Author: akingsnorth

TANZANIA    2 0 2 2

Hernia International Foundation

Slovenian-Austrian-Swiss (Liechtenstein) Team Mission

Malya, Tanzania March 20^th-26^th 2022

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Malya Village with its Health Center (MHC) was host for a Hernia International (HI) mission for the first time in its history. The reason for the mission was Dr James Marco, a skilful and ambitious surgical resident, who was inspired by HI-charisma after visiting the village of Momella during our 2019 mission.

The week-end travel from our homes to Malya HC took us 32 hours and even 42 hours for some of us.  Three consecutive flights from Vienna (Zürich) to Doha, Kilimanjaro (Arusha) and an internal flight to Lake Victoria (Mwanza) were followed by an almost 3-hour jeep ride from Mwanza to MHC. Unfortunately we had to fly without our experienced anaesthetist Dr. Michael Wirnsperger, who was Covid-19 positive some days before departure.

Our team consisted of 5 members:  2 surgeons, 1 radiologist, 1 scrub nurse and  1 nurse anaesthetist. Additionally, surgical consultant Dr. Avelina Temba, Rev. sister of our Lady of Usambara from Korogwe joined us for two days and her presence enabled us to import medical equipment without notable delay. It should be emphasized that every HI-team travelling to Tanzania in the future should apply for importation of ALL medical devices and drugs at the TMDA website online at least 3 months before the mission to avoid serious bureaucractic issues at the airport.  We imported 205 kg of equipment and drugs in 12 bags. No additional fee for excess luggage was payed at the Zürich airport thanks to Manuelas’ negotiation skills and her past Red Cross connections.

Checking patients for surgery was the first task on Sunday evening and Monday morning. As MHC is a village, far away from civilization, patients came every single day after they were informed via posters, local radio and social media. Every single day, there were just enough patients for 1 day, not too many, not too few. The youngest patient was 1 month old, the oldest had 90 years.

The turnover of the patients was fluent. We were not used to taking a lunch break, but biscuits, water and delicious cashew nuts were sufficient between operations. Besides performing operations on hernias (numerous recurrent and scrotal), assisting the local doctors and nurses was high on our priority list. We took time to do this as education and teaching might be of at least as much importance as performing the operation itself. Local doctors (Dr Temba, Dr James Marco and Dr Mchemba) became more independent and self-confident under our supervision.

Parallel operations on 2 tables, including suspending hernia operations to give precedence for Cesarean sections (performed by local doctors), enabled 46 procedures on 38 patients in 4,5 days.

Dr Rems (experienced consultant, past chief surgeon and hospital director) and I were happy to see grateful patients and improved surgical technique of local surgeons. Wolfgang, a skilled nurse anaesthetist from Feldkirch, Austria was completely souverain in performing general anaesthesia in patients of all ages and built a trustful team with the anaesthesia staff at Malya HC (medical officers William and Mathias). For our scrub nurse Manuela from Lichtenstein, this was the 4^th international mission, after serving in Cameroon and on Red Cross combat missions to Syria and Bangladesh several ears before. Once again, the presence of an experienced radiologist turned out to be a reasonable decision. Marija performed 41 US-exams, including in OB-GYN and on our surgical patients pre- and sometimes postoperatively. Due to the high mean age of patients after inguinal hernia repair under spinal anaesthesia, US check on evenings post operatively was a routine in elderly patients (average age of adult inguinal hernia patients was 58 years). Due to untreated benign prostatic hypertrophy in some of these patients, unrecognized urine retention post spinal anaesthesia might be an  underestimated but serious issue in commonly forbearing and compliant patients. In these cases we performed urinary catheterization and gave adviced on further management.  

Good work in the hospital was also possible because we were accommodated well in the christian MMCT Guest House (bed, breakfast and dinner). Malya HC might not be able host additional hernia missions in the near future, as Dr James Marco is moving to the Ngudu District Hospital, 33 km away. But a visit of the surgical chief of staff Dr Misana from that hospital  brought us a new invitation. They have great need and abundancy of patients. Mesh surgery is not performed in that remote part of Africa at all, compared to hospitals and health centers of our last missions (Korogwe, Arusha).

Among 38 patients (with 46 procedures), we operated on 5 children (13%) and 33 adults (87%). 7 patiens (18%) were female. The most frequent diagnosis was inguinal hernia (29 pts, 76%), followed by Jabouley`s procedure for hydrocaele (8 pts, 21%). In inguinal hernias in children, Mitchell-Banks repair and in teenagers and young adults a 4-layer Shouldice procedure was performed;  Lichtenstein repair with LDPE mesh was performed in theevast majority of patients with inguinal hernia. In incisional ventral hernias, the sublay procedure was the method of choice. We performed 1 orchidectomy in a patient with a giant hydrocaele and testicular atrophy. Other diagnoses/operations were for acute appendicitis, mastitis in a newborn (extremely rare according to published data), abscesses, undescended testicle, benign breast lesions and skin tumors. We placed suction, corrugated or Penrose drains after almost all operations on big incisional and scrotal hernias, and some hydrocaeles. Our anaesthesia team also helped in Cesarean section.

In OT 1 (good lights, we brought diathermy), mainly general anaesthesia was performed, while procedures in OT2 (no surgical lights, without diathermy) we used spinal and local anaesthesia.

We felt privileged for having no complications (minor or major) which we attribute to a not overcrowded programme. Again, we took enough time for every single procedure, without any hurrying. Good working and a friendship-building atmosphere was a result of mission preparation several months before, not to mention sister Avelinas attitude and prayers throughout the mission as an additional factor.

Team Members:

Dr Miran Rems – consultant surgeon, Jesenice, Slovenia

Dr Jurij Gorjanc – consultant surgeon, team leader, Austria & Slovenia

Dr Marija Jekovec – consultant radiologist, Ljubljana, Slovenia

Manuela Logan – scrub nurse, Grabs, Switzerland & Lichtenstein

Wolfgang Walser – anaesthesia nurse, Feldkirch, Austria

Our sponsors:

Medical Center Gorjanc

Implantoloski institut / Implant Institute

Hospital of St. John of God St. Veit/Glan

Krankenhaus St. Vinzenz Zams

LKH Feldkirch

Spital Grabs

Kirurgija Bitenc University Medical Centre Ljubljana

The first joint mission of the Surgeons in Action and Hernia International Foundations following the Covid-19 pandemic has been carried out in Bopolu City, a small Liberian inland town of 3200 inhabitants located in Gbarpolu County, home to approximately 90,000 people. It is the first campaign to be conducted in this destination, and the reason is that this is where Dr. Peter George is now working.

Peter George has been the collaborating doctor of our two foundations for many years and is now the head and medical director of Jallahlone Hospital, the reference health centre for the whole county. This is my third campaign in Liberia that I have coordinated with him, and he has always shown great organisational skills and leadership in his country.

The preparation of the campaign has been very complicated since it was suspended on two occasions as a result of the spread of the Covid pandemic and the restrictions on entry to Liberia even for people from countries with a high vaccination rate and the possibility of carrying out routine diagnostic tests for active infection such as PCR or antigenic tests. On two previous occasions in 2020 and 2021, the campaign was postponed when everything was organised and the plane tickets had been bought, which is why it has meant a great financial, moral and resilience effort on the part of the team members.The team members were three surgeons (César Ramírez, Pablo Muriel and Sarai Ayllón), two anaesthetists (Sandra Casares and Beatriz Fort) and three nurses (Francisco Gómez, Rebeca Sanabria and Julia Cáceres), and we all received authorisation from Dr. Peter George from the Medical and Dental Council of Liberia to practice since our professional documentation was sent electronically. The initial expedition included a fourth surgeon, Marta Roldón from Málaga, who was unable to travel due to a positive PCR test the day before departure.

The departure of all the team members was on Thursday 20th January in the afternoon and we met in the evening in Madrid; Pablo and Beatriz left from Barcelona, Sandra was in Madrid and the rest of the team members from Malaga. The trip was made with Air France (Air Marocq has stopped operating flights to Liberia in the pandemic) and started in the early hours of Friday 21st with the Madrid – Paris flight at 6 a.m. and from Paris we left on Friday 21st at 12.25 p.m. to arrive in Monrovia at Roberts International Airport at 8.25 p.m. on a direct flight. As part of the security protocols we followed in order to get to Liberia, all team members travelled with a certificate of having received three doses of messenger RNA vaccine and a certificate of a negative PCR test carried out at least 48 hours before departure to Paris. Each team member was required to pay $150 for diagnostic tests for active infection on arrival in Monrovia and on departure, and these tests were carried out by airport health staff on arrival and by the laboratory manager at Jallahlone Hospital in Bopolu three days before our departure from Liberia, both of which were rapid antigen tests.Once we had passed the Covid health checkpoint at the airport, Dr. Peter George was waiting for us at the baggage claim (as he always does) to facilitate the logistics of transporting the 23 pieces (over 500 kg) of equipment we had brought, for which we had to pay an excess of 1200 Euros at the airport in Madrid. Since it was after 10 p.m. on the 21st upon our arrival, that night we slept at The Blue Lagoon in Monrovia, an acceptable hotel with a swimming pool available and which is a frequent place for the Liberian middle class. On the morning of the 22nd we left Monrovia for Bopolu, a drive of almost 5 hours to complete a little over 90 km on a road that is terribly bad, full of potholes, rocks and that becomes unbearable at times. We arrived in Bopolu City at 3 o’clock in the afternoon and were welcomed with a big party by the women’s association of the city. There is an important feeling of protection of the role of women and they are looking for a situation of equality that does not yet exist in Liberia, a country where the structure is still very patriarchal. After a warm presentation at the hospital by the health and administrative authorities, we unpacked all the material and placed it in the hospital facilities and then went to our place of residence to take possession of the rooms and carry our suitcases.

Jallahlone Hospital is a medical-surgical centre with the typical structure of small Liberian hospitals located outside the capital, in the style of the one we knew in Ganta City (E&J Medical Center).

It has an operating theatre equipped with a ventilator in which interventions can be performed under general anaesthesia; the usual activity of this operating theatre outside the campaigns are caesarean sections but also herniorrhaphy (I don’t know how often), hence the large number of reproduced inguinal hernias that have been operated on in this campaign, easily identifiable by the type of incision and because they did not have mesh in place.

There is a hospital ward for men, another for women, another for children and a fourth, a maternity area. The second physical space that we have set up as an operating theatre has been a regular medical care room in which we have placed two stretchers for transferring patients who are somewhat unstable, but which have been used to operate on hernias and major outpatient surgery. In the operating theatres there is only one electric scalpel which works irregularly; we have brought two from Spain and we have given one as a gift to stay there in the Hospital. In the main operating theatre there is no air-conditioning but there is a ceiling light that works acceptably from 10 a.m. onwards, which often goes out and is interrupted; in the other room there is air-conditioning, which makes it more bearable, but there is no light and it is essential for the surgeon and assistant to use headlamps.

There is no wifi network in the hospital or in the whole region, and in order to connect to it we had to buy a router at the airport, which had to be progressively recharged during our stay.The accommodation site was about 300 metres from the hospital and is a building that is not used regularly (there are no visitors or tourists there) and has about 25-30 rooms equipped with a bed (with mosquito netting but with a base of boards that acts as a bed base and usually breaks), a bedside table, a fan and a bathroom that has no electricity or running water (there is a large bucket of about 100 litres from which water is drawn with a ladle to take a shower and clean the toilet for daily needs). The stench is unbearable in the bathroom as the drains run under the shower tray. The food as always in

Liberia is quite acceptable, and Peter makes sure that we always have fresh fruit (pineapple and papaya very tasty), vegetables (especially tomato and cucumber) and a diet based on rice and fried chicken every day. We supplemented each day with cold meats of all kinds, cheese, piquitos and olive oil which gave us a lot of comfort. Every night we had cold beer and carbonated drinks of all kinds in our accommodation, where dinner was brought to us. Similarly, we had a fridge at the Hospital in Dr. George’s office which was always stocked with water and soft drinks to compensate for sweat and exertion losses. Every day we were picked up by two vans at 7 a.m. and taken to a small room 50 metres from the Hospital where we were served breakfast and by 8 a.m. we were at the Hospital every day.

The working day was quite organised and each day we had 20-30 patients there who we saw little by little and filtered to indicate the surgeries for the following day, taking advantage of the time between one surgery finishing and another starting. The working days were interrupted by a 30-45 minute lunch break in Dr. George’s office and then lasted until about 10.30-11pm. Each day early in the morning we would visit the inpatients to assess for postoperative complications and discharge them.

A total of 7 and a half days of work, including from Sunday 23 January at 8 a.m. until Sunday 30 January at 3 p.m., were spent. A total of 152 patients were operated on

185 surgical procedures were performed, which can be grouped as follows: 109 inguinal hernioplasties (15% bilateral and another 15% reproduced); 20 umbilical / epigastric hernioplasties; three large eventrations, two of which were associated with abdominoplasty; nine giant goitres in which five total and four subtotal thyroidectomies were performed;

Tthree splenectomies for giant splenomegalies; ten hydroceles; five cryptorchidectomies; one orchidectomy for neoplastic neoplasia; one orchidectomy for neoplastic neoplasia; and one orchidectomy for testicular neoplasia; one radical hysterectomy and double anexectomy for giant ovarian neoplasia; one radical right nephrectomy for a 25 cm tumour dependent on the right kidney; two cord cysts; 21 minor surgeries under local anaesthesia (lipomas, sebaceous cysts, granulomas and keloids); and one hygienic surgery for the removal of a very advanced acral melanoma.

The only major complication recorded was the need to perform a temporary tracheostomy on a patient with postoperative disnoea due to paresis of both vocal cords (both recurrent nerves had been preserved and there is an imaging record). In all other surgeries we had no major or minor complications recorded. The two surgeons at Jallahlone Hospital (Dr. Dahrly and Dr. Dwanna) actively participated in the vast majority of the surgical procedures as assistants and we tried to explain as much technical knowledge as possible. The cooperation of the nursing staff, anaesthesia assistants and anaesthesia technicians at the hospital was excellent and made us feel very comfortable.

During our stay we were greeted by the major of the county of Gbarpolu and we had an audience with the senator of Bopolu, who thanked us for our presence as this was the first international team they had received and made me realise that Peter George is a very well positioned person in the eyes of the authorities and a reference point for health in the region. I would like to point out that with the sponsorship of the United Arab Emirates, a large hospital is being built in Bopolu, which is well advanced and has all kinds of services, more comfort, more space and more operating theatres. Those responsible for the work, who are Lebanese, have been very kind to us and have invited us to have lunch one day in their facilities.

To sum up, Jallahlone Hospital is a perfectly prepared site for surgical campaigns and Peter George is an influential person, with great influence among his people and great organisational skills. It is to be hoped that many more missions can be held in Bopolu in the future, especially when the new hospital is completed. Overall, it has been a very hard mission from a physical and working conditions point of view, but all members of the team have been very satisfied and satisfied with the work done and the results. The average cost per volunteer was almost 2000 Euros per person, including flights, transport by car in Liberia, food and accommodation.

The death of Dr RR Tongaonkar, renowned rural surgeon and prime protagonist for the use of mosquito net for inguinal hernia repair, occurred tragically on 7^th September due to COVID-19.

Rising from humble origins in rural India, Ravi graduated from the prestigious BJ Medical College, Mumbai with record Merit scores and chose Surgery for his career. He decided to settle in his birthplace of Dondaicha, Maharashtra State, which in the late 1960s was a small town of 17,000 population, 150km from the nearest District hospital. Two buses a day stopped in the town and there was a railway halt on the line to Pune. Local transport was by bullock cart. During the next 50 years, the population tripled and Ravi established a thriving Clinic (some say a “Mayo Clinic”) providing humane and affordable (free for the indigent) care to the community. A chance meeting with a surgeon using mosquito net for hernia repair, inspired Ravi to take up this techniaue and instigate its global promotion, which will be his lasting legacy.

Born on 17^th November 1939, Ravi’s early life was strongly influenced by both his Father, a Freedom Fighter (who on 15^th August 1947 had the honour of bringing down the British Union flag on the Collector’s Office in Dhule, and hoisting India’s tricolour) and Mother (a teacher) who inculcated a selfless sense of duty. Their Mother tongue was Marathi and Ravi was not schooled in English until his arrival at Medical College. After paying for his food and lodgings, he had so little money that he wrote lecture notes on pieces of waste paper he had stitched together. With similar determination to succeed he stood first in every MB BS exam and his postgraduate MS. Shortly after these significant achievements his parents arranged for his marriage to Asha. He later related that their first meeting to discuss their future, took place in a railway canteen. Following the wedding (after which the procession took place in a bullock cart), Ravi declined the offer of the post of lecturer (with an assured path to Professor of Surgery) and decided that he and Asha (at the time a medical house officer) would establish a practice in Dondaicha.

Appropriate accommodation for the clinic was in short supply, but eventually they settled in an old Swedish missionary’s bungalow which had five rooms suitable for development as a medical centre. From Day 1 the practice was hectic and involved a huge burden of medical ailments as well as surgical operations. Work continued until 8 or 9 o’clock at night, six days a week, relentlessly. In his acclaimed book “Making of a Rural Surgeon: An Autobiography” Ravi describes in vivid detail the trials and rewards of these days as he brought the practice into the 21^st century with modern equipment and medical supplies. He and Asha developed radiographic skills, Asha trained in anaesthesia and created a basic diagnostic laboratory. In 1986 Ravi attended a laparoscopic course arranged by the Indian Association of Gynaecological Endoscopists and introduced diagnostic laparoscopy to his practice. He taught himself TransUrethral Resection of the Prostrate on a potato model. His resourcefulness and eagerness to be at the cutting edge of surgery was enormous.

It was in 1986 that at a chance meeting with Dr Brahma Reddy from Kurnool, at a workshop in Hyderabad, Ravi was given the chance to pursue a project which required all his intelligence, tenacity and academic brilliance – the use of mosquito net for inguinal hernia repair. His seminal publication in 2003 in the Indian Journal of Surgery reported over 300 cases meticulously followed with excellent results. Many other publications have followed.

Global recognition occurred in 2009 at the European Hernia Society meeting in Berlin.

The pinnacle of success was receipt of an Innovation Award at the World Innovation Summit on Health in Doha in 2013.

At a recent international conference Ravi is quoted as saying “Since the year 2000 at a modest estimate, till today around 35,000 hernia surgeries were performed across the world using mosquito net mesh”. Hernia International contributes about 2000 of these cases annually.

In recognition of his excellence in Rural Surgery, Ravi has been President of the International Federation of Rural Surgeons and President of the Association of Rural Surgeons of India.

In 2012 I visited Ravi’s hospital in Dondaicha and operated with him. I will remember him as a lively, warm and noble human being whose priority was the well-being of the members of his community.

Andrew Kingsnorth

Director, Hernia International

Team members:

Surgeons:                    Trent Cross (Team leader)            Australia

                                    Mohan Jayasundera                Australia

                                    Hans Moser                            Germany        

                                    Jurgen Meyer                          Germany

                                    Markus Heiss                          Germany

Anaesthetist:   Peter Schuller                         Australia

Hernia International mission to Mongolia May 2015

This mission to Mongolia was a two part mission, with great contrasts in facilities and case mix. In the first week Trent, Hans, Jurgen and I travelled to Bayankhongor airmag, a rural centre around 15 hours drive from Ulaanbaatar. The second week was based at the Second General Hospital in central Ulaanbaatar, where we were joined by Markus who replaced Jurgen. The whole mission was co-ordinated by Enkhee, who not only provided all logistics support, but came with us on our long trip to Bayankhongor airmag, and ably helped us throughout the varied and challenging mission.

Bayankhongor is the administrative capital of the airmag (province), serving a population of 80,000 many of whom are rural herders. Although the distance from Ulaanbataar is around 700km, the journey across the empty steppe took over 15hours, arriving at around 2am.

However, the country side was beautiful in its barrenness, with the winter snows still melting on the grass steppe.

The local Hospital administrator and provincial governor both went to extreme lengths of hospitality to make us feel welcome. Some of the highlights include: a full traditional Mongolian concert performance in the concert hall, performed specially for the Hernia International team; Accommodation provided for us at the local hotel; Visits to the local Natural History Museum which specialised in the regional Gobi Desert flora and fauna; A grand dinner provided by the provincial governor in his private restaurant; and after our last day at the hospital, a huge traditional Mongolian feast in a yurt with the obligatory vodka toasts.

In the hospital we were provided with two operating theatres and divided the cases between the German and Australian teams.

The local surgeons were very keen to learn, and by the end of our week were performing most of the operations with our guidance.

As well as adult hernias, there was a large volume of paediatric cases, including many redo hernia operations and orchidopexies. The incidence of cryptorchidism seemed to be very high, perhaps due to the extreme cold endured over the winter! We were continually amazed at the stoicism and bravery of the local children.

Every lunchtime we were provided by an amazing assortment of different traditional Mongolian fare provided by the hospital kitchens. At the end of the week we were all fluent in the Mongolian and Russian terms for the surgical instruments and other important vocabulary!

After this busy first week, where we were humbled by the hospitality of our local hosts, we headed back to Ulaanbataar. Trent and Jurgen returned early, with Trent and Markus to present at the First Mongolian Congress of laparoscopic and endoscopic surgery. The remaining team members took a detour, visiting the Shargaljuut Sanatorium. This involved a 3 hour drive across the steppe on dirt four wheel drive tracks through pristine rural country side. The emptiness was punctuated by local herders and their yurts. We were lucky enough to visit one, as one of the herdsman was a relative of the driver, and were allowed to ride his horse and sample the traditional fermented cheese. The Sanatorium was definitely an eye opening experience, based around various hot springs which were used to treat an assortment of illnesses.

The second week at the Second General Hospital was a contrast in facilities and cases. The Hospital had been visited by previous operation hernia teams, and were particularly keen to learn more advanced techniques. Several laparoscopic inguinal hernia repairs were performed (both TAP and TEP), a giant parastomal hernia repaired demonstrating the Sugarbaker technique, as well as a wide variety of adult hernias. We were ably led by our team leader throughout this mission, which was definitely full of excitement and action!

Mohan Jayasundera

Report of the mission in Ganta City (Liberia) from 8.-15. Feb. 2020

The team consisted of 3 members: Leo Mitteregger from Austria (general surgeon and team leader), Fernando de Santiago Urquijo from Spain (general surgeon) and Christine Kirchberger from Austria (scrub nurse).

The mission was planned several months ahead. For Christine it was the first visit in Africa. We met at Brussels airport and arrived together at the airport in Monrovia at Friday, Feb 7th in the evening. We were picked up by the medical director of E.&J. Medical Center, Dr. George, and his driver. We did not have any problems with our extensive luggage at the customs. We brought appr. 100kg additional luggage because of many useful medical items. The trip to Ganta took almost 5 hours directly to Jackie’s guest house where we had our lodging and our meals (breakfast and dinner).

Next morning, Saturday, 8th Feb., we had a welcome celebration in the waiting hall of the hospital. Afterwards we checked some patients and selected them for surgery. There were so many patients so that we started in the afternoon right away using two theatres – one for adults, one for children.

Till Feb. 14th we operated 36 children with 42 interventions and 36 adults with 40 interventions. Each child got two soft toys, one before and one after the operation. Twice we had a break because of a Cesarian section done by Dr. George himself.

Every day after finishing work we did a ward run to check the operated patients and examined the patients for the next day.

 At the end of the mission each of us had to pay 670 USD for lodging and meals for 7 days. In addition we were requested to pay 450 USD for transportation (Monrovia – Ganta – Monrovia, guest house – hospital and retour). After a short discussion we paid 300 USD (100 USD each). That’s why we would say that Liberia is rather expensive.

Nevertheless we enjoyed our mission very much and the response of the staff and of course of the patients was great and rewarding.

I think we will come back again to Africa.

Leo Mitteregger

Esther and Jereline Medical Centre, Ganta City, Liberia

November 30^th – December 8^th 2019

This was a four surgeon Hernia International Mission:

John Hobbiss, Colorectal Surgeon, UK

Mahesh Pai, Vascular Surgeon, UK

Emma Sidebotham, Paediatric Surgeon, UK

Thorbjorn Sommer, Bariatric and Colorectal Surgeon, Denmark

John and Thorbjorn had been on previous Hernia International mission, John on the first trip to Ganta City in July 2017, a first trip for Mahesh and Emma. This was Hernia International’s 7^th trip to Ganta City. We arrived together on the evening of Friday November 29^th, on a flight from Brussels, being met pre passport control by Dr George, Chief Medical Officer, Esther and Jereline Koung Medical Centre.

We spent the night in Monrovia and were driven to Ganta City next morning, arriving around midday. After lunch we proceeded to the Medical Centre. Dr George had already triaged and admitted 4 paediatric patients and having unpacked our equipment we got the mission started by operating on these that afternoon.

And that was how the mission progressed so that running four theatres, over the 7 and a bit days of operating we operated on 197 patients (plus complications detailed below and the caesarean section Torbjorn assisted with!) repairing 222 hernias, predominantly inguinal, some femoral, with occasional umbilical hernia repairs and hydrocele surgery.  

This was only possible due to the large number of patients Dr George had attracted to come for assessment and surgery by an excellent radio campaign to get the message out about the mission, even after a previous mission only two weeks before. Furthermore, Dr George saw all the patients in clinic, triaging them and admitting them to the wards, so that we were simply in theatres ready to operate, with only a handful of patients triaged for surgery that we then declined to operate on (e.g. umbilical hernias in infants). Getting started in the mornings sometimes felt slow but once we began, for the three adult theatres, the next patient was sitting on a chair outside the room ready and waiting to be examined and operated on. For the paediatric patients we did a ward round to assess and mark them then they were brought to theatre as soon as the one was sent back to the ward post op.

We had one anaesthetic technician/nurse between the four theatres, Emmanuel from Sunday to Wednesday with Abenego from Thursday to Saturday, and some input from a third nurse anaesthetist, Cyrus, who went from theatre to theatre giving spinals with great efficiency and efficacy, with occasional caudals and supplementary ketamine for the children.

The theatre staff were extremely helpful and many were excellent surgical assistants. Othello in the paediatric theatre was particularly helpful, doing a ward round with me, helping to translate and compiling lists of the patients for the day.

 There was a local surgical trainee, Wanaka, who operated for several days with Thorbjorn who was able to train her well to perform mesh hernia repairs over the course of the mission, an excellent adjunct to the performing of surgeries. In total we lost about two days of operating spread over two of the four theatres for caesarean sections and laparotomies. 

I operated on 50 children and two older teenagers but my adult colleagues humoured me and took me through 3 adult mesh hernia repairs so that I’d feel better prepared to do adult hernias if there were less children on a future mission.

We stayed in Jackie’s Guest House about 2 miles from the hospital, safe, clean air conditioned accommodation with a plentiful supply of hot water and internet access. Jackie’s has a restaurant where we ate most of our meals. It also has a small shop where we purchased drinks and snacks to take for lunch along with nuts and energy bars we had brought from home: this kept us going through the day as there was no true break for lunch and the large size of our other meals meant that we did not need more.

We left Ganta City on Sunday morning. Our flight was not till the evening so we were fortunate to meet and be entertained to lunch at the Boulevard Hotel in Monrovia, by Mr Jeremiah Koung and his associate Mr Ibrahim Hamdan, who had established the Esther and Jereline Medical Centre and donated it to the local community, giving us the opportunity to explain the purpose of our mission with Hernia International and Mr Koung to explain some of his further aspiration for improving healthcare facilities in Nimba County and throughout Liberia.

Complications:

Whilst in Ganta  we also came across complications of hernia operations performed by previous Hernia International missions and cases subsequently operated on by the local team. We operated on four such cases, two of whom had an infarcted testis. It was a stark reminder that the sort of cases that we were operating upon have the potential for serious complications

Equipment:

Esther and Jereline Medical Centre are able to provide very little equipment beyond surgical instruments. UK style disposable drapes and gowns are available for surgeries performed such as caesarean sections but are not allowed to be used for the Hernia International surgeries, to the point that we were expected to provide gloves for the staff assisting us as well as for ourselves. This inevitably requires some compromise in the gowning and draping we would perform in the UK against what is adequate for some degree of asepsis and what is feasible to bring as luggage on the mission.

Essentials:

Gloves – surgeon and assisting theatre staff

Skin Prep solutions

Sutures (we thought that we were going to run out and Dr George obtained more, which we paid for, through the local pharmacy. These were Chinese manufactured, appeared to be finer than the equivalent Ethicon sutures and expensive)

Face masks

Hats

Surgical scrubs

Local anaesthetic

–          bupiuvicaine for spinals (multi use stoppered vials best, even if these would be single use in UK)

–         Lidocaine or bupivacaine for local infiltration/LA procedures.

Drapes

Gowns

John brought many boxes on Co-amoxiclav to be given for at least the mesh hernia repairs for 48 hours post op. We understand from the theatre staff that the patients were charged for them. We had no role in them being given out as these were taken over by Dr George when we unpacked the equipment.

One theatre of the rooms we used had an operating light, head lights were essential in all other rooms. There was sometimes a wait to get the electricity running in the morning but little interruption of the lists once running.

Alcohol for hand prep is also useful. The water ran out by the end of some days.

Expenses:

This is an expensive mission compared to many in Africa. The Liberian economy currently works largely through the US Dollar. Accommodation is Western prices: we paid $60/night in Ganta, plus paying an extra night to secure the accommodation, and $75 in Monrovia. All food is in addition to this, and again at Western prices $20-30/day, we bought snacks for lunch. Transport for the week within Liberia cost $480 for the team.

There is also the expense of equipment to bring that is greater than many Hernia International projects. We paid for 16 vials of bupivacaine, more bottles of skin prep and elastoplast tape in addition to the sutures. Bringing more prep and local anaesthetic would be helpful.

Acknowledgements:

We wish to thank the following organizations for supporting this trip

Dorothy Whitney Elmhirst Trust

BMI Beaumont Hospital, Bolton

Circle Hospital, Bath

Molholm Private Hospital

Teal Laboratory Services Limited

REPORT KENYA CAMP DEC 2019

 TEAM

This first campaign of “Cirujanos en Acción”in Engineer was offered us by Hernia International and was organized in a record time of two months. In it took part experienced volunteers like José Miguel Morán Penco, paediatric surgeon in Clideba, Badajoz, the nurses PepaFornier Coronado from the Matero-infantil Hospital Clideba, Badajoz, ConcepciónVilchez Rodrigo La Fe University hospital from Valencia and Manuela Dorado Alvarez from Rio Hortega Hospital of Valladolid. 

As new members came the general surgeons of the University Hospital of Plana Vila Real (Castellón), José M Guallar Rovira and Vicente Pellicer Castell, the anaethetists Santiago Fernández Gacía of the University General Hospital of Castellón and Álvaro Becker Cárdenas of the Sagrat Cor Hospital of Barcelona, Valeria Solari, paediatric surgeon of the Sozialmedizinisches Zentrum Ost (Viene, Austria) and Antonio M Satorras Fioretti, general surgeon of the Public Hospital of Mariña, Lugo, whose hospital gave most of the medication we used.

We started on the night of December Friday6 from the Madrid airport in a flight Ethiopian Airlines with a stop at Addis Ababa, arriving at Nairobi on the morning of Saturday 7and were received by Peter Karanja, our local coordinator, who had to solve in customs at the last moment the paying of charges for importing materials and medicines.

After a travel of several hours by bus, delayed by the need of buying clothes for two members whose luggage had been stolen in Madrid or did not reach the airport, we reached the hospital at night and were received by the director of the center, Dr Junius Ntwageh.

On Sunday, after arranging the material we had brought with us, we began selecting cases. After the treatment given in the local media there chiefly came paediatric patients who were examined by us for the final selection.

 HOSPITAL

Engineer is a rural place in the Nyandarua County, two hours from Nairobi and a few kilometers South of the equator, close to the natural reserve of Aberdares. Given its altitude and the fact that it coincided with the rainy season, the presence of mosquitos was minimal, and we were told that there were no malaria cases in the whole zone.

 The Engineer County Hospital is a public centre made up by several buildings of one or two stages. In one on them was the surgical area in which we had a large operation theater where we placed two tables, and a close room with four beds, two of them monitoriced for the immediate postoperatory.

 We had two respirators that worked with Halotano, Isoflurano (supplied by the hospital as we could not get it in Spain) and nitrose oxide, as well as just one electro scalpel terminal to which were added the two we had with us. More problematic was to get tubulaters for the lactants, though they were got form another hospital.

 We also had a small place where we could carry out minor surgery interventions with local anaesthetics, and a resting place where we eat what the hospital itself sent us.

The hospital has several surgical instrumental sets which, even irregular, allow the carrying out simple surgeries like hernias or tumors of soft constitution in adult patients. For paedriatic patients we used sets we ourselves had brought.

Although the hospital does have an autoclave there has been some difficulty to sterilise the instruments quickly; many white coats and cloths were disposable and supplied by us. We also used our own gauzes the usual gauze as the usual sterilization was in containers and it took too much time.

In the center there is also a radiology and ultrasound service and we asked for some studies, as well as a laboratory that carries out a hematological study and routine hematological test of VIH in all surgical patients. It besides offers assistance in toco-ginecology, maternity and infections, and it has a pharmacy that took care of the remaining medicines at the end of the campaign.

The patients were hospitalized in several rooms of the mother-child pavilion with nurses in charge, where several rooms of four or six beds were occupied one night at list.

The collaboration of the center staff was remarkable – with one more day or work on feast days – to be able to work on a greater number of patients, particularly those of nurses Beatriz and Erasmus and Rachel, the lady superviser of the operation theater with the preparation of sterilization of material. Also, the help of Shadrak and Daniel in consultations and when having to move.

ACTIVITIES

We suddenly realized that we had not received the necessary permission from the Health Ministry that would grant us to carry out assistential activities. Even when we insisted again and again the situation continued the whole afternoon and the morning of Monday, during which we received the visit of the Ministry for Health of the County. It was only in the afternoon when the license was signed and we finally could begin the campaign.

 Besides, Thursday 12 was Jamhuri Day or Independence Day, a national feast that in which, in spite of our insistence we could only work in the morning (while we used the afternoon to visit Lake Naivasha with its hippopotamuses) and Saturday 15 at noon we finished up, so that we lost two full days for administration problems.

 Working in two – and at times three – operation theaters we treated 80 patients with a total of 96 procedures. The majority were pedriatic (42 children and 38 adults) with ages between 3 months and 86 years, and predominantly men (61 men for 19 women).

 The anaesthetics given have been general (43), regional (19) and local, with sedation (6) or without it (12).

 In paediatric patients we carried out 27 orquidopexies for not descended testicles, 14 inguinal herniotomies, 5 umblicals, 6 circuncisions, and it treated a hand retractable burn, exploration of a cervical mass and one urethral dilatation.

 In adults we carried out 15 hernioplasties (6 inguinals, 5 umbilicals, 3 epigastric and one femoral), 6hidrocelectomies, exeresis of 17 hurts in soft parts and one orquidopexia. Besides we urgently treated a cesarea and sew up a face wound.

 The larger part of patients spent one night in the postoperatory room. No significant complication appeared.

 Staying Places

The only hotel with minimal standard for our stay in the neighbourhood was the Musa Garden, with simple rooms and without real Wifi. The price of 50 euros for person and night, breakfast included seemed too much to us. Supper in their dining room with soup, rice and vegetables and meat or fish cost about 7 euros per person and night. After that the terrace was used for relaxing a while.

Meals were taken in the same operation theater in order not to lose time, with a half morning breakfast and lunch with several options (rice, vegetables of various kinds and meat).

 As it was the time of the rainy season, we suffered constant humidity, so that we could not dry up our clothes from one day to the next.

On the last night the county Gobernor offered us supper together with the authorities and workers of the hospital thanked us for the work done, gave us several gifts and insisted on our coming for more campaigns and promising to solve all administrative problems.

 There was only left now our coming to Spain on Sunday after a visit to the Nairobi National Park In order to prepare a new campaign in a hospital with instalations and staff which allowed us to work properly.

Expenses

FOR EACH VOLUNTARY

Flight tickets… 600 euros

Stay (50 euros night, 8 nights)….400 euros

Suppers (7 euros night, 7 nights)… 42 euros

Price for volunteer… 1.042 euros

TOTAL COST… 10.420 euros

RECOMENDATIONS FOR FUTURE CAMPAIGNS

Election of dates that may not coincide with local festivals (December 12), preferably during the dry season.

Previous confirmation of temporal licences.

Need to take with us at least one diathermy generator.

Need to take all the paediatric instruments and some set for grownups.

Need for paedriatical tubulaters.

Little disposal of gowns (take disposable ones).

Price of lodgings more economical.

REPORT GATUNDU CAMP KENYA- NOVEMBER 2019

SURGEONS IN ACTION IN COLLABORATION WITH

HERNIA INTERNATIONAL

INTRODUCTION

The Gatundu campaign of November 2019 was proposed by Surgeons in Action Foundation, and the same as in the rest of the campaigns it has meant a new challenge and effort during the previous months for the creation of a team of volunteers, and above all the logistic aspects as the getting of medical surgical essential for our work, as the Gatundu Hospital does not have the necessary supply. Obviously the difficulty in communication with the responsible people of the Center in order to now the number of volunteers and material resources need for the Campaign.

The economic budget was high with the expenses of the visa, flights, transport, staying and food for the team, the Surgeons in Action Foundation and a donation of the Coro Divertimento de Pamplona in collaboration with the Zuasti Club which organized a concert in order to get funds for this Campaign.

THE PLACE

Kenya, placed at the east of Africa, has a population of 51.303.010 persons. Its capital Nairobi has 3.130.000 inhabitants, and currency is the Kenyan chelin (1KES = 0’01 euros). It is a republic with many parties. The majority of its people are Christian, with 35 % Protestant and 30% Catholic, about 30% Muslim, 5% animists, with Suajili and English, apart from many tribal languages.

The PIB per capita of Kenya, good indicator of the life level, was 1.449 euros (Spain 28.156 dollars), and it is the 152 place in 192 countries,and the index for Human Develoment or IDH, which the United Nation elaborates to measure the progress of a country and the life level of its inhabitants, it is found in the 142 position, which indicates that its inhabitants have a very low life level. Gatundu is a small village in the Kiambu with 1.600.999 inhabitants, and it is placed at an hour by car in Nairobi. The first president o of Kenya, Jomo Kenyatta, was born here, and he has a stylish residence on top of a height over Gatundu, in contrast with the buildings in the city which are very precarious, most of the lodgings are very precarious, the majority of the lodgings and shops are at both sides of the main road; they are buildings of a single story with cheap roofs; the shops are distinguished by posters over their entrances and where they advertise their business, there are plenty of small shops of fruits and vegetables, then churches and schools of different kinds; in the side streets there are many little shops of fruits and vegetables, churches and schools of different creeds; in the side streets without asphalt the doors of the houses remain always open. People live with a dollar a day. Rice, vegetables and other products from the field are their food.

VOLUNTEERS

  A team of seven volunteers of the Surgeons in Action Foundation:

2 general surgeons: Dr. Manuel Cires and Dr. José Hernandez

2 paedriatic surgeons: Dr Lola Delgado and Dr. Jesús Redondo

2 anaestetists : Dr Pilar Murga and Dr. Ana Pizarro

1 nurse: Lola García

This campaign was carried out in collaboration with the British ONG Hernia International Foundation.

We brought about 200 kg of medical-surgical material in 12 great parcels with the typical bags of rafia bought in the Chinese shops. All that was collected by the volunteers in the hospitals. The Hospital directors put at our disposal a van with a driver which took us directly from the Hotel to the Hospital, besides of the shifting to the Nairobi airport.

 FOOD AND TRANSPORTATION

We were lodged at the Maxand Hotel (https://maxlandhotel.co.ke/ which is half an hour by car from Nairobi and about 20 minutes from the Gatundu hospital. It is a very safe hotel, as it is within a walled up place with entrance access controlled by safety guards. The rooms are individual with bathing room and beds with mosquito net, as also good conditions for cleanness and hygiene. It has wifi which works very well in the rooms as in the hall and dining room. Breakfast is buffet type. There is a commercial center by the side of the hotel with small shops, pizzery and a supermarket where we could buy all we needed. The price of the Hotel with breakfast and supper included is about 60 dollar a day. The pay of the Hotel can be done in dollars or with a credit card.

Next to the Hotel we visited a religios-focolar Center called Mariopolis Center, http://mariapolsispiero.org/mariapolis-center-wim/, which is a very quiet citadel with several buildings of friendly aspect with a friendly aspect offering the possibility of lodging at a much more reachable price about 30 dollars a day in individual lodging of 25 dollars in for sharing a room which perhaps should be valued as lodging in future campaigns in Gatundu. If more information should be needed one can contact the mariopolicecentrewim@gmail.com.

It is absolutely necessary to have local coins, the Kenyan chelin for the payment of small expenses like drinks, meals, remembrances, etc. We recommend the change to be done at the airport itself on arrival, as there are no exchange places in the Gatundu area, and they accept payment in local coins only.

“LEVEL IV GATUNDU HOSPITAL”

It is a hospital financed and built in 2013 by China at an expense of 11 million dollars, and which was inaugurated in 2016. It is an annex to the old Gatundu Hospital made up by several one store pavilions communicated between themselves , with many green zones.

There are 5 levels; in the lower stage there are urgencies, admission and ambulatory services, two hospitalization stages, with several rooms of eight beds each where operated upon patients are lodged. An area of Gynecology and Obstetrics on the second stage, and on the third stage a surgical area which has two operation theaters called “Theaters 3 and 4” which are not sufficiently used and in which we carry out our activities.

 They are wide and relatively new, although with very little material. The working of the lights is correct and steady without any need for the front lantern. They are two respirators which work well and one console of electric scalpel Valleylab in Theater 3 which works well. On Theater 4 we installed an electric scalpel which is property of our Foundation.

The REA room is very basic only. In it were monitorised patients after surgery watched upon by a lady doctor of the Hospital.

There is a room for relax for the staff which we used as an office to write down the report as also as dining room as they served there our lunch which was cooked meat, rice and vegetables, besides coffee and mineral water.

The surgical area has also a place where we placed all the material brought for the campaign; we found material from formal campaigns as mosquito nets of different sizes coming from Hernia International: sutures, dressings, general anaesthetics like Halotano, antibiotics, needles and Abocaths, needles for raquideal anaesthetics, endotraqueal tubes, larynx masks, facial masks, ventimask, vesical and nasogastric catheters, surgical and disposable dressing gowns, new pajamas, bandages, electrical stapler, skin stapler,surgical gloves, masks, antiseptics to wash hands, and other surgical instruments in good condition that allowed us to have 8 boxes and were quite usable for the Campaign. To this material has to be added the material left over at the end of the Campaign. We evaluated everything , classifying in order all the material, and we told the one responsible for the operation theater the need to make a list and inform our Foundation as perhaps we would have to take anything with us for a future campaigns.

The sterilization is carried out in autoclave the works with heat.

The operation theatre staff was directed by the chief engineer David Karuga, and we want to stress his friendliness and working power to the point of being quite necessary for our daily work. There were also Medicine students who helped us and showed much interest in knowing our work.

It is a pity we could not get the help of local surgeons, whom we did invite to take part in different surgical sessions, as the formation of personal staff is one of our first activities so that in the future perhaps our help will not be necessary. But we will also surely show our regret not to have been able to be there for the Campaign with the Director of the Centre, Dr. Gitaud, whom I finally could not meet, in spite of kept contact through electronic mail during the months previous to our coming to Kenya. It would have been much more interesting to have been able to speak of logistical questions, as the getting better patients In number as in the type of pathology, just as well as the need to have a list of the material kept in the Hospital, in order to organize future campaigns in the future. Well, it could not be, although I am not less surprised by the lack of interest and the lack of cordiality with my team.

SURGICAL ACTIVITY

Before the beginning of the Campaign a technical writing was sent telling Dr. Gitaud that the voluntaries team could carry out from 20 to 25 surgical interventions a day, giving a total number of 100-125 interventions.

Finally, during the 5 days of the Campaign 86 surgical operations took place. The patients were previously selected by local doctors, and the selection and preparation of the clinical history, was remarkable. We did not take up urgent surgical pathologies.

86 patients were operated upon, almost forty less than expected.

29 interventions on adults and 57 on children.

ADULTS:

18 Men; 11 Women

17 Inguinal hernias (Lichtenstein technique)

5 Umbilical hernias. Umbilical hernioplastia.

3 epigastrical hernias

1 Hydrocele

3 Incisional ventral hernias

General and spinal anesthetic

CHILDREN

35 MALE; 18 FEMALE

22 UMBILICAL HERNIAS – 10 INGUINAL HERNIAS – 15 CRIPTOQUIDIAL – 2 SKIN GRAFTINGS – 1 ANAL EXPLORATION – 1 URACO CYST – 1 CIRCUNSITION- 1 PENIS CURVING – 2 HIPOSPADIAS – 1 LIPOMA – HEMANGIOMA

General anaesthesia

The Campaign run from 1 to 11 November 2019.

On Friday 1 we started from Madrid and Bilbao at 6:55 h. towards Nairobi via Frankfurt with Lufthansa Airways, arriving at our destination at 21:25 hours. We went to the Maxland Hotel in Juja Citynext to G. It was a journey of more than 14 hours, which went without problems except for a difficulty during the check-in the Madrid-Barajas Airport: there was overbooking that almost left three volunteers stack, but which could be solved finally. In Kenya there was no difficulty, and the local workers were very kind.

On Saturday 2 we went to the Gatundu Hospital, where we were received by the nurse responsible for sterilization, we visited the different surgical areas and we carried out work of cleaning, orderings and classifying medico-surgical material as well as the organizing of two operation places. We could not begin on that day the surgical activities as we had planned, as we had not called any patients. From Sunday 3^rd to Thursday 7 we carried out five surgery sessions between 8 and 19 hours , apart from the daily visit of patients already operated upon.

Finally, on Thursday 7^th evening we started, some of us on our way to Tanzania and others to lake Naivasha where could see many hippopotamus   and water birds in order to proceed in Friday 8 to the Masai Mara National Park, enjoying two rest days; we carried out a safari seeing many wild animals in their habitat, with herds of herbivorous, depredators watching and masais dressed in their traditional dresses asking for dollars for letting themselves be photographed. We went home on Sunday 10^th November at 23:10 hours from the Jomo Kenyatta lntl of Nairobi, back to our places in Madrid and Bilbao at 12:35 hours of Monday 11^th November. Those intense and unforgettable 11 days were thus left behind.

BUDGET

The cost of the medico-surgical material is not placed in this budget.

Total cost of the Campaign (visa, plane, hotel, maintenance): 7.700 euros

Cost for volunteer 1.100 euros

Signed: Dr. Manuel Cires

Gatundu Campaign responsible 2019Surgeons in Action

TANZANIA    2 0 1 9

Austrian-UK-Slovenian

“Hernia International” Team

Mission in

Korogwe, November 11^th-16^th 2019

Korogwe Hernia International (HI) missions have a history – we were already the 12^th HI-team to this town in the Tanga region. It consisted of 9 members: 3 surgeons, 2 anaesthesiologists, 1 radiologist, 1 medical student, 2 nurse anaesthetists (one of them with additional skills in repairing medical devices). 

Invitation from Dr. Avelina Temba and Korogwe hospital and the mutual trust within the team from last year was spontaneously leading towards another mission here. Competent anaesthesia team from Feldkirch, Vorarlberg, Austria (Dr. Wirnsperger, Dr. Lienhart, nurses Sarah Bertsch, Daniel Döwa) was a call for a strong surgical part (Mr. Shambhu, Prof. Omejc, Dr. Gorjanc). The majority of the team came together in Triniti Hotel close to Dar es Salaam airport. Shambu came to Momella Village in the north after my 1^st Mission there. We travelled to Korogwe from different parts of Tansania. Due to much better roads than in the past we arrived to hospital at the same time after 6-7 hours drive.

Checking patients for surgery was the first task on Sunday evening and we were able to write operating programme for 3 days already, including 2-3 pediatric cases every day. The youngest patient with a big inguinoscrotal hernia was just over 1 year old., the oldest patient had 82 years.

Already familiar team members of Korogwe general hospital were very motivated and the turnover of the patients was fluent. We were not used to take a lunch break but rather stop earlier in the evening after finishing 5-6 cases per table, finishing the day with surgery in HIV positive patients. Local doctors (dr. Ahmed, dr. Tedi, dr. Heri) assisted and also performed a decent amount of hernia repairs under our assistance in order to get more and more independent in modern hernia surgery.

Parallel operations on 3 tables, including stopping theatre 3 occasionally for cesareans (performed by local doctors), enabled 79 procedures on 65 patients in 5 days.

 The presence of an experienced radiologist again turned out to be a very reasonable decision. Dr. Marija Jekovec took this time a portable ultrasound machine with her and performed 95 US-exams, including in OB-GYN and on our surgical patients. Daniel repaired 2 anaesthesia machines, 2 monitors and 1 oxygen concentrator. Consider taking a specialist like him on other missions as well. Having a motivated medical student Franziska Ganster with us turned out to be a very good idea, because she took care of small things that we tended to forget and was also learning by assisting to both surgeons and anaesthesists.

Good work in the hospital was also possible because we were accommodated well in the recently built Korogwe Executive Lodge. Very comfortable rooms and a restaurant with tasty breakfast and dinners enabled us to restart our work fresh and enthusiastic.

Korogwe hospital is definetelly ready to host new hernia missions in the future, according to invitation of director dr. Michael and sister dr. Avelina. They get every year new young GPs and doctors to assist and learn from experts. Anyway, there is a question if they need HI missions as hard as 12 years ago. Definetelly there are hernia patients, that they can manage by themselves. But among them, there are cases every year that present a big challenge even to very experienced hernia specialists.

Among 65 patients (with 79 procedures), we operated on 14 children (21%) and 51 adults (79%). 14 patiens (21%) were female. Sixteen patients (24%) had umbilical hernia>1cm and suture repair (direct closure or Mayo repair) was performed in all children with this diagnosis and underlay or sublay mesh repair in adults. The most frequent diagnosis was inguinal hernia (33 pts, 51%), of course. In inguinals in children, Mitchell-Banks repair with fascial suture was performed; in teenagers and young adults Shouldice procedure and Lichtenstein with LDPE mesh were performed. In a re-recurrent hernia in 1 old patient and in 1 adult with cryptorhidism orchidectomies were performed. In incisional and epigastric hernias (8pts, 12%). Other diagnoses were hydrocaele (13 pts, 20%), where Jabouley`s procedure was performed. Additional procedures as rectus diastasis combined with umbilical hernia were performed in some patients. We drained big incisonals, scrotals and some hydrocaeles with suction, corrugated and/or penrose drains. Our anaesthesia team also helped in CPR of 2 newborns after cesarean sections.

Due to an expert anaesthesia team (many times anaesthesia was performed by locals under their supervision) 20 general anaesthesias with ET-tube or LMA were performed, 44 pts received spinal anaesthesias and 2 procedures were done in local anaesthesia. All pediatric cases received additional caudal blocks for postoperative analgesia.

We felt privileged for having no complications which we contribute to not overcrowded programme. We also took enough time for every single procedure, without any hurrying. Last by not least, sister Avelinas prayers were accompanying us always during the whole fulfilling week.

Team Members:

 Prof. Dr. Mirko Omejc – consultant surgeon, Ljubljana, Slovenia

Mr. Shambu Narayan Nadav – consultant surgeon, Oban, Scottland, UK

Dr. Jurij Gorjanc-consultant surgeon, team leader, Austria; Slovenia

Dr. Michael Wirnsperger-consultant anaesthesiologist, Feldkirch, Austria

Dr. Hannes Lienhart – consultant anaesthesiologist, Feldkirch, Austria

Dr. Marija Jekovec – consultant radiologist, Ljubljana, Slovenia

Sarah Bertsch – anaesthesia nurse, Feldkirch, Austria

Daniel Döwa, anaesthesia nurse, Feldkirch, Austria

Franziska Ganster, medical student, Munich, Germany

Our sponsors:

Kirurgija Bitenc

Splosna bolnisnica / General Hospital Slovenj Gradec

Implantoloski institut / Implant Institute

University clinical centre Ljubljana

Medical center Gorjanc

Hospital of St. John of God St. Veit/Glan

TANZANIA    2 0 1 9

Austrian-Slovenian-Swiss

 “Hernia International” Team

Mission in

Momella, November 4^th-10^th 2019

Africa Amini Alama – AAA (www.africaaminialama.com) is a charitable hospital, located on the tableland between Mt. Meru and Mt. Kilimanjaro in Northern Tanzania. The name AAA means “place of trust in the future of Africa” or also “Africa, we believe in you”.

The organization was founded by Christina Wallner und Cornelia Wallner-Frisee just 11 years ago. After Austrian radiologists, like dr. Celedin, made contacts to the organization and donated some devices, we were encouraged to start the cooperation between Hernia International (HI) and AAA. This first “inspective” mission consisted of experienced HI specialists in order to treat as many patients as possible, but also to check the possibility for further cooperation.

Our team consisted of 8 members: surgical consultants Christoph Sträuli and Jurij Gorjanc , surgical resident Lara Maniglio, anesthetist Katharina Wentkowski, gastroenterologist/endoscopist Klemen Mojškerc, anesthetic/theatre nurse Petra Koch, medical device expert Michael Wentkowski, medical device expert assistant Alex Koch.

Good communication between our team and Mag. Dr. Cornelia Wallner-Frisee started almost 1 year ago and the mission was well prepared. All our patients were treated free of charge exclusively on humanitarian basis. The hospital is compared to African standards surprisingly well equipped. They even started to perform basic laparoscopic operations and we also performed 1 laparoscopic appendectomy with very elementary equipment that we intend to improve.

Experienced anaesthesiologist Katharina performed general and spinal anaesthesia to both operating tables while teaching the two local anesthetic nurses. Alan and Fanuel are very experienced in spinal anesthesia already. Training concentrated on safe general anesthesia in children, low flow technique to reduce the use of anesthetic gas and regional plexus techniques. Nurse Petra was of great help in anesthesiology and surgery. In addition she trained the local theatre nurses in hygiene standards. Christoph and me enjoyed performing surgery as well as educating talented Lara and local surgeons Dr. Kombo and Dr. Sebastian. Dr. Kombo is already very independent in various procedures as a young consultant and Dr. Sebastian has indeed a fine feeling for surgery. The majority of patients had hernias and hydrocaeles. Michael and Alex repaired the sterilizer, diathermy machine, CO2 regulator, endoscopy and laparoscopy monitor and many more. In addition they organized a 4-days hands-on workshop to train local engineers in maintenance and repair of medical devices. Excellent endoscopist Klemen brought the endoscopy in the hospital to a higher level, also performing some polypectomies.

Our team did not meet before but as Dr. Wallner-Frisee stated, we worked together as if we have known each other for a long time. We started surgery at 8.30 in the morning, had a lunch break in the hospital restaurant and then proceeded with surgery and recruiting new patients on the ward till sunset.

Good work in the hospital was also possible because we were accommodated very well in the Lodges Nature Homes and Hillside Retreat. There is basic accommodation available on the hospital campus as well, but it was already occupied by other volunteers.
Thursday afternoon we visited a Massai boma in the evening. On Saturday (after finishing work) the whole team walked and drove through the nearby Arusha National Park.

Statistics on 32 patients (36 procedures):

Children…………………………………………………….6 Pts (18%)

Women……………………………………………………………8 Pts (25%)

Inguinal hernias…………………………………………….…20 Pts (62%)

Incisional, epigastric, umbilical hernias……………..8 Pts (20%)

Other diagnoses (appendicitis, foreign body)………2 Pts (6%)

In children the inguinal hernias were repaired with Mitchell Banks technique, with or without fascia closure, according to age, respectivelly. Suture repair was used in children with umbilical hernias. In teenagers, Shouldice technique was instructed and local surgeons loved to learn this approved meshless technique. In incisionals, epigastric and umbilical hernias in adults, sublay repairs were performed with LDPE and PP-mesh. Surgery was performed in spinal anaesthesia (20 Pts) and general anaesthesia (12 Pts).

Additional work:

Gastroscopies…………………………………….……..10 Pts

Colonoscopies…………………………………………….3 Pts

OPD…………………………………………..daily up to 30 Pts

Repaired machines and devices:

Autoclave for theatre…………………………………………1

Diathermy machine……………………………………………2

Laundry machine………………………………………………1

Refractometer/Optimetry……………………………………..1

CO₂ monitor……………………………………………………..1

Anaesthesia gas monitor……………………………………..1

Endosopic camera color adjustment……………………….1

Perfusomat………………………………………………………1

Electromyography and stimulator device………………….1

Invasive plexus stimulator…………………………………….1

Colorimetric blood analyzer…………………………………..1

General training for local engineers (electricians, car mechanics, carpenters)

Topics: Types and composition of medical devices (diagnostic, surgical, therapeutic, invasive versus non-invasive). Electrical and biohazard safety measures, electrical characteristics, general main power concept and safety checks, typical maintainance tasks, systematic disassembly and assembly devices, testing procedures and strategies to detect typical failures.

Our team:

Christoph Sträuli – consultant surgeon, Switzerland

Jurij Gorjanc – consultant surgeon, Austria (team leader)

Katharina Wentkowski, consultant anesthetist, Switzerland

Klemen Mojškerc, consultant gastroenterologist, Slovenia

Lara Maniglio, resident in surgery, Switzerland

Michael Wentkowski – medical engineer, Switzerland

Petra Koch, DGKS – Austria

Alexander Koch – Austria

Report written by:

Jurij Gorjanc, MD, PhD, General Surgeon

Hospital of St. John of God, St. Veit/Glan

(Krankenhaus der Barmherzigen Brüder)

Austria

 Our sponsors:

Kirurgija Bitenc

Splosna bolnisnica / General Hospital Slovenj Gradec

Implantoloski institut / Implant Institute

University clinical centre Ljubljana

Medical center Gorjanc

Hospital of St. John of God St. Veit/Glan