic Robert – Surgeon, Australia

 – MaAngeles Torrico – Surgeon, Spain

 – Celia Moreno – Surgeon, Spain

 – Claudia Tinoco, Surgeon, Spain

 – Eugenio Briz – Anaesthetist, Spain

 – Vicente Cuquerella – Anaesthetist, Spain

 – Mara Garcia – Scrub Nurse, Spain

 – Natalia Rodriguez- Scrub Nurse, Spain

 There was a very enthusiastic involvement of all staff in the hospital, including the Medical Director, Surgeons, anaesthetists, nurses, and all support staff.  The local surgical team was led by Dr Ronald Medina and Dr Luis Bernaola, Consultant Surgeons. 

Ventanilla Hospital is a Level II District General Hospital and has approximately 100 beds and 5 operating theatres. It is staffed with 6 anaesthethists and 17 professional scrub nurses. The Department of Surgery carries out conventional hernia surgery, biliary surgery, both laparoscopic and open; ano-rectal surgery and peripheral tumours.

Theatres:

The hospital has five operating theatres, clustered in a single surgical area. Four of those theatres were made available to the campaign, leaving one to cover their own emergency work in general surgery and Obs & Gynae.Of the four available theatres, two were standard, purpose-built theatres and the other two were small military, field-operating theatres that are coupled to the main building in a semi-permanent fashion.

 Patient Population:

Patients were recruited at a national level. All recruited patients were assessed in advance and offered detailed information, consented and given instructions regarding preparation for surgery, including personal hygiene. As a result all patients that attended looked relaxed, well groomed and comfortable.All patients were clerked and admitted to the ward by the local interns and then transferred to the surgical area were they were re-examined by the surgeon, marked accordingly and had an opportunity to have a further conversation with the operating surgeon.

Anaesthetics were mostly spinal, a number of cases had their operations under local anaesthetics and all paediatric patients and those with large incisional hernias had general anaesthetics. The anaesthetic team were extremely keen and helpful.

 The surgical trainees participated actively in all the surgeries.

Results

Surgery:

Number of procedures: 169 

Inguinal: 57

Crural: 9

Incisional: 9

Umbilical: 76

Epigastric: 17

Spiegel: 1

Complications:

Follow up information is still pending. I shall report on that as soon as it is available.

 Discussion of results

Observations, procedures and knowledge transfer throughout this mission

 – Sterility in theatre              – The operating theatres were kept in pristine clean conditions. The hospital staff kept excellent asepsia and antisepsia measures throughout the whole visit. The nursing staff were instrumental in keeping an impeccable theatre discipline and technique.

              – Scrubbing: No brushes were available for scrubbing, only clorhexidine foam was utilised.

              – Antiseptic preparation of the operative field: Only clorhexidine soap was utilised to prepare the operating area. A film of soap was normally left before draping and commencing the operation.

– Patient dignity

              The local team were very pleasantly impressed by our uniform approach to patient’s dignity. They self-criticised the fact that they were less concerned with regards to keeping the surgical patients decently covered throughout the whole process, including examination, transferring to operating table, anaesthetics, surgery and postoperative management. The local team considered this an important learning point to take on board.

– Marking the operation side and site

              The local team saw with interest our routine practice of marking the side of the operation at the time of preoperative examination and consent. They expect to adopt this safety technique.

– Preoperative morning briefing:

              The local team normally undertakes a morning ward round to review the patients scheduled for surgery on the day, and for final pre-op indications.There were no morning briefings in the operating theatres during the campaign. Perhaps this should be implemented in subsequent missions  

 – WHO checklist Pre and postop:

              The surgical team undertook the WHO checklist before and after each surgery. This is common practise in Ventanilla Hospital and the visiting volunteers kept this routine.

Communications

              There were no visible telephone landlines in the clinical areas, however, communications were very effective thanks to the local team, which successfully ran the whole campaign on a Whatsapp platform.                  

Discussion with lectures from local professionals and from the visiting volunteers.

Opportunity for networking:

              This mission was an opportunity for networking with our colleagues from Peru. As a result, we have been invited to conferences and congresses; at least two local doctors have shown interest in visiting our centres for training.

Case discussion Whatsapp group:

              The local team has developed an international group, based on Whatsapp, for discussion of clinical cases of interest. This platform has remained very active.

Promoting presentation of results:

              These report and results have been made in collaboration with the ventanilla team and we have suggested to the surgical residents that they may find material here for a presentation in a local or regional surgical conference.

Hernia International

Mongolia June 2019

USA/UK/MGL team

Ulannbattar/ moron

Mary Jane Reed, MD, FACS, FCCM Team Leader June 24-July 5, 2019

 Summary: Mongolia and Hernia International have had a long standing relationship and this was the 10^th year working in collaboration with the excellent surgeons in both Ulaanbaatar and Moron.

Dr Naraa was our Mongolian host and was instrumental in making our HI mission successful.

 Enkee was our in country coordinator who was a wonder in organization and relations. Our teams worked in Hospital 2 in the capital of Mongolia, Ulaanbaatar and in Moron Hospital in Moron, Khovsgol providence. The teams evaluated and operated on 45 adult patients with inguinal, umbilical, post-operative ventral hernias, phimosis and cryptoorchism in Ulaanbaatar over 4 days. In Moron, the team did half pediatric hernias. Including adult inguinal and ventral hernias total of 24 cases were done in four days.   The HI hernia team were co surgeons on all of the cases with young attendings or senior residents at Hospital 2 in Ulaanbaatar and regional surgeons in Moron. The Hernia International team consisted of three surgeons all experienced in global surgery.

Biku Ghosh, a senior British surgeon with extensive experience in all aspects of general surgery including pediatrics and breast cancer. Dr Ghosh donates his time extensively to global surgery projects including HI. Dr Mary Ann Hopkins is new to HI but not to global health. She is a fellowship trained laparoscopist and advanced hernia expert who also is the Director of Global Initiatives of New York University Medical Center. She brought her expertise to teach repair of large complex ventral hernias.  I rounded the team out as the second US surgeon. Although not my first global surgical mission leadership, it was my first time with HI. I am a acute care surgeon and critical care surgeon with advanced laparoscopy and bariatric surgery background.

June 24-28, 2019-Hospital #2 Ulaanbaatar. The team brought 100 pieces of mesh in various sizes, suture and dressings. No mosquito netting was used in this mission. Although the majority of operations were inguinal hernias, a third of the cases included large post-operative ventral hernias.  

A few bilateral hernias were performed laparoscopically.

Lectures on hernias and other general surgery topics were delivered by the HI volunteers.Ulaanbaatar is a busy and vibrant city.

Our hosts assured that we experienced some of the sites.

 June 28, 2019-Dr Naraa and a Hospital #2 team of residents escorted the HI team to Moron by ground. This is a long trip via road but full of incredible sites.

 July 1-July 5, 2019– HI-Mongolian team operated at the Moron hospital. Here, the HI team operated with regional surgeons. Half of the patients were pediatric hernias with the adult cases equally divided with inguinal and post-operative ventral hernias.

 And we very much enjoyed getting to know our hosts.         

                                                    

MEMORY OF THE MISSION OF “CIRUJANOS EN ACCIÓN” AND “HERNIA INTERNATIONAL” IN FREETOWN (SIERRA LEONA) ON 15-23 JUNE 2019

(Police Hospital and Connaught Hospital) 

 This has been the first mission that “Cirujanos en acción” (CA) and “Hernia International” (HI) have carried out in Sierra Leona. The initial place for this mission was the Makeni district in the inner country, a zone needing badly surgical help in hernia pathology according to the request of contact with HI at the end of 2018, but due to logistic problems it took place finally in the capital of the country, Freetown, and simultaneously in 2 public hospitals, the “Police Hospital” (PH) and the “Connaught Hospital” (CH).

 The “Cirujanos en Acción” team was formed by 10 persons according to the needs of the initial campaign. Four general surgeons: Cesar Ramirez (Málaga), Teresa Butrón (Madrid), Hermelinda Pardellas (Vigo) and Guadalupe Moreno (Ibiza); a paediatric surgeon, José M. Morán (Badajoz), three anaesthetists, Salvatore Catania (Huesca), Beatriz Fort (Barcelona), and Sandra Casares (Ibiza); and, to complete the team, two nurses, Francisco Gomez (Malaga) and Silvestra Barrena (Madrid).

The previous coordination, after the last moment discarding of Makeni’s destiny, has been very troublesome; in order to organize everything we had the great help of Dr. Biku Ghosh, an Indian surgeon, working in the UK for many years, who usually volunteers with the “Saving Lives” ONG and who had just finished a mission in Freetown. The key contact persons in Sierra Leona have been at PH Dr. Paul Fillie (responsible surgeon) and Dr. Mohammed Jalloh (director in charge), and in the CH Dr. Samba Jalloh (a young “practitioner” of Freetown very much implied in coordination work of humanitarian missions) and Dr. James Boima (surgery chief in that centre and high prestige surgeon and national consideration plus absolute reference, of Sierra Leone).

The starting point of each of the team members were their cities of origin, and we all got together at the Paris airport to begin the flight to Freetown. We arrived to our destination on Saturday 15^th late in the evening, and we were received at the airport by Dr. Paul Fillie. More than 20 pieces were booked with more than 350 Kg of material, and in this occasion I want to underline the Air Europa collaboration as they allowed us to travel with excess luggage without additional cost. The Freetown airport (Lungi International) is very far from the city, in a gulf that makes it necessary to take a “ferry” for about 35-40 minutes to arrive, as otherwise there are almost 4 hours by car; this forces us to arrange the times of arrival and of leaving the country in function of the times of the ferry. On reaching the city and disembarking we got a warm welcome by the PH staff, and besides that we had a bus of the Sierra Leone Police for our displacements in the city.

Our stage was arranged in The Jam Lodge, a fairly central hotel which had been recommended by Dr. Ghosh and which we had booked by “Booking.com” previously. It is a decent hotel, with hot water, a good breakfast and in which the Wifi works not good; the price or the room is about 50 dollars a day for single or double room. We daily gathered at 7 a.m. in the morning to plan the day, and at 8 a.m. the bus came to take us. We had a great help in Suleiman Conteh, a young student of political science, who has experience in helping humanitarian missions and who every day sent us food and drink in the two hospitals; the price of food and drink has been about 3 dollars for person a day, but as in both hospitals we paid for food for the whole staff that worked with us the increment was important (we have paid on an average 150 dollars a day for food). The local money is the “lion”, but in fact everybody works with American dollars and this is what we used. On Friday 21^st June night, after the last word in the operation theatre, Dr. Mohammed Jalloh was kind enough to invite our whole mission staff and operation theatre PH staff to a common dinner which was very much appreciated and valued.

The process of gathering and selecting patients by Dr. Fillie in PH has been really good, so that there were more than 250 patients ready to be examined, the majority with a severe hernia pathology, which we evaluated on Sunday 16^th June along morning and evening; in CH there were hardly 30-35 patients selected, some of them with small hernias, all selected by Dr. Boima. In PH there was only one respirator and two operation theaters; in CH we also had one respirator and two operation theaters (both with respirator, but one of them only for children) and this was the first problem we have met as the flow of PH patients to be operated upon in CH was not the desired one, and the administrative facilities have not been good either. Finally, in CH we were given on the last days a third operation theater so that we could fulfill the expectations we had come with. In the PH there was no facility for sterilization of the material so that everything had to be sent to the CH, and this has always been a problem from the logistic viewpoint. Even so, given that we have some boxes of surgical material of our own for children and adults that we had taken from Spain we have been able to help in this. In the PH only an electric scalpel was working and it was of poor quality, that is why we have been able to operate effectively in only one room; in CH they have two electrical scalpels, but only one was working properly, so that it has been fundamental that we had brought from Spain an electrical scalpel provided by Teleflex. CH is a large hospital with more than 200 beds, while in PH there are no more than 30 beds, and this, given the bad coordination between both centers has also brought logistic problems shifting from one centre to another, and this has created internal tensions, sometime unpleasant. From our part, and given that children could be operated upon only in CH, we have decided to divide the team in 2 working groups, one with an anaesthetist, a lady nurse and two general surgeons for the PH and another with two anaesthetists (one of them specifically for children), two general surgeons for the PH and another with two anaesthetists (one of them specifically for children), two general surgeons, one paediatric surgeon and a male nurse for the CH. I can say that it has not been a good experience, and I do not recommend that in future campaigns we work in two hospitals at the same time, and divide the team members even more in countries where we cannot communicate by phone between us because there is neither an accessible phone neither an accessible phone line nor wifi for “whatsapp” communication between hospitals.

On Monday 17 June, which was the first day to begin operations, we have not been able to begin till the afternoon because we have spent the whole morning in the Sierra Leone Medical Council in Freetown; even when all the requested titles had been sent by mail, and the inscription forms had been properly filled in the Medical Council, we have had to go through a personal interview in order to confirm our ability. In that way we have had only 4 and a half days of work, which we have made good use of as far as we were allowed. In PH we had no time limit to work, still in CH we were first told that at 7 p.m. the health workers were leaving and so we could not operate from that time on. This time limitation in CH was extended in the last days with the hint that we could work from that time. This time limitation in CH was enlarged on the last days with the suggestion of giving some help in the shape of economic help for the operation theater staff, as it is apparently assumed habitually in this hospital and which has looked very strange to us.

On the whole we have been able to operate upon 126 patients of which 96 have been adults and 30 children; till the time of leaving, and reporting our direct communication with Dr. Fillie today there have been no mayor complications. The number of surgical procedures carried out has been 144, as in some patients 2 and 3 procedures had been carried out simultaneously (19 hidroceles and umbilical hernias).

It is very important to stress that 70% of the inguinal hernias were H3 or H4 or more invalidating, as we have selected for treatment those that seemed more complex and more invalidating and required more time. On the last day of the mission we operated upon a giant goiter in a 12 year old girl with compressive complication which could not bear decubitum who was discharged the next day without any disphony or symptoms of hipocalcemia.

In spite of all the organizing problems that have troubled us, we can say that the campaign objective has been achieved, and from the view point of the number of patients operated upon the mission has been a success. The Police Hospital is a center where in the future new campaigns will be had because the interest of leaders and surgeons to collaborate with our foundations is maximal and the predisposition is absolute. It would be very interesting to be able to solve the problem of the sterilization of the material (they have no autoclave) and to dispose of another electric scalpel in order to make 100% use of the second operation theater they have. After 2 months I am keeping a periodical relation with Dr. Fillie and I believe it is worthwhile to work in this country habitually.

Dr. Cesar Ramirez

Trainee’s Report – Omar Nasher

Location: Gatundu Level 5 Hospital, Kenya – Africa

Period: 18/05/2019 – 24/05/2019

Team members: Magdi Hanafy (Surgeon – Team Leader), Iain Muir (Surgeon), Omar Nasher (Surgeon), Gudrun Graf (Anaesthetist), John Pickering (Operating Department Manager), Vicki Clark (Nurse), Sue Dale (Nurse)

Since before entering medical school, I always had the dream to participate in a charity medical mission as I believed it would have been a uniquely rewarding experience.  Hernia International gave the opportunity to join the UK Team on the mission to Gatundu in Kenya and I was very grateful for that.

Prior departure, I had several email correspondences, phone calls and a meeting with John Pickering who, having been on numerous missions himself, was able to share his wealth of knowledge and mentally prepare me for what was going to be an amazing life experience. After a long direct flight from London, we arrived at Nairobi International Airport late at night where we were greeted by Cyrus, our exceptional driver/guide in Kenya, who drove us to the hotel.

There we received a smiley welcome by the hotel staff who were able to provide us with warm food despite our late night arrival. The following day after an early breakfast and a 45min adventurous drive through a spectacular countryside of fertile lands and coffee plants, we reached Gatundu Hospital. Upon arrival, we unloaded the jeep of all the boxes containing our equipment which included gowns, gloves, suture materials, instruments, medications and teddy bears for the children.

 After having been greeted by the hospital team we started working. Johns, Vicki and Sue unpacked all the equipment, created surgical trays and tidied up the two operating theatre so that they then became perfectly functioning and organised.          I, Magdi, Iain went to assess the patients (adults and children) on the surgical wards to make sure that the proposed surgery was clinically indicated and we then created our first elective operating list for the following day. Gudrun did a pre-operative assessment of the patients and along with Sue made sure that all anaesthetic machines, equipment as well as medications were ready and safe to be used.

 During the whole week we operated on multiple patients with different pathologies ranging from various types of hernia to undescended testis and hydrocele. All patients stayed in hospital one night after surgery to make sure that they were well post-operatively before going back home which in some cases was quite far away. Every day we reviewed the patients operated the previous day, perform the planned surgeries and then assessed new patients for the following day.

 I had a great pleasure and enjoyment in interacting with the brilliant local doctors, physician associates and nurses who were always accommodating any request we had and demonstrated a great level of enthusiasm as well as willingness to learn despite the limited available resources. One day I was also asked to deal with a 38w newborn with exomphalos (not antenatally diagnosed) and faced the challenge of needing cling film which the Neonatal Unit did not have. Fortunately a member of staff was able to get it near the hospital so that we could initiate the immediate management plan for the baby before transferring him to a tertiary centre in Nairobi.

    The parents and patients were incredibly appreciative for what we did and they really made me feel truly grateful to be in the healthcare profession.

   One day I was given an informal tour of the hospital by one of the interns and visited different areas such as the medical wards, emergency room, radiology, maternity, etc. Wherever I went, people wre always smiling and welcoming me to make me feel as if I was at home.

 Furthermore, I delivered a Paediatric Surgery teaching session which I thought it was going to be only for the surgical doctors but it then turned out to be a session for every staff member including the medical director. The session was well received and found helpful despite my initial apprehension.

My birthday happened to be during the mission period and I must say it was one of the most memorable ones. The mission itself and the team I was with definitely made it a very special day for me.

 This charity mission was a fantastic life experience during which I learned how to best utilise the limited available resources to look after patients and allowed me to reinforce my teamworking skills as I interacted with people belonging to a totally different healthcare system.

 I would definitely recommend this experience to any healthcare professional and I am already looking forward to the next mission!

Omar Nasher

SpR in Paediatric Surgery

Hernia International Volunteer

Bewal (Pakistan) Hernia Camp 2019 Report

Steve Lindley

The week leading up going away is normally the time when excitement kicks in, but on this occasion, re-tension of indo-pak relations and the fact that my passport (bearing a previous Indian visa) was sat in the reject pile at the consulate, meant that I was rather anxious.The few days before I was set to leave, my concerns had evaporated. We arrived in Pakistan and convened at the impressive Bewal International Hospital to meet the team.

The team consisted of hospital co-founder Atiq; an ex-pat Pakistani who works in Birmingham, UK as a vascular and general surgeon, his brother; Khaleeq a maxillofacial surgeon who also works in Birmingham and is the hospital’s co-founder, was on hand to assist and arrange much of the logistics to the mission; Richard, a general surgeon from Tasmania, Australia and myself, an enthusiastic General Surgical registrar from the UK. Our anaesthetists comprised of Sahjaad and Zehrin, (UK Consultant Anaesthetists) who tirelessly kept the list running with unwaveringly effective spinal anaesthesia.

 Atiq, Steve, Sahjaad, Richard, outside Bewal International Hospital

Healthcare in Pakistan can be poor, with limited access to good quality services, particularly in rural areas. Most treatment is not free of charge, and so healthcare inequality is significant and the burden of simple treatable pathology vast. The hospital was built in 2010 with money raised in the UK to support a secondary care facility for Bewal, a small town of 300,000 people, 50 miles south of Islamabad. In the months prior to our arrival, we advertised the hernia camp, and patients presented from the surrounding area, were seen and worked up by the hosptials’ resident medical officers in preparation for our arrival.

We set aside 4 days for our 3 surgeons to work into the evening and through the repair of 76 patients with 81 hernias. Hernias included epigastric, paraumbilical, inguinal, femoral, paediatric (inguinal) and one or two recurrent hernias. Almost all of the cases were performed under spinal anaesthesia, apart from the epigastric and paediatric hernias whom had general anaesthesia. To add to the variety, as we were leaving after a long day of operating, we were met at the entrance with a young patient with a bleeding AV fistula. Duty bound, we took the girl to theatre, explored her wound and salvaged her newly formed vascular access. Everyone left with an eve n warmer feeling than the previous days had given us, although significant more tired!

Steve Operating with the hospital’s OPD

Khaleeq assisting Sahjaad perform a spinal anesthetic

The hospital staff who worked with us all week were tirelessly supportive. The scrub team showed unbelievable levels of dedication and hard work: cleaning theatres, sterilising equipment, recovering and discharging patients, time and time again. Without their support, we could not have repaired one, let alone efficiently repaired all 81 hernias. We were also lucky to be visited by several local surgical residents who scrubbed-in and lent a hand.

 The team at the end of the day, still with plenty of food remaining!

The visiting team were hosted like royalty in a new, beautiful, family house across the other side of the town from thehospital. We were spoilt and never left hungry with an abundance of authentic Pakistani cuisine, laid on my an excellent inhouse chef, and visited frequently by friends and family, keeping us going during the working day.Atiq and Khaleeq were kind enough to show the visiting team around Bewal and onto Islamabad. We were welcomed into the local secondary school to observe ‘presentation day’, and were invited to give speeches. We were also received by the local MP for and treated to even more impressive food. Islamabad is a striking new settlement overlooked by the rolling Margalla hills. We spent lunchtime on the last day admiring the views, before rounding off the trip by visiting Rawal lake, the Pakistan monument and Faisal Mosque; the fourth largest mosque in the world.

 A view of Islamabad from the Margalla Hills

Atiq giving a speech to the local school.

Sahjaad, Richard, Atiq and Khaleeq at the Faisal Mosque in Islamabad

 This hernia international mission has proven itself again to be a thoroughly successful endeavour, with a tally of 374 hernias repaired since 2014. The team in Bewal, along with Atiq and Khaleeq have the wheels well-oiled to ensure that many of the local residents have a chance at receiving free, life-changing, safe surgery. From my perspective, this opportunity has been incredible, combining the hugely rewarding experience of contributing to the teams’ achievement of fixing 81 hernias with a thoroughly memorable and privileged tour of Pakistan, the likes of which is not afforded to the average tourist.

REPORT UGANDA Campaign 2019 (16/22 -3-19)

HOLY INNOCENT HEALTH CENTRE, KAMUTUR. Bukedea

Spanish Team, Hernia International.

 Team leader: Enrique Navarrete

Team:

Surgeons: Enrique Navarrete, Pilar Concejo, Cristina Gonçalves, Kiko Marsal

Anaesthetist: Mar Felipe, Meritxell Ojer

Nurses: Emma Dueñas, Isabel Rodriguez, Mayte Huertas

Once more we returned to the Holy Innocent Health Centre; After our mission jointly with Surgeons in Action, in December 2017, our Team organizes with Hernia International a week of cooperation in this “Rural -Based Hospital” founded in 2014 by Moses Aisia and located in the rural village of Kamutur, Bukedea Region in Uganda.

On the 2017 trip, we arrived at the centre in the early hours of the morning after a very long journey, so this time we wanted to spend the night in a hotel near Entebbe airport, and start the last 270 km lap on Sunday. However, Moses preferred the group to continue the trip once passport and customs had been cleared.At 2:30 p.m., we started with our well-travelled van to the HIHC and arrived, with no incidents, around 12pm at hospital, similar to the 2017 trip, very late and very tired. We stopped to eat chicken legs and fried bananas.

For my colleagues it was the first visit to the centre, and for me the second visit to Kamutur.The distribution of the group was different from the previous visit, with part of the Team staying in one of the huts and the rest in rooms in one of the pavilions at the centre. On Sunday 16.3.19 a 6. Am the team began the day at sunrise, going to get water at the well in order to have an “African shower” (shower cube). The well is manual and supplies water to the community.

After breakfast, we started the day organizing the operating theatre in the new pavilion that Moses had built, and which was to be the place where we would spend most of the day during that week. Likewise, the four surgeons began the pre-operative visit of more than 50 patients who came to be examined and assessed or surgery. That same Sunday, Moses had decided that we should start, and after lunch we started the task at the operating theatre finishing the day after 8 pm in the evening. Tired and contented we enjoyed the first dinner at the HIHC.

From Sunday March 16 until Friday at 12 o’clock had operated on a total of 80 patients, mostly with inguinal hernias, with more than 110 procedures.

Prior to the work in the operating theatre, two of the surgeons had visited the outpatient clinic and the other two with the help of one of the nurses had visited the patients who had been operated on the day before to evaluate the postoperative procedure and discharge from hospital.Most of the patients stayed the night and left on the day after they were operated; on only tree patients needed more days of admission, for wound care and intravenous medication. A child with a serious recurrent testicle problem and two adults, one with a large ventral hernia and a another that needed amputation of the first toe for an infectious process with osteomyelitis.

On Thursday night, Moses prepared a “surprise party” with music, buffet and could drinks (it was not usual to have could water or beverages the rest of the week), All the collaborators during that week participated in this gathering including the cooks that were in charge of preparing our meals every days and those of the rest of the staff.

On Friday we programmed the operating room until noon and then started our trip to Entebbe, where we had booked a hotel near the International Airport on Friday, to start our return home on Saturday morning.  The whole group is very pleased with the work we did at HIHC during that mission. We left a lot of surgical material like sutures, meshes, pain-killers, and antibiotics at the Centre for the future missions to use.

Kiko Marsal

Surgeon

REPORT OF TANZANIA CAMPAIGN

23 February-3 March 2019

   Leader team: Eduardo Perea

General surgeons: Manuel Bustos Jiménez , Eduardo Perea del Pozo, Abdul Razak Munchef , Ana Sennet Boza (R5).

Anesthetists: Inmaculada Benítez Linero, Guiomar Fernández Castellano.

Nurses: María del Mar Martínez Gómez, Inés Sánchez Rey

We have found a center very different from last year and in my personal experience also different from the previous campaigns. We have worked in the two centers where Sister Avelina works, being very well received and welcomed at all times.

– We have been quoted by 20 children who have not operated because they do not have anesthetic tools or a pediatric surgeon to ensure an experienced technique.
– The operated goiters (5) have gone without complications and we have all been able to perform a hemithyroidectomy to avoid substitution treatment.

– the major pathology is the hydrocele with a lower percentage of hernias
– Sister Avelina operates daily in the center, therefore the patients recruited were less and with less advanced pathology (large number of hernias M1 and L1 of the class EHS)
– The hospital consists of operating room infirmary, therefore with a nurse who came with us it would have been enough.

On the other hand, the group has worked at the rate you already know, operating 8 to 14 patients a day with a hematoma as the only complication. We have learned from previous campaigns and I believe that having experienced staff has avoided problems and we have improved over last year. It is not up to me to assess my work as the leader of this mission, but the performance of the group in general has been outstanding.

The economic  effort has been somewhat higher, the lodging was not included as in Benin, the tickets and transportation has been more expensive and we have not been able to count on the help of Surgeons in Action or other external aid.

Another issue, however minor, has been media coverage. The mission has been supported by the Virgen del Rocío Hospital and the activity has been published on the networks of the same and those of the Association through Bea with whom he spoke daily.

We have many things to improve, Teresa and Andrew, but overall we are very happy with the people we have been able to help. Hopefully we can see each other soon, meet and prepare new projects together as well as outline the mission of the coming year.

Thanks for the opportunity to collaborate with you. Thanks to you.

EDUARDO DEL POZO

2019 REPORT LIBERIA

MEMORY OF THE MISSION HELD BY “CIRUJANOS EN ACCIÓN” FROM 26/01/2019 TO 02/02/2019 IN THE ESTHER AND JERELINE MEDICAL CENTER OF GANTA CITY (LIBERIA)

This is the second mission I have directed in Ganta City (Liberia) in less than a year and it started at the same moment we came out from there in April 2010 after the first successful one.

We left out many patients without operation, we were very well treated and besides we were left with the thorn that we could not operate women in Liberia with a pathology that is endemic there, the gigantic goiter. From the beginning it was a formidable challenge. The expedition was finally made up by 7 members: Cesar Ramirez (surgeon and team coordinator), Oscar Cano (surgeon), Marta Jimenez (lady surgeon), José Miguel Moran (paedriatic surgeon), Sonia Trabanco (anaesthetist) and Paco Gomez (infirmarian). We started each from his or her city on 26 January (Málaga, Santander, Badajoz, Barcelona, Gran Canaria and Madrid) and we met at the Casablanca airport to take the Air Maroc flight of 23 hours towards Monrovia. After 4 hours flight in a commercial plane with a horrible heat, we arrived at Monrovia at 2.25 a.m. where the Medical Director of the Esther and Jereline Medical Center and alma mater of the local mission, my friend Dr. Peter George, and the main authorities of that center were waiting for us; the Monrovia airport has not changed at all in 9 months, it is as miserable and lacking in security and luggage control, with only one customs gate which works with great leisure. In this campaign we have again had trouble with our luggage (15 bags of 25 Kg each from Málaga including a generator for the electric scalpel and a Ligasure lent, respectively, by Teleflex and Medtronic) and the help received by the from the earth staff in the Málaga airport has been miserable without any understanding of what we were doing and having to pay almost 500 euros for excess luggage to be able to take everything. It is intolerable that they tell you that you have a limit because the plain is small, and then, when you pay, the limit has ceased to exist. 

The way from Monrovia to Ganta City takes almost 3 hours and a half on a rudimentary byroad, and we were on 3 miserable lorries that Dr. George rents for us during all our stay in Liberia. Our place in Ganta City has again been Jackie´s Guest House, the hostal-pension in which we had individual rooms at the price of 50 euros each including breakfast: it is the best in the city and we have hot water, aircondition and one meal of the type “tex-mex”, more than acceptable, which we get for breakfast and super “in situ” and is taken to the E&J Medical Centre at the noon meal time.

There is absolutely nothing to see in Ganta City and no possibility of excursions to places of tourist interest, and so our days were very intense and much repeated. Every morning we met at 7.30 a.m. for breakfast, and half an hour later they took us to the Medical Centre.

The first day there was a large amount of patients waiting for us, about 400 persons who had been recruited the previous days by Dr. George and his E&J-MC, children and adults, and particularly a great amount of cases (almost women) of giant deforming goiter. I had promised them that if they managed to get a working respirator for goiter surgery, we would daily operate tiroidectomies in one of the operating theatres.

Every day one of the surgeons and the pediatric surgeon had at our disposal a small room for consults where we saw the patients, explored them and selected them for surgery. We have not asked for a single preoperatory and patients (children and adults) have been operated upon after clinical evaluation.

The E&J-MC is something similar to what in Spain could be a small ambulatory in which there are two operation theaters with very basic sterility conditions and they arranged two small patients rooms to use as third and fourth operation theaters, so that during a good part of each day we were busy simultaneously in four operation rooms; we were given only one electric scalpel and it was used for children, so that thyroids have been operated upon with Ligasure, and in the two operation theaters in which we operated hernias there were no lights in the ceiling and no electric scalpel, so that we had to operate with the frontal Photophore and in the dark with cold scalpel, ligature and dissecting scissors.

They have practically no material since in the medical centre they only had cesareans, although they are beginning to do some urgent surgery in urgent cases like acute appendicitis. We have taken with us 3 complete sets of surgical material to operate hernias and one for pediatric surgery which we have gifted to the EandJ-MC after the end of the mission; similarly we have used in full the more than 400 Kg of surgical material we had brought since they hardly have any gloves, gauzes, compresses, antiseptics, sterile gowns, sterile camps or apposites (in fact, since our coming they have used our material for their surgical needs). Similarly we had taken with us and donated more than 200 boxes of omeprazole, paracetramole and analgesics for them to use in Ganta City.

During the mission we operated upon a total of 186 patients (45 children and 141 adults) in which we carried out 268 surgical processes; in this way in 74 patients (almost 40%) we carried out 2 or 3 surgical procedures. We were surprised at the great amount of patients with inguinal hernia who had umbilical hernias of at least 1.5-2 cm, and even more as their largest part they were young patients, thin and with apparently good mussels. We have used 80 mosquito nets donated by Hernia International and about 100 nets of low molecular weight which had been donated by BBraun; even so there were more than needed. One of the aspects more remarkable in this mission is that we operated upon 35 total tiroidectomies with giant goiter, and only in one case has a reoperation been needed for disnea in relation with paresia/paralysis immediately recurring, so that the patient could leave without problems after the traqueostomy. We have not had any striking postoperatory hipocalcemia, and we had brought 18000 LT4 tablets which we left with Dr. George so that they can give alternative treatment to patients operated upon in the next year and a half. The patients remained for a night (the hospital some common rooms of 3-4 patients and then a large common ward for men and another for women where at least 20 patients could be accommodated in each) and we examine them at the beginning of each day so that they could be admitted and no problem remains. A patient operated upon for an epigastrical hernia showed a sharp neurological during the operation, had a heart-lung stop and died during the operation. 3 patients have shown minor postoperatory scrotal hematomas which have not needed any special care. Dr. George explicitly asked us to carry out two urgent operations for an ileal perforation and an obstetric hysterectomy for a postpartum atony with massive bleeding, both with a favorable postoperatorion.

The medical and administrative authorities of the E&J Medical Center have given us all possible facilities. We have received, as in the prior occasion, all kind of help and they have tried to make us as comfortable as possible. On the day we came just as in the day we departed they greeted us with local songs and prayers from the local people, and as a sign of thanksgiving they gave us cloths with tribal motives which we’ll keep with much love. They have urged us to come back as soon as possible as there is much need, abd for us it has surely been an unforgettable mission.

NOTE: We thank the Teleflex, Medtronic and BBraun for their contribution to the campaign.

Fr. Cesar Ramirez