Author: akingsnorth

GATUNDU KENYA- REPORT 2018

Gatundu is a small village of about 20.000 inhabitants in the province of Kiambu, an hour by car from Nairobi, which is famous for being the birthplace of Kenya’s first president (JomoKenyata) and of the actual president, UhuruKenyata, his son. Even though there are many religions known there, the Catholic one is the main one. The city’s infrastructures are primitive, without asphalt on the streets, and with a population that lives on a rent of15 per person and day. Rice, vegetables and other products of the field are the basis of the economy and the fare in Gatundu.

Preparation for the mission

The Gatundu campaign 10/2018 was organized according to the administrative authority of the “IV Gatundu Hospital” (Dr. Gitau) in the period of two weeks between September 28 and October 12 in 2018, with a total of 10 days for surgical activities which were carried out on 3 surgical tables simultaneously (one for children and two for adults). With a view to operate upon 6 patients per operation theatre and session we formed we formed a team of 10 from the “Cirujanos en Acción” Foundation (one pediatric surgeon Dr. Morán, three general surgeons, Dr. Ramirez, Dr. Fajardo and Dr. Sanchez-Relinque, two anaestesists, Dr. González and Dr. Agullló, one family doctor, Dr. Sabater, and three nurses Mr Gomez, Missis Gall.) We offered to extend our operations to include goiter).

Two weeks before the beginning of the campaign we were told by the hospital administrative authority that we would operate for five days, while we had dedicated much time and effort for three months. Finally the intercession of Dr. Teresa Butrón extended the period to 7 days, but only to operate on two tables simultaneously (a third one being ready in case of great need); we were also told that they had been able to get 85 patients in all, not more.

We have carried out the protocol visits to External Health in the respective provinces, strictly following the rules for vaccination and profilaxis required in a visit to Kenya. We got our visas contacting by mail the embassy to receive them by registered mail which is better in practice than the electronic visa.

The journey

The journey to Gatundu begun with our two groups starting on the morning of Friday 28 December, one group from Málaga (stopping at Estambul and arriving in Nairobi at 2.15 a.m. on 29^th September) and another starting from Madrid (with stop in El Cairo and arriving in Nairobi at 3.45 a.m. on 29^th September.) Due to a delay of more than 1 hour in the starting of the Málaga-Estambul flight, the Málaga group lost the connection to Nairobi and had to remain 24 hours in Estambul, arriving in Nairobi on the morning of September 30. The meeting of the whole group took place on the morning of Sunday 30 September at breakfast time. For 6 members of the team this was the first “Cirujanos en Acción” campaign.

We had 480 Kg of medical and surgical material to take to Gatundu, 400 from Málaga and 80 from Madrid. In Málaga we had serious problems when registering at the Turkish Airlines desk, as the person in charge absolutely refused to cooperate (while the land people were charming). We had to leave 65 Kg of material in the airport ad they wanted us to pay 2900 extra euros for extra luggage. This lack of cooperation on the part of Turkish Airlines is so glaring in contrast with other airlines that I think we should try new strategies to avoid that trouble in the future, as the behavior of the airlines does not fit with our preference for the most deprived people. 

The arrival in such places always implies some kind of conflict as the sensibility of Air Companies does not fit at all with the commitment of our Foundation to work for the poorer people.

The arrival in these places always implies some trouble in customs, so that it will be convenient to get some kind of help to accelerate matters. No kind of communication was established in spite of all our efforts. We found help in the document the Kenya ambassador in Spain gave us and in which he indicated the in an official document our presence there and all the material we carried with us. I want to record my thanks to the ambassador Bramwe Waiaula and to Mr. Javier Gomez, member in the Kenya embassy, for their help in all moments.

Even so, and in spite of all documents you can show them, they will always try to show that some papers are missing and that we had to pay customs taxes. We have to stand firm, to insist that we are coming to help the people and that we do not need any more documents.

STAYING PLACES AND TRANSPORTATION

We are staying at the Maxland Hotel, half an hour by car from Nairobi and about 20 minutes from the Gatundu Hospital. It is a fine hotel, clean and with a good image, equivalent to a 3-4 star in Spain. It has a very clean and large swimming pool ready for use, the rooms are cleaned daily, the beds have mosquito nets and the baths are very decent. It has wifi that works very well in the common zones (hall and dining room) and not so well in the rooms. Every morning they gave us breakfast at 6.30 a.m. with bread and the possibility of fruit, cereals, black beans, bacon and scrambled eggs, and you could also take an omelet prepared with the ingredients you wanted. Next to the hotel is a shopping centre with a great supermarket in which you can buy anything at a good price, and where we went daily (it closed at 10 p.m.) for whatever we needed. Every night the members of the team met in the hotel dining room for dinner with the team members, as there were no places to walk and no other eating options to choose. Dining out in Nairobi is only advisable if you are ready to put up with two hours to go and two to come back in terrible traffic, as we did on Saturday 6^th October as a farewell. The hotel price including breakfast about 35 american dollars, and it can be paid in that money or in KSH, the local Kenya money equivalent to 0.015 (so that 100 KSH make one dollar).

Transport from the airport to the Maxland and back both ways to the hotel to the Gatundu hospital took place in a 12 places jeep supplied free by the Hospital. I can only say that the driver, Cyrus, is a serious person, that he drives very well and he has given us much safety in spite of the traffic being horrible in that zone of the country, constantly through roads without asphalt, without traffic lights, and with cars and motorcycles overcharged and often on the wrong side.

THE HOSPITAL

“Level IV Gatundu Hospital” is a hospital recently built (2013) with the help of 11 million dollars by the Chinese government (all the notices in the hospital are in English and Chinese) which helps the old hospital actually in partial use. The new bloc has 5 heights, a low one for urgencies and admissions, two por hospitalization with six rooms with eight beds each, occupied by our operated patients (even so with an occupation not above 50 percent) and two zones of operation theaters, one of gynecology in the second story and another in the third one with two operation theaters (“Theaters 3 & 4) in which we had worked daily. The operations theaters are roomy and relatively new, although they lack much material as could be expected; the lights of operation theater 3 have not worked in the hole week, and operations have been possible thanks to the use of photophores which I recommend to bring always with us. There are two respirators that work very well and a Valleylab electric scalpel which works well. In the other operation theatre we have worked with the electric scalpel we always carry with us.

The recuperation room is very rudimentary, it was empty and we kept there patients been observed for a while after operation by some nurse in the hospital till they could be sent to a room. The operation room area has also a little room in which we have kept our material, and a place for the staff in which they daily sent us our half-morning breakfast with tea, coffeeand greens, and a lunch with rice and greens. They also brought us bottled mineral water. For sterility we had an autoclave which worked by heat (there are no gas systems) and which gave us trouble only one day when the whole village was left without supply and we were left without any water. We had taken with us three boxes of specific material for hernias, although the hospital has a number of boxes full of passable surgical material but without any order. There were no right angle dissectors in any box, and most of the Kocher pincers had no grasp at all.

The staff in the operation theatre and other helpers was excellent and very dedicated, whether the chiefs (David Karuga and Weru Kennedy) or the helpers and students that helped us. I want to mention particularly the lady doctor responsible for the coordination of doctors and patients, Victoria Kithinji (Vicky for us) who showed a great human value, professionalism, availability and capacity to communicate with our team.

SURGICAL ACTIVITY

During the 7 days of surgical activity in the Gatundu Hospital we worked on patients selected by local doctors and listed day to day by them. We also worked on some surgical cases that came to the hospital, given the scarcity of surgeons. On the whole we worked on 82 patients (42 adults and 40 children) with 104 surgeries divided as follows:

ADULTS: 17 inguinal hernioplasties (7 Rutkow-Robbhins& 10 Lichtenstein); 3 umbilical hernioplastics; 15 total tiroidectomies; 3 traumatic wounds; 2 Hiatic hernias (Nissen); 2 hiatic hernias (Nissen); 2 hidrocelectomies; 2 queloidal surgeries in the auricular pavilion; 1 eventration; 1 fimosis; 1 over infected fascitis;1 autologos skin insertion; 1 giant testicular tumor of germital stock; and 1 pediunculated wart.

CHILDREN: 16 umbilical hernias; 14 criptorquidial; 10 inguinal hernias; 6 hidrocels; 3 fimosis; 1 hipopasdias; and 1 case of non differenciated genitals.

We have had only 2 post-operative complications, a minor one (inguinal post-operative) and a mayor one(disnea and larynx ‘estridor’ which was treated with a temporal traqueostomy). A week after coming back to Spain I personally contacted the patient and lady doctor Kithinji who informed me that an indirect laryngostomy had been made in which can already be observed a proper performance of the vocal cords so that we can expect that the patient will be decanulated in the following weeks. All patients, except the one mentioned above, were dismissed the next day and no complications have reported. Even today we are in daily contact with lady doctor Kithinji to solve all her doubts in the follow up and revisions of the patients operated upon.

TEACHING ACTIVITY

On the first day we received the visit of Dr. Gitau who proposed to have an activity with the CME (Continued Medical Education). It was an excellent idea and we fixed Thursday 4^th October at 8 a.m. The presentation was a success with a great interest on the part of the young internal doctors of the hospital. The place was full for an activity that took 60 minutes with contributions from lady doctor Fajardo (“Basic concepts of inguinal hernia and its treatment), Dr. Morán (Timetable for children paediatric surgery) and Dr. Ramírez (“Options for surgical treatment in the multinodular goiter”.

EXPENSES

All the expenses of the campaign were contributed by the ten volunteers, and they divide as follows:

Journey (by plane both ways): 4627 euros

Maxland Hotel: 4150 euros (45 euros for person and night)

Meals and transportation: 15 euros for person and day (1350 euros)

Instruments afforded: 825 euros. 

From the point of view of patients operated and hours spent we can say that the aim of the mission has been accomplished.

From the point of view of the organization, once we arrived in Kenya everything went well: hotel reservations, transport, operation theater and collaboration on the part of the Hospital staff.

I think that to organize such a mission it is essential to have a direct and clear communication between the leader of the same and the local collaborates of the Hospital in order to define the type of pathology and the way of working (essentially the number of working days, the number of operation theaters available and the number of patients). I believe this aspect can definitely be improved because we have planned a human team and the medical and surgical material that has overvalued the expectative of the work to be carried out. I ask the local coordinators to improve this aspect in future missions.

Finally the fact that in 7 days were operated only 23 hernias in adults leaves me with mixed feelings. It is true that we have operated for very complex and exacting cases, but very few patients were recruited for hernia in a campaign run by “Hernia International” and “Surgeons in Action”.

While saying that some points could be improved I am delighted to say that I would come again to Gatundu in order to help the people there.

Hernia International (Spanish Team) mission at Mongolia. 2018

 The Team:

Enrique Navarrete de Cárcer, surgeon. Team Leader. Sevilla

Francesc Marsal Cavallé, surgeon. Tarragona

Juan Carlos Gomez Rosado, surgeon. Sevilla

Jose Lozano Cavalo, anesthesist. Sevilla

The cities:

1. Hospital General Básic de Tsetserleg

Tsetserleg, also transliterated as Cecerleg (Mongolian: ????????, lit. ‘garden’) is the capital of Arkhangai Aimag (province) in Mongolia. It lies on the northeastern slopes of the Khangai Mountains, 360 miles (600 km) southwest of Ulaanbaatar. It has a population of 16,553 (2000 census, with Erdenebulgan sum rural territories population was 18,519), 16,618 (2003 est.), 16,300 (2006 est.)

Tsetserleg is geographically located in the Bulgan sum in the south of the aimag. It is not to be confused with Tsetserleg sum in the north. In 1992 Tsetserleg was designated as Erdenebulgan sum, which has area of 536 km².

 2. Second General Hospital Ulanbaator.

Ulaanbaatar, formerly anglicised as Ulan Bator /?u?l??n ‘b??t?r/ (Mongolian: ???????????, [????m.b??t???r], Ulaγanbaγatur, literally “Red Hero”), is the capital and largest city of Mongolia. The city is not part of any aimag (province), and its population as of 2014 was over 1.3 million, almost half of the country’s total population.^[1] Located in north central Mongolia, the municipality lies at an elevation of about 1,300 meters (4,300 ft) in a valley on the Tuul River. It is the country’s cultural, industrial and financial heart, the centre of Mongolia’s road network and connected by rail to both the Trans-Siberian Railway in Russia and the Chinese railway system.^[3]

The city was founded in 1639 as a nomadic Buddhist monastic centre. It settled permanently at its present location, the junction of the Tuul and Selbe rivers, in 1778. Prior to that occasion it changed location twenty-eight times, each new location being chosen ceremonially. In the twentieth century, Ulaanbaatar grew into a major manufacturing center.Ulaanbaatar is a member of the Asian Network of Major Cities 21. The city’s official website lists Moscow, Hohhot, Seoul, Sapporo and Denver as sister cities.

The tour:

One way, was made from the city of Barcelona, ​​in flight with the company China Air, with a stopover in Beijing. The duration was 16 hours including the technical stopover at the Beijing airport, where we need to go through the security check again. Fortunately, there were no delays or customs incidents. We do not carry clinical material or medicines. Only about 80 meshes already sterilized and properly packed.

Upon our arrival at Ulaan Bataar International Airport, both Enkhee (in charge of all the coordination and logistics of the mission), as well as Dr. Sinchan and Dr. Chadraa and Telmen, staff surgeons and resident of the Second General, were waiting for us.

The first week of work was performed at the basic general hospital of TseTserleg. The transfer there, was made immediately from the airport. The city was located 600 Kms west of UlanBataar. The trip was organized completely by Enkhee and we traveled in an SUV and a van for luggage. We traveled for 11 hours along the Mongolian steppe, stopping several times to stretch our legs, recover strength and take some pictures of the landscape.Dr. Naranthuya, head of surgery at the hospital and her staff, were waiting for us at the destination. We met the hospital in the surgical area and reviewed the patients the next day.

The accommodation is made free of charge (thanks to the hospital staff’s deference), in a small hotel very close to the hospital. Breakfast, lunch and dinner was always prepared in the hospital, also free of charge The working week at TseTserleg was Monday through Thursday, since on Friday we needed to travel back to the capital UlanBaatar, to be there on Friday night. 

Dr. Naranthuya and her team, together with the surgeons who accompanied us, had selected all the patients of the week and we reviewed them every day. The majority were patients with inguinal and umbilical hernias, and 2 large incisions. 4 children and 7 adults. There were no more selected patients and 2 were rejected for surgery due to severe concomitant pathology. A bilateral inguinal hernia was performed using a laparoscopic TAPP approach. 

All the patients left the following day. There were no complications.The collaboration of all the hospital staff was complete, and their hospitality similar. Breakfast and lunch was made every day at the hospital and dinner at a cafeteria near the hotel, which was also booked and paid for by the hospital. The infrastructure of the hospital is basic, and the operating rooms (2) meet the minimum conditions to be able to work: sterilization center, basic instruments, modern anesthesia system, electric scalpel and adequate light. However, the catalog of sutures is scarce and in small quantity. They do not have meshes for the repair of hernias, and although there is a modern laparoscopic tower, the laparoscopic instrument is obsolete. Antibiotics, analgesics and anesthetic drugs are basic and scarce.

After the return trip (12 hours) to the capital on Friday, restful rest in a great hotel near the Second General Hospital, which Enkhee achieved thanks to his good work. Saturday dedicated to know the capital and surroundings. On Sunday we went to the Hospital, to meet Prof. Naraa and his team, made up of several surgeons and residents, who made us a great welcome, with food and Vodka included. Visit to the facilities and visit the patients scheduled for Monday.

From Monday to Thursday, surgery to double the operating room and on Monday to three simultaneous operating rooms. The facilities are great, with a modern and functional surgical area. The collaboration of Prof. Naraa’s team was complete. Daily we were accompanied to review the patients of the previous day and the few who were admitted several days. The control of the patients was complete by the local surgical team.

In total, 25 patients underwent surgery in 4 days, all of them with large incisional hernias, or recurrent or large inguinal hernias. 7 of the patients were operated by local surgeons and assisted by a team surgeon.  There were no complications, and all the patients had left on the Saturday of our departure.

On Thursday afternoon, we devoted 3 hours to presentations and videos about the new techniques of abdominal wall, the clinical guide of the EHS and the types of meshes available today. They were followed with a lot of interest by the whole department of surgery, and non-facultative personnel.

The only drawback is the absence of surgical meshes, which usually do not have. The catalog of sutures is correct in quantity and variety.

Once again, the infinite kindness of all the hospital staff, from Prof. Naraa, to all the Staff, residents and auxiliary surgical staff. We have definitely felt at home or in our hospital in Ulan Bataar.

In summary:

The experience has been absolutely positive. The hernia pathology is prevalent in that country, although it is not a health problem. Perhaps it would take more training from local surgeons, so that they can master all the modern techniques in wall surgery. Local surgeons in both the capital and rural hospitals are eager to know and develop modern techniques for the repair of hernia pathology, but may not be able to access it for organizational or economic reasons.

I think Hernia International has a fundamental role in teaching and training Mongolian surgeons.

For future teams that wish to cooperate in this country, I summarize some tips:

It is a fascinating country to know. The kindness and hospitality of its inhabitants, it is worth experiencing.

Trust completely in Enkhee: elle is in charge of the coordination and organization of everything related to logistics and transfers.

It is essential to carry some basic surgical material, especially for work in rural hospitals, with worse infrastructure. This includes sutures and surgical meshes. No need to take medication or anesthetic equipment.

There are modern and fully functional laparoscopic towers, but with laparoscopic and scarce obsolete material, especially in rural hospitals. Local surgeons demand teaching in laparoscopic abdominal wall techniques.

The general infrastructure of the country is acceptable, although the distances are large and require a day of travel both on the way and on the way back. The local food is excellent, although very different from the European or American. In Ulan Bataar, there are restaurants or places to eat all kinds of foods.

Mongolia is a great destination for Hernia International teams. The sanitary infrastructure of the country is improving, but local surgeons demand training and training in modern open and laparoscopic techniques, to be able to implement them in the portfolio of services of their hospitals.

Enrique Navarrete de Cárcer

Team Leader

KAMUTUR CAMPAIGN. BUKEDEA DISTRICT.

UGANDA. SEPTEMBER 2018

SURGEONS IN ACTION FOUNDATION

1.      TECHNICAL REPORT:

a.      DATES:

A team of 8 people: 3 general surgeons, one pediatric surgeon, one anesthesiologist, two surgical nurses and one professional photographer.

8 packages with a total of about 240kg of surgical material and medicines.

Departure from Madrid on Friday 9/14 at night and arrival in Madrid on Tuesday 9/25 in the morning.

Saturday 14th: Very long car ride from 9:30 am in a typical Ugandan taxivan from Entebbe, crossing Kampala, with a technical stop to pick up two oxygen bullets, which will travel all the way with us, until arriving at Kamutur, a village in a rural setting in the Bukedea district, at 19:30h in the evening. We crossed roads of all kinds, fortunately during the dry season, we enjoyed the Ugandan landscape, we stopped to eat typical chicken legs and fried livers on skewers, and we even had time to change a wheel for a blowout.

Sunday 15th to Friday 20th: Surgical interventions, from 8:00 am to 8:00 pm, in 2 simultaneous operating theaters.

b.      ADULT PATIENTS:

95 procedures performed in 83 adults, 34 in women and 49 in men.

As a summary, it can be highlighted:

-36 inguinal hernias, 5 bilateral. Mosquito mesh provided by Hernia International and PLP meshes contributed by the volunteers have been used.

-2 infraumbilical laparotomies for two right ovarian masses resections, one 7cm and one 20cm, previously diagnosed by ultrasound provided by the patient.

-3 large incisional hernias with PLP retromuscular mesh (Rives)

-14 hydroceles, including 3 scrotal masses of doubtful diagnosis that required orchiectomy.

-1 breast tumor, quadrantectomy.

-30 soft tissue procedures, including keloid scars, some very complex, and several tumors up to 15cm in diameter.diámetro.

c.      PEDIATRIC PATIENTS:

14 procedures were performed in pediatric patients, 7 in boys and 4 in girls, from 2 to 17 years of age.

Inguinal hernias: (raphias) 4 rights, 1 left. 3 of them associated with hydrocele.

Other procedures: 3 soft tissue tumors, 1 cord cyst, and 1 ganglion and 1 hydrocele.

It is important to point out that, even though we had a pediatric surgeon with us, and we advised it to the hospital with sufficient time, there has not been a recruitment campaign for pediatric patients, fearing that they were not finally operated. Unfortunately, in the two campaigns prior to ours it was not possible to operate on this type of patients, and that has meant that the influx has been very low. Hopefully, this trend will be broken as of our campaign, and a more constant pediatric care will be consolidated in the next ones.

Total procedures: 109

Total patients: 94, 56 men and 38 women.

d.      COMPLICATIONS:

Until the time of leaving Kamutur on Friday evening, all patients were discharged on the same day or after a night of hospitalization, with no complications, except for patients with laparotomies or with drains after eventroplasties, which remained for up to 3 days, or patients with a long distance from the hospital, who stayed for up to two days. According to a subsequent report by Moses Aisia, head of the Hospital, and Dr. David Oikia, physician in charge, there have been no complications in any patient.

2.      CAMPAING REPORT

a.      THE PLACE

Uganda is a country in East Africa, bordering Kenya, South Sudan, Congo, Rwanda and Tanzania. It is an independent country, belonging to the Commonwealth, since 1962. It has had a very convulsive recent past, and currently maintains a relative socio-political calm, with a presidential regime led by Museweni, which has governed 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 around 52 years. The district of Bukedea, where Kamutur is located, is a district with about 120,000 inhabitants, in a rural environment, and with 80% of its population below the poverty line.

The Holly Innocents Health Center (HIHC), is a private hospital center, created from nothing,  thanks to the enormous work of Moses Aisia, a social worker, who began to build the center after a terrible personal story, and is getting basic health care to an entire region of the district. The entire project, which is fully structured and planned, will turn it into a Hospital with all the basic services, although at the present time there is still much work to be done and a large investment of money, personal and material resources is necessary. At present, it gives attention to gestation and delivery, it has a hospitalization area, laboratory with basic diagnostic tests, and a surgical pavilion in the process of construction, very advanced. Among the health personnel, hospital nurses, midwives and surgical nurses stand out, with a great capacity for work that we have been able to confirm, and a doctor paid for by the center itself, Dr. David Oikia, who carries out commendable work with scarce media, and who stays in the hospital from Wednesday to Sunday, alternating his activity with that of university professor in Mbale, in a government post, on Mondays and Tuesdays. Recently, the center has been certified as Level 4, which in the Ugandan health system corresponds to what we know, saving distances, such as Community Hospital.

The hospital center is clean and tidy, and our fundamental workplace, the surgical pavilion, although still unfinished, has allowed us to work in two operating theaters with enough fluidity, understanding the circumstances in which the surgical campaigns of our Foundation normally take place, quite far from European standards applied to an operating room. In any case, we have maintained a circuit of asepsia-antisepsia more than acceptable, using a pressure autoclave and organizing the instruments in small kits, helped with all the sterilized single-use material that we carry with us. Although we did not have surgical lighting, still without acquiring, we have been able to work with “alternative” lighting with sufficient security. We have organized a circuit for transferring patients from the hospitalization block to the operating room. We have enabled a pre-surgical waiting area and a postanesthetic recovery area with two beds inside the pavilion. We have been able to work with 3 local nurses very efficient and willing, to which we thank their great capacity and joy.

b.      THE TEAM

On September 14th, Friday night, we started from Madrid a team of 8 people:

-Carlos de la Torre Ramos, pediatric surgeon,

-Rocío Fernández Sánchez, general surgeon,

-Ana Gay Fernández, general surgeon,

-Beatriz Revuelta Alonso, anesthesiologist,

-Nuria Agulló Marín, 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. This is the second campaign in the HIHC of the Foundation, after the first of a team held in December, still without having the surgical pavilion. In addition, in April there was a campaign of Hernia International, an organization that initially contacted the HIHC, but they had very poor results, for various reasons that it is not time to analyze, but differ a lot from what our team experienced. This location of the HIHC is likely to become one of the locations most valued by our organization, due to the enormous needs of the population, the great willingness of all the local hospital staff to collaborate and participate in the campaigns, and the improvement of the facilities projected or in the execution phase, very advanced taking into account how it is all in Africa.

Together with the medical team, this time a professional photographer participated in the campaign, with the aim of collecting audiovisual material to make a documentary film about this place, its reality, its needs, and the task that the Surgeons in Action Foundation has out here.

c.      LOCAL STAFF

In the hospital there is only one doctor, Dr. David Oikia. For our work, we counted on 2 nurses in the operating room (Florence and Esther Norah), who did circulating work together with our nurses, and cleaning and sterilization. In addition, we work with two hospitalization nurses (Karoline and Emmanuel). In addition, two guards performed all the work of circulating patients. It is fair to acknowledge to all of them the enormous effort made and the joy with which they have shared the work with us. His deficiencies in surgical training have been replaced with his dedication and willingness to work. We were very pleased to note upon our arrival the cleanliness of the facilities, which we were able to verify how it was maintained day after day by the cleaning team.

It was very exciting the party-ceremony of welcome to the team, in the back garden of the hospital, where there were speeches, gifts, dinner … and many dances, in a demonstration of gratitude that we deeply appreciated.

Moses Aisia, director of the center, sets an example with an enormous capacity for work, and transmits that implication to all the staff. He is the real engine of the hospital, the one that deals with getting financing to finish the project, designed by him, and was always with us pending of anything that we needed.

We have lived in the hospital center, in 3 rooms with very basic resources.

d.      EQUIPMENT

The hospital has very limited means. Focusing on the surgical pavilion, it is worth mentioning:

-The pavilion is unfinished, so it still can not be used at full capacity according to its projected structure. The exterior construction and the partition of the different rooms is finished. Only some rooms are paddled on floors and walls. There is still no running water and electricity. Therefore, there is no light of any kind installed yet.

– At present the projected operating rooms (3) are not yet operational, since the work is not finished. In this campaign we have used two rooms that are projected as offices when the pavillion will be finished. In those locations we have achieved the basic conditions to turn them into an operating room. In addition, we were able to use a large main room already finished as a warehouse and as a waiting room, another unfinished room as a sterilization room, and another room as a postanesthetic recovery room.

-With regard to the equipment:

Two electrocautery generators are available. One of the two, we were not able to make it work, and it’s going to be sent to repair. Instead we used one that we brought, happily. It is essential to carry both the adhesive grounding plates and the scalpel terminals, since there are practically none there.

They have just acquired an anesthesia machine, which is not yet operational because it is necessary for the company to send a technician to finish checking it and put it into operation, an appointment that is planned immediately, so that it is operative for the next team that goes to operate there.

Currently there are two complete oxygen bullets, which we ourselves collected from Kampala.

We have used an oxygen concentrator that we have transported from Spain, and that we have left there, thanks to the donation of the company Oximesa, managed by our pediatric surgeon Carlos de la Torre.

We have used a diesel engine por electric power that the hospital has, and that has worked correctly for the use of these equipment.

The light for the operating room has been provided by the frontal lights that we all carry from Spain, and which have been essential at some moments.

The two main actions to be carried out in the pavilion, well known by Moses, are the electrical installation, through solar panels, and the piped water.

Regarding the surgical instruments, there is a basic reserve of surgical instruments in the hospital, but we have taken surgical instruments to make about 6 basic kits, which have allowed us to work with fluidity, supported by the cleaning and sterilization in the autoclave by the local nurses.

Regarding fungible material and surgical clothing, the needs are enormous.

We have used much of the material we have worn, including gauze, compresses, gloves, dressings, disposable sterile drapes, sterile disposable gowns, iv anesthetic medication, IV antibiotics for prophylaxis, mosquito mesh and antiseptics for surgical scrubbing, among other things. Without this material, to propose a campaign of these characteristics to this place is impossible. The next teams must bear in mind the need to provide all this material.

e.      ANESTHESIA, ASEPSIA AND SURGICAL EQUPMENT

All adult patients have undergone surgery under spinal anesthesia, supported according to the cases with more or less deep sedation. In soft tissue tumors, as a general rule, local anesthesia has been performed with sedation.

In children, surgical procedures have been performed by general anesthesia in spontaneous ventilation, with the oxygen concentrator, and no doubt thanks to the experience and professionalism of our anesthesiologist.

We have transported all the necessary medication from Spain. There we found a small assortment of medicines from other previous missions, or acquired by the hospital, but, without a doubt, it is very important that any campaign that is organized, at least for now, has the need to ensure its own anesthetic medication.

Basically, they have a “sterilization” room where they keep the packages with the sterile material, and where an autoclave of type “express pot” is put on a wood fire, with a pressure gauge. The system itself is rudimentary, but effective to achieve sterilization of the material.

Surgical clothing is very scarce, with few cotton cloths. We use a large amount of disposable cloths that we carry from Spain, as well as disposable gowns.

All of our adult patients with mesh implants receive a dose of cefazolin 2g iv in the anesthetic induction, which we have taken.

Regarding the surgical material, the situation is equally bad, as it corresponds to the type of hospital it is. We carried a lot of material that is essential that other missions also carry, from gauzes and compresses to sterile gloves, drains, dressings, steri-streaps, sutures, elastic bandages, etc.

Of course, there are no meshes for performing hernioplasty. We have taken a large quantity of meshes “mosquito”, sterilized thanks to the work of Hernia International, which sterilizes, packages and labels individually, and from here we take this opportunity to thank. In addition, we have taken some polypropylene meshes with a larger surface area and some double-layer mesh to ensure a special need that has not been met.

The surgical instruments are very scarce. We have used our own instruments divided into small kits.

f.       OUR LIFE AT KAMUTUR

The alarm clock sounds at 7:00 a.m. It’s time to get up, take a big bucket and go to the hospital well, in the middle of the central square to fill it with water. There is a lot of hustle and bustle at that time, and you always find a child in the well who gladly applies it to the crank of the well to fill the bucket. Then you have to go through the kitchens to add enough hot water, to your taste, and approach our “shower”: a stay with walls of approx. 1,5m high, outdoors, where we could improve the technique of the “shower cube”. The mornings are fresh, about 20º max. After (or before, according to tastes and needs) we enjoyed a wonderful communal latrine, which I do not intend to describe here, but which is far from what any of us understands as a bathroom.

All meals were made in a nice covered terrace, with a menu basically the same every day, clean, cooked there, and enough to feed, without great difficulties. Practically all the members of the team have suffered, to a greater or lesser extent, a gastrointestinal disorder, which in no case has been serious, nor has it prevented our daily work. If anything, it has deepened our knowledge about the operation, cleaning schedules and presence of native fauna in communal latrines.

Our life in this place has been very simple. We have always felt very well treated and very accompanied. Apart from the hospital life, which occupied a large part of the day, our social life was limited to conversations around the table. Especially at night, when, after dinner, we enjoyed one (or two) wonderful bottles (75cl) of Nile beer, some days even something “cold”, with an entertaining conversation. Some confessions about anecdotes of our lives that I will never reveal will remain for the secret of our team.

Our rooms, one for the 3 boys, one for the three girls, and one for Nuria and me, were quite basic, with the beds as only furniture, but clean and comfortable enough to spend a week. There is a bathroom with shower-sink and toilet bowl finished, but still without pipe water, so it is useless, for now.

We have paid $ 70 each for the room and the food, for the whole week. .

Communication with the outside world can only be done through the Ugandan telephone network, through SMS or international tariff calls.kits.

The concept “tourism” is very far from this place. Kamutur is in the middle of nowhere, in a rural environment where families still live in traditional huts in the countryside, without any basic services, and dedicated to a subsistence economy based on agriculture and livestock. There is a primary school, which we were able to visit, that serves the children of this community, with very basic resources.

Regarding the rest of the country, we have been able to complete an in-depth learning about the road network and the landscape of a large part of its territory, since we have made some 1600km in less than 3 days, in a taxi-van whose amenities I will not describe, to visit, at the end of the trip, the famous Bwindi Imprenetrable Forest, and its no less famous mountain gorillas. An unrepeatable experience, in every way.

CONCLUSION

In short, we consider that this campaign has been a success, both for the number of patients we have been able to operate, without complications, and for the satisfaction of the team for the great deal received by the authorities and local staff. Moreover, if possible, after the bad experience of the previous team of Hernia International that was in April. This report aims to serve to demonstrate that, with obvious improvements that need to be undertaken by the hospital management, it is perfectly feasible to carry out surgical campaigns safely in this center.

I believe that this place should be an important work goal for our organization. There is a lot to do, and the people here are eager to receive help.

Strengths of this place:

– Moses Aisia, true engine of the hospital. His ability to start, from nothing, this center, is incredible.

– The hospital itself, a true center of hope for this place, with a very needy population, immersed in poverty.

– The treatment we have received and the willingness of the staff to work with us.

Improvement objectives:

– Complete the surgical pavilion. This task is fundamental, and should be carried out as soon as possible. Includes complete work, equipment, and communication corridors with the rest of the hospital. In addition, as planned, it is convenient to carry out the surgical hospitalization building next to the pavilion.

– Medical material: To date, any campaign must have the need, already explained, to carry with it necessary medical material. It would be highly advisable to progress in supplying the hospital with this material, by the center’s management.

– Hosting of team members. A space must be adapted for the correct rest and basic hygiene.

Budget: For information purposes, and without going into too much 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 flight, not especially expensive. The other, the costs of accommodation and maintenance, which have been almost non-existent ($ 70 for the entire 6-day stay), in addition to road transport, about $ 450 round-trip all the equipment. In the budget has not accounted for the cost of all the material we have contributed, in total about 240kg.

COST (ONE PERSON): Aprox. 900€

TOTAL COST: Aprox5.600€

Fdo: David Fernández Luengas

Campaign leader

Surgeons in Action

Report on hernia mission Brazil July 2018- Dominique Robert

 Brazil is a bit far away from Australia but worth the trip, lovely people, good surgical setting and competent surgical teams. Joao Pessoa is a big town, 1,800,000 inhabitants mainly living in blocks of flats around 30 levels. There are food outlets and fruit and vegie shops everywhere. Their beer is light and their Caïpirinas are absolutely delicious.

Day one was at teaching hospital Santa Isabel, 5 operating theatres well equipped, day 2 at Itabaiana, a rural local hospital one hour out of town, day 3 at Mamanguape, another rural hospital, one hour out of town but very active, day 4 hospital Santa Isabel, day 5 hospital Universario a very big teaching unit with everything available, day 6 at Santa Isabel. There are long working days because of the time spent in transportations around. Recruitment of patients does not seem to be an issue as the cities are big. I did or assisted for 23 hernias on 22 patients. There was no hernia done under local anaesthesia as the Brazilians Anaesthetists are in favour of spinal analgesia which they master very well, no problem on my side and it seems easier for their recovery units.

We were very well treated and fed in every hospital, the Juniors have an active role and are very keen on learning, ask questions and do not hesitate to challenge our techniques. I was a bit surprised we did not have to operate on more children. I think this was worthwile both for them and us. There was good companionship during all these days and I am quite keen on returning next year After time was very good too with plenty more restaurants, drinks and good food, quite often with the surgeons we worked with during the day.Excellent ambiance.

Thanks to Christiano and Christiano, Pericles the local surgeon organiser and all the Junior and senior surgeons Brazilian or from overseas we worked with, Andrew, Leo and Gail accomplished anaesthetist and Whatsapp Champion.

Benin 2018 Report

Mission report, Dangbo, Benin July 2018

The team this year consisted of 3 surgeons, Christine Russell, Richard Turner (both from Australia) and Thorbjorn Somers from Denmark + Anaesthetist Philip Gribble with critical care nurse Amy McLennan. This was our second trip to Dangbo in southern Benin; the mission in 2017 had demonstrated multiple, impressively large hernias and the workload was significant

The Hopital Auberge de L’Armour Redempteur is run by the local catholic nuns and only operates with visiting international teams; there are several visits a year from Spanish teams who clearly provide a broad & regular service. Mme Opportune is the leader of the nuns and a doctor to boot, though was not available to assist with the surgery. The operating conditions were basic but clean, the single operating room having two beds to work with [and is air conditioned]. The anaesthetic equipment was basic, the monitoring largely non-existent, and the Oxygen supply being one large cylinder and only in theatre.

We arrived in the Saturday prior to operating on the Monday. Sunday, we were presented with over 60 people to evaluate and many came for review with non-hernia issues [enlarged thyroids, metastatic disease, multiple unusual skin lumps, a 7month old with cleft palate, a 15yo inter-sex pateint]. Preparatory assessment had been done locally but was a little variable; 3 patients were cancelled as having uncontrolled HT [>210] and one had severe LVF.  Whilst we were there to focus on hernias, we were able to include several hydrocoeles, a couple of haemorrhoidectomies as well as keloid & lipoma removals in to our operating list. Of the 41 operations, 25 were hernia repairs.

Despite basic conditions, we were wonderfully looked after by the nuns, picking us up from the airport 90 min drive away; accommodation and food [and the evening beers] was all provided for us. The accommodation was spartan, but air conditioned, and the showers hot. There are no local facilities to access ‘extras’ though we really didn’t need anything; we did, take some theatre snacks which was a nice comfort. There is no reliable wifi service and phone contact was patchy to existent.

The weather in July/August was also noted to be far more pleasant than in April when we last visited; then it had been hot and humid building to the wet season, this time mid-20’s and far more comfortable.

From Australia, we had been supported by 2 local service groups [Rotary & Lions] to pre-purchase medications locally [especially Ketamine and Morphine], as well as bringing 2 pre-used diathermy machines from Australia to supplement their local equipment, all of which was very gratefully received.

One of the nuns, Sr Ruffina, performed the task of operating room manager and worked extremely hard, both before and after our work day, as well as Gabin Hounnou , the sole, post-op nurse. The aftercare was limited as it was a communal ward [in a separate building] with up to 10 people, but Gabin managed to perform admirably with limited equipment.

All operations were performed under either LA + sedation, or spinal; all hernia operations were planned TAP block under U/S guidance + infiltration. No GA was made available due to the lack of post-op care and the absence of a recovery area].The memorable morning of 2 patients singing a call & response duet at high volume (under the influence of the Ketamine) was a clear – and very

funny – highlight.

All the surgeons noted the difficult and ‘stuck down’ nature of the Beninoise hernia, so even apparently small examples provided a surgical challenge. The clear gratitude was also a delight and privilege; possibly the most rewarding post-op round one could have.

Suggestions for a future visit

# Prior liaison with Fr Martin of the Dangbo diocese allowed us to get him to order medications locally; we gave him 4 months warning and he was obliging to trust us to bring the money when we arrived. This worked very well we were guaranteed of critical supplies without having to transport it from Australia.

# The monitoring is basic to non-existent; we took 3 finger oximetry probes and left them there but  self-supply may be sensible. Capnography would have to be imported as well; ECG’s can be done but only if the patient is sent to the capitol, 2 hours drive away.

# Language was an issue for us, with only 1 fluent French speaker. Many patients do not speak French, only the local Fon, which makes communication even more challenging. The local support was ever present, though no interpreters were available. Without fluent french, there are clear difficulties.

 – one suggestion may be to bring a French vocabulary list for common medical terms as an adjunct

# The issue of duplicate medications and equipment was noted. The resident, residual supply of medications is large and somewhat eclectic & most of what we arranged was additional to requirements [though given the unreliability of storage in Dangbo, we ended up using mostly our own, ‘fresh’ supplies]. Whilst it may be difficult in Dangbo, information of what is present prior to a team visiting would be very helpful to direct resources to what is needed. This may be tricky, due to difficulty in email communication and limited local resources, though any prior information would certainly give a better service

# One specific suggestion for a next time would be to bring wrist bands for identification. The combination of the language barrier, unfamiliar names & difficulty in recognising patients clearly opens the door for error. A simple name + operation would significantly improve patient safety and surgical flow.

# Surgical practices [eg fasting times, post op care, routine preparation] have advanced in western practice compared to Dangbo and providing standardised information at the beginning would be helpful.

# Bring simple cleaning equipment [alcohol wipes, hand gel].

# We noted minimal supply of N Saline for mixing drugs; possibly bring a few 250ml bags of NS for this, eg 1 a day.

# Dr Gribble brought a hand held U/S machine for TAP blocks that was very useful and improved post-op analgaesia significantly; this was also utilised in pre-op assessments to aid in diagnosis.

# An Ampoule breaker would have been very handy; the local glass ampoules frequently shattered &/or were very difficult to crack

The local instruments vary widely in quality and we did leave several self-retaining retractors [for example] that were needed.

Whilst our visit this year did not have the same challenges as 2017, certainly the appreciation from both the patients and the nuns was obvious. Dangbo is a small unit but the HI mission provides surgical access to a group of people who have otherwise minimal opportunity. We left with the clear message that they would like us back.

Campaign Hernia surgery, Ventanilla June 2018

The campaign of Hernia International and Cirujanos en Acción took place in the public hospital of the Ventanilla neighbourhood in Lima, Peru, from 11^th 21^th last June. 8 days of full work.

Team: General Surgeons: Jose Mª Perez Alfranca (CA), Nicola Clemente (HI), Juan Porta Medina (CA), Irene Miron (R4), Laia Torrent (R3), María Pitarch Martínez (R4)             Anaesthesists: Beatriz Fort Pelay (CA),   Javier Mora Burbano (CA), Guadalupe Sedeño(CA).

The group arrived in Lima on the 9^th and 10^th last June and lodged in the Miraflores neighbourhood at about 20 km from the hospital.

The Ventanilla public hospital is 11 years old, it has about 10 royal beds for the surgical service, with 14 surgeons, 6 anaesthetists and 17 nurses. They are very well prepared at their level (level II), and very specially the one of the infirmary with excellent collaborators. We would like to express here our appreciation for such professionals. 

The social and financial traits of the neighborhood are rather low, being in the periphery of the area controlled by the Barrio del Callao with its tendency for independence, self-control and closeness to the harbor and the airport.

The daily trip from our quarters to the hospital through a thick traffic took between 30 and 45 minutes. We reached the Centre before 8 a.m. and started our work at once. We dealt with 20 to 25 patients, and we finished at 4 or 5 p.m. Between 2 and 3 we had lunch. We want to express our thanks for the menu as well as to the staff.

The surgical staff deserves special mention, particularly Doctor Bernaola.

The operation theater has 5 rooms. We operated in 3 of them, and occasionally in 4 with the collaboration of local surgeons. The 5^th was reserved urgencies which, as is usually the case, were gynecological urgencies.

The patients were listed in a waiting list which had been prepared through an “Informative Campaign” through local media of the Callao Regional Government which insisted on the gratuity of our work. This gratuity did not reach the intervention as such and the anaesthetic and surgical material which the patient usually has to pay from his pocket in spite of it being a public hospital.

The list included local patients who had been previously examined the surgeons from the Department in their pathology and preoperatory. Both were seen by our group who approved them all except for two cases in which the previous pathology was not found.

About 170 patients from about 150 (as recorded in another document) were treated. The group contributed anaesthetic material, medicines and sutures. We used the instruments of the Centre.

The results of the campaign are recorded in a separate document.

As a commentary on procedures we must say that they were chiefly ambulatory and relatively simple, against what one expected to find in such a depressed zone. Factors like the difficulties to remain hospitalized postoperationally 24-48 h. made it impossible to treat other pathologies as we would have wanted.

With due protocol we were welcomed and given farewell by the Direction and Head of service in two official meetings, and we treated to night supper on the 21^st.

We end by saying that our group of voluntaries has shone an excellent technical level and a human quality which have made of those days a fantastic experience.

My personal greeting for all of them. They have been fantastic companions.

Dr. José María Pérez Alfranca

Team Leader

Hernia International Mission:

Bewal, Pakistan, April 2018

 If you were to choose an ideal location for a Hernia International Mission, it is unlikely that Pakistan would come to mind. Since 2014, however, the Bewal International Hospital in the Pothohar region of Pakistan has successfully hosted such a mission with a tally of 293 hernia procedures completed.

Pakistan-Kashmir Border

Officially the Islamic Republic of Pakistan, created in 1947, this beautiful country is home to diverse landscapes ranging from hilly and mountainous regions through ancient and historical monuments and finishing in bustling, crowded cities. Perhaps most notorious and very evident is the hospitality and generosity of its inhabitants.

Many people in Pakistan, particularly those in rural areas, are affected by both poor access to healthcare and the variable quality of these services. Bewal itself is a small town approximately 50 miles from Islamabad on the east border of Tehsil Gujar Khan in the Rawalpindi district. The Bewal International Hospital, which opened in 2010 serving a population of approximately 300,000, is a modern facility that aims to provide quality healthcare services for those in need, regardless of ability to pay.

Bewal International Hospital

 The hospital has 2 operating theatres which were ready and waiting for our 4 days of operating from the 2^nd to the 5^th April. Patients had identified in the weeks leading up to the mission and were ready and waiting for our arrival on the Monday. Our team consisted of Atiq-Ur Rehman, who alongside other ex-patriot Pakistanis’ had designed, fundraised for and overseen the building and running of the hospital and its’ previous missions, Dr Sajed Mohammed, a consultant anaesthetist based at Russells Hall Hospital, Mr Hakan Gök, a consultant surgeon specializing in hernia surgery from Turkey and myself. Mr Khaleeq-Ur Rehman, a maxillofacial surgeon and a founding member of the hospital was also on hand to assist and arrange much of the logistics of the mission.

The Team outside the Operating Department

Operating

 Over the 4 days we performed 71 hernia repairs, including inguinal, umbilical and epigastric herniae as well as a couple of incisional hernia. The vast majority of these were performed under spinal anaesthesia. Paediatric hernia repairs were also performed under general anaesthesia which provided its own unique challenges given the age of the anaesthetic machine and the difference in monitoring that is accustomed in England. To provide some variety, an open cholecystectomy and 3 excisions of lumps were included in the mix.

We were supported by an incredibly hard-working team from the hospital, without whom the mission would not have been possible. In particular we would not have been able to accomplish the number of operations we did without the work of the local ODP who not only performed a large number of spinal anaesthetics, but also acted as runner and assistant on a number of occasions. In addition to this, surgical residents from nearby hospitals attended each day which was a high help.

Having worked hard over 4 days we allowed some time to see some of Pakistan and spent a day sight-seeing around Islamabad. Islamabad is a new city, surrounded by beautiful scenery including the Margalla Hills which provides views over the entire city. Other sights included Faisal Mosque, one of Asia’s largest mosques which is said to hold around 100,000 people and is a mix of both traditional and modern architecture, and the Pakistan Monument which highlighted the unique history of this country.

Margalla Hills

The Pakistan Monument at dusk

During the week we were fortunate to be housed in a beautiful (and new) family house in Bewal with the added luxury of an excellent chef. Numerous family members and friends visited providing support (and more food), making us feel welcome and at home in their country.

The week spent in Pakistan was an amazing experience. Having the opportunity to visit this beautiful country and be welcomed into the community was an immense privilege. The ability to provide surgical care to members of the community was an added bonus. I would encourage anyone looking for a challenge to consider a Hernia International mission and contemplate the captivating country of Pakistan as your destination.    

 Emma Upchurch

Surgical Registrar, Gloucester Royal Hospital

MEMORY OF THE MISSION CARRIED OUT FROM 19 TO 28 APRIL 2018 BY “CIRUJANOS EN ACCIÓN” IN THE “ESTHER & JERELINE MEDICAL CENTER”OF GANTA CITY (LIBERIA)

The Ganta City (Liberia) mission was proposed several months in advance, and from the start it was a wonderful challenge: for the majority of the members of the team (except the lady anaesthetists) that was our first visit to Africa. The team was finally made up by 9 members:

César Ramírez (surgeon and team coordinator), Javier Moreno (surgeon), Elena González (surgeon in residence, 5^th year), José Pradillos (paedriatric surgeon), Inma Giménez (anaesthetist), Ana López (anaesthetist) plus Paco Gomez, Sara Corredera and Verónica Fernandez. On April 19 we started each from his or her city (Málaga, León, Valencia and Murcia) and we met in the Casablanca airport to take our Air Maroc flight and its 23 hours to Monrovia. Then after a 4 hours flight in a commercial plane with unbearable heat, we reached Monrovia at 2.25 a.m.

We found waiting for us the Medical Director of the Esther and Jereline (E&J) Medical Center and alma mater of the local mission, Dr. George, and the highest authorities of that center. The Monrovia airport is small, all up-and-down, and lacking even the minimal conveniences of safety and luggage control, with a single customs with works with utter laziness. In this mission we’ve had no problem with our luggage (10 bags 30 Kg each, including a generator for electrical scalpel) thanks to the help we got at the Málaga airport from an Air Europa pilot, Nacho Ballesteros, personal friend of Dr. Javier Moreno, who worked hard to get everything properly done. For Verónica, Sara and Elena this was their first mission with “Cirujanos en acción“; the rest of us had already taken part in previous campaigns.

The way from Monrovia to Ganta City takes almost 4’30 hours along a rudimentary commercial road, and we occupied 3 local lorries that Dr. George books for us for all our stay in Liberia. Our lodgings in Ganta City are in a small guesthouse called Jackie’s Guest House where we have been able to choose either individual or shared room; that is the best available in the city and we have hot water, air-condition and a “tex-mex” meal, more than acceptable, which does for breakfast and supper “in situ”, and is taken along to the E&J Medical Center at lunch time.

There is absolutely nothing worth seen in Ganta City and no possibility for any excursion to touristic places, so that our days had been intense and very repetitive. Every morning we met at 7.30 a.m for breakfast, and half an hour later they took us to the Medical Center. On arrival we found a group of patients (children and adults) who had been called by the local doctors so that we would evaluate them.

Daily one of the surgeons of our team and the paedriatic surgeon had a small room in which we saw the patients, examined them selected them for surgery. No pre-operation information has been asked by us, and the patients (children and adults) have been operated after the surgical evaluation.

The E&J-MC is something similar to what in Spain could be a small ambulatory with two operation theaters whose sterility conditions are just basic, and then a small room for patients had been arranged for a third operation theater. We have practically no material as it is a medical center in which only caesarians are performed, and now they are just beginning to carry out some caesarians as acute appendicitis.

Though there are respirators in the operation rooms they cannot be used because there is no oxygen; thus when general anaesthetic with breading help is required for some patient, this has to be ventilated by hand by the anaesthesist.

We had brought 3 whole sets of surgical material to operate hernias and one for paediatric surgery which we donated to the E&J-MC when the mission was over. We have fully utilized the more than the 300 Kg of surgical material we had brought with us, as they hardly have any gloves, gauze, antiseptics, sterilized gowns, sterilized fields, dressings (in fact since our coming, they have made use of our material for their surgical needs). Similarly we have taken their and the donated to them more than 200 boxes of omeprazole, paracetamol and analgesics for their use in Ganta City.

During the mission a total of 175 patients have been operated upon (83 children and 112 adults) with 249 surgical interventions. In 74 patients (almost a 40%) several 2 or 3 processes have been carried out. We have been struck by the amount of patients with inguinal hernia who associated umbilical hernias of at least 1.5-2 cm, and all the more as the majority were young, thin and with apparently good mussels. We have utilized 80 mosquito net gauzes donated by Hernia International and about 100 large opening and low molecular wait which had been donated by BBraun; we had enough and to spare. The patients remained for a night (the hospital has some common rooms for 3-4 patients and then one large common hall for men and another for women, were at least 20 patients could be accommodated. They were revised by us early each day to be able to release them and realize that there was no problem. A patient operated upon for an epigastric hernia had to be operated again for an important hematoma on the first day after the operations, and 4 patients have presented minor postoperation scrota hematomas which have needed no intervention. For a personal petition of Dr George we operated upon two young women with evident symptoms, who otherwise they wound have never been healed.

The medical and administrative authorities of the E&J Medical Centre have been most help from the start. We have received all kind of help, and all have tried to make us happy. On our arrival and farewell we were received with local songs and prayers by the local people, and as a special thanksgiving they have gifted us clothes with local motives which we’ll keep with all love. They have repeatedly asked us to come again as soon as possible because they are very much in need, and we surely will do it as it has been an unforgettable mission.

TANZANIA    2 0 1 8

1^st Austrian “Hernia International Foundation” Mission

Korogwe, February 24^th – March 3^rd 2018

Our group was the 10^th Hernia International team to Korogwe. It consisted of 6 members: 2 surgeons, 2 anaesthesiologists, 1 radiologist and 1 nurse anaesthetist.

Before our travel, we did not all know each other. Through common friends, a team was assembled , which later showed to be a good one. We travelled separately. Unfortunately, the intended plan to host the first African surgeon on Hernia International Mission (Dr. Peter George from Liberia), had to be abandoned due to problems during his flight. The team met in Triniti Hotel close to Dar es Salaam airport. After breakfast, we travelled to Korogwe on mainly good, but busy roads for the next 6 hours. During this trip, and later on in the hospital, an observation was made that after being here in 2015, Tanzania has been making progress in every sense (roads, traffic rules, infrastructure,…). In Korogwe hospital, we were warmly welcomed by the hospital’s medical director and Dr. Avelina Temba as the 10^th Hernia International team, after starting in 2013.

        

 Warm welcome in front of the Korogwe hospital

Immediately after that, we visited the patients and arranged the surgical programme for the first day. We nearly managed to retain all of our equipment with just 1 piece of lost luggage missing. We bought sutures from a local pharmacy. Operations were planned parallel on 3 tables, however this had to be reduced due to the unpredicted absence of 1 surgeon. However, our host, Dr. Temba was willing to operate on table 3 on almost all days. Operations started with 3-4 paediatric cases on table 1, these patients got general anaesthesia and caudal blockage, then we continued with adults, mostly also in general anaesthesia due to large hernias. On table 2, mainly large inguinoscrotals, up to H420 cm-(Kingsnorth classification) were performed mainly in spinal anaesthesia. On table 3, Dr. Temba performed diverse procedures, mostly in local anaesthesia, partly in spinal as well. Table 1 and 3 were sometimes occupied by local surgeons performing emergency procedures. A very well organised, local team was of big help to us. Also, there was a big interest from local surgeons to learn modern hernia procedures.                                                   

   1 OT was well air-conditioned, the other partly (AC was out of order on the second day) so Maria and Marija showed a lot of bravery, working at 37 ^oC while wearing surgical coats. Strong headlights were a good idea to take with us. Although lighting were working in 2 theatres properly, they were not very bright. The diathermies were working well, despite regular power cuts.

 Maria and Dr Agripina during surgery

 Jurij during teaching retrorectal Rives-Stoppa

In the first three days, the work in all three operating theatres (OTs) ran smoothly from 8 am to 9 pm or even later. Arranging the surgical programme for the following day was the last task every evening. On day 3, after a good dinner in a local grill restaurant on Korogwe main road, we decided to reduce the working hours for next 2 days. This was done partly allowing teambuilding and to enable the local staff to relax and tidy up in the evenings. On the next day, after finishing surgery, we were honoured by visiting the monastery and private hospital of The Sisters of Usumbaya (a catholic order of sisters, to whom surgeons Dr. Avelina, Dr. Archangela and Dr. Dativa belong). Around their monastery various tropic trees with diverse fruits were growing, and considering the peaceful atmosphere of people praying, we almost had the impression of being in the garden of Eden. The private St. Joseph Hospital close to the monastery has just been expanded with a new maternity ward. In this building, a donated ultrasound machine, a gift from Dr. Michael Wutte from Austria, which we brought to Tansania,  will be installed.

On the last day, after finishing surgery, we visited a local market acompanied by surgeon Dr. Ahmad and were in awe of the diversity of groceries and other articles sold by the locals. The final evening party, organised by ourselves and hospital staff in our guest house (Magnificent Korogwe Resort), consisted of speeches thanking the work that had been done, a buffet dinner and some dancing.

Special thanks were given to local surgeons, who performed the early morning rounds every day for all of the patients. This was a big time saving for us, allowing us to start with surgery immediately after arriving to the hospital. The Korogwe hospital has about 15 doctors and 100 beds, making this organisationally possible. We personally checked dressings and removed drainages in incisionals and some large inguinoscrotal hernias Korogwe hospital has about 100 beds, around 15 doctors are working there.

 Michael, Hannes and Sarah during education, which was an important part of our mission   

Ultrasound procedures were very useful not just for our patients (undescended testicles, hernias, …), but also for emergencies. Unfortunately, regular power cuts limited the number of ultrasound checks we could carry out. When Marija, our radiologist, was not busy in X-ray department, she assisted Maria in OT2. Women are capable of multitasking! This proof came also from Sarah, the anaesthesia nurse, who helped everybody, besides being a great support to our skilled anaesthesiologists Michael and Hannes.

Lunch break and refreshments were always welcome. The kitchen lady Scholastica took abundant care of us (rice, vegetables, some local specialities, chicken, water, coffee, peanuts).

Staying in Magnificen Korogwe Hotel was a good suggestion, given to us by Dr. Katharina Wentkowski from Switzerland. It is much closer to the hospital than other Korogwe guest houses. 20 USD/night was reasonable, but there was no WIFI available This was solved by our radiologist, who bought a local Tanzanian SIM card and offered us to use the hotspot.                  

In 5 working days we performed 72 procedures on 66 patients (16 female, 50 male) on 2, sometimes 3 tables. Our anaesthesia team performed two additional long-term general anaesthesia’s for emergencies. The average age of the patients was 44,4 years. The oldest patient was 100 years old (no official confirmation), the youngest 1 year and 2 months. The majority of patients had large inguinoscrotal hernias (34).

We repaired inguinals using the Lichtenstein (33 patients) and the Shouldice technique with one young patient. In 15 paediatric patients with inguinal hernia, the Mitchell Banks and Ferguson techniques were used. We performed 4 incisional repairs (2 sublay – retromuscular Rives Stoppa and 2 onlays), 11 direct umbilical repairs, 2 undescended testicle repairs (orchidopexies). We were blessed having no complications. The anaesthesia was predominantly spinal with 43 cases, 22 patients had a general anaesthesia, local anaesthesia was done in just 11 cases.

A lot of above mentioned procedures were partly or fully performed by local staff (surgeons, anaesthesiologists, nurses).

For the second time, the presence of a radiologist on our mission confirmed to be a good idea: 12 performed ultrasound diagnostic checks preoperatively, 12 other outpatient ultrasounds, 2 emergency ultrasounds and 18 sonography checks on pregnant women (altogether 44, including education).         

Special thanks go to  the well coordinated work between anaesthesia and surgery and of course, with local experts. We did not need to talk much to find right solutions in situations that needed to be discussed. The comment of Dr. Avelina was very appropriate: » It was a calm and blessed mission«.

Although we travelled as the 1^st Hernia International team from Austria, our skill, experience and enthusiasm originates from different countries and hospitals. The anaesthesia team comes from large clinic (Feldkirch in Vorarlberg) in the west of Austria and surgical team comes from Carinthia (south Austria). The radiologist, whose task was performing preoperative ultrasounds and introducing the donated ultrasound machine to local doctors, came from Ljubljana clinical centre (Slovenia).

–         Michael Wirnsperger (consultant, anaesthesiologist, 1^st mission)

–         Hannes Lienhart (consultant, anaesthesiologist, 1^st mission)

–         Sarah Bertsch (anaesthesia nurse, 1^st mission)

–         Marija Jekovec (consultant, radiologist, 2^nd mission)

–         Maria Greiner (consultant, surgeon, 2^nd mission)

–         Jurij Gorjanc (consultant, surgeon, team coordinator, 8^th mission)

 To view a short film about the mission, click on the following link:

https://drive.google.com/file/d/1ybgCiGFt-re7jdts3lpVskLRhiBWy61e/view

FARAFENNI GENERAL HOSPITAL

 REPORT ON HERNIA INTERNATIONAL MISSION

 (SPANISH GROUP) TO THE GAMBIA

12^th – 16^th MARCH 2018

Compiled By

Farafenni General Hospital Management

Farafenni

North Bank Region

The Gambia

20^th March 2018

BACKGROUND

The Hernia International Organization a multi – European Humanitarian group started partnership with Farafenni General Hospital in 2007 marking the beginning of the organization’s first Hernia Camp in the Gambia.

Preparations for the March 2018 Mission began in December 2017 with the submission of a letter of intent to Dr Andrew Kingsnorth coordinator for Hernia International from the Spanish team leader Dr. Antonio Satorras a General Surgeon. The team includes; 1 General Surgeon; 2 paediatric Surgeons; 1 Anesthetist and 2 Theatre Nurses.

OBJECTIVES

The objective of the 2018 mission were;

1.      To offer surgical services mainly hernia but not limited to hernia alone to patients needing surgical care including children.

2.      To reduce the backlog of patients on waiting list for surgery at Farafenni and other facilities in the Gambia.

PREPARATION

Following clearance for the mission obtained from the Office of the Director of Health Services, Ministry of Health & Social Welfare dated 2^nd February 2018, the Hospital Management established a local support team including a Doctor; Anesthetist Technicians; Theatre Nurses; General Nurses and other support staff to work with the mission. From the success registered in the last Hernia Misssion, the local team were encouraged to work with the vistiong team hence the establishment 3 key task-forces.

1.      Clinical: assigned with the responsibility of screening and booking (including contact details) of all hernias and related cases seen at the clinic.

2.      Communication: responsible for sensitizing the general public including health facilities using the local radio and influential community members.

3.      Logistics: Identifying and mobilizing the required resources needed for the mission and these includes; medical supplies, drugs and personnel.

The units that were fully involved in the preparation process included Administration; Nursing Department; Operating theatre; Laundry; DRF Unit; Security; Generator Unit and Catering Unit.

SUPPORT FROM MANAGEMENT

To achieve success in this mission, Management ensured that;

1.      The visiting team’s movement was well coordinated with support from the office of the Director of Health Services by providing transportation from the Airport to Farafenni and back to the Coast after the completion of the mission.

2.      The visiting Doctors and Nurses were cleared through the Ministry of Health.

3.      Drugs and supplies needed for the camp were made available.

4.      Staff identified (local team) were available at all time (8AM – 9PM daily) during the course of the surgery.

5.      Food and water was available to avoid interruption of services by providing lunch for the local staff while a hospital cook prepared meals for the visiting team.

OUTCOME

The 2018 Spanish Hernia Mission operated on 51 patients with varied surgical conditions. Of the total cases performed, hernia represents 72.5%; Lipoma 7.8%; hydrocele 15.6%; and Keloid 3.9%. Of the total patients operated on 46 (90.1%) were males and 5 (9.8%) were females. Gambians represents 84.3% of patients and non-Gambians accounted for 15.6%. Children under the age 5 represents 15.6% of all patients operated on.

SEX	NATIONALITY	CONDITIONS	AGE DISTRIBUTION
M	F	Gam	Non-Gam	Hernia	Lipoma	Hydrocele	Keloid	< 5yrs	> 5yrs
46	5	43	8	37	4	8	2	8	43
90.1%	9.8%	84.3%	15.6%	72.5%	7.8%	15.6%	3.9%	15.6%	84.3%

Table above shows summary statistics of the 2018 Spanish Hernia Mission  

CONCLUSION

The Mission was a success despite the feeling among the team that more could have been done. However, given that it was only 3 months ago when we had a camp that operated on 78 patients, registering 51 for this mission is a significant milestone. I must also acknowledged the transfer of skills between the visiting team and the local team.

The Hospital Management would like to register appreciation to the Spanish Mission and by extension to Hernia International ably coordinated by Dr. Adrew Kingsnorth. The local staff must be commended for their dedication and commitment. We also register gratitude to the Ministry of Health for the technical support and encouragement through out the process.

Wandifa Samateh(MSc,RM,RN)
Chief Executive Officer
Farafenni General Hospital
Ministry of Health and Social Welfare
Banjul, The Gambia