Author: akingsnorth

REPORT SHINYANGA. TANZANIA 2018

We began our journey to Tanzania at the Barajas airport on 9^th March 2018. We met a few hours before to pack the material and get to know the whole team. For some of us it´s the first experience as cooperators, others with some previous experience, but all with the same illusion that this type of missions entails. We invoice without problems 9 packages of 23Kg each one. A long trip awaits us, from Madrid to Addis Ababa (with a stop in Rome) and from there to Dar es-Salam, where we have to spend a night before leaving for our final destination, Shinyanga. At the airport we obtain the visa for entry into the country without problems, although after a long wait. We passed the customs with all the material without problems thanks to Dr Chacha, pediatrician in Shinyanga hospital, who comes to pick us up at the airport with all the necessary permits. We have more than 24h of travel, so we went to the hotel to leave all the luggage and go out to explore the city. The driver of the hotel takes us for a walk around the city, to a market of local crafts and finally to enjoy a pleasant dinner in a restaurant with terrace by the sea. The next day we know the fishing port and the market, where there is a frenetic activity with people cleaning and selling fish or cooking to eat there. There are also multiple stalls where they sell starfish, all kinds of shells of all shapes and colors imaginable. We also visit the national museum, a good place to get to know the culture and history of the country we visited. To finish our short stay in Dar es-Salam we went to the beach to taste the warm waters of the Indian Ocean, unknown to many of us.

We return to the airport to catch our internal flight to Mwanza, where we landed at 9:30 p.m. on 11^th March. There, our hosts pick us up with a bus to transport us to Shinyanga, where we arrived after 2 p.m. The hotel they have chosen for our stay is very pleasant, with spacious and comfortable rooms, bungalow type, with air conditioning and WiFi connection (although it started to work on the thirdday of our arrival). There are a garden area and terrace for outdoor dining, which allowed us to have very nice dinners next to our well-deserved beers after the long days of work.

 The next day we finally arrived at the Shinyanga hospital, 3 days after our departure. There, Dr George, surgeon in charge of coordinating the mission, and Dr Onesmo, who has been in charge of recruiting patients, await us. With them we began to coordinate to start operating patients as soon as possible.

We are informed that each patient (except children under 5 years of age) must pay 80,000 TZS (approximately 29 euros) for hospital and personal expenses. In addition, there are waiting for us 2 inspectors of the TDFA (Tanzanian Food and Drugs Authorithy), who review all the material for hours, confiscating everything they do not consider adequate (sutures recently expired) and withdrawing medication with an expiration date nearby.

Meanwhile, we started reviewing patients and scheduled the first surgeries. Once all the material was placed and the operating room was prepared, we began to operate that same day in the afternoon. We settled in one of the 3 operating rooms available in the hospital, to operate in two tables separated by a screen.

One for children and one for adults. And so we began a very hard campaign, working about 14 hours every day. The selection made by Dr Onesmo was excellent, it was only necessary to review some patients with diagnostic doubts and some pediatric patients. Approximately 18 patients were operated daily, with a lot of effort and dedication from our team, who every day gave everything to carry out all the daily work, including Sergio, our photographer, who did an accelerated nursing assistant course. The collaboration on the part of the native staff was quite deficient, although I must emphasize the enormous collaboration of Dr Onesmo, Dr Nelson, Simon (anesthesia technician) and of course, Ezequiel, who did everything on their part to help us. The work days were so intense, that we didn´t have any time to know the city, only the surroundings of the hospital and the hotel. Every day they served us the lunch in a hospital room. The food was good and plentiful.

After 5 and a half days of intense work, we are ready for our return. Again driving to Mwanza, with a tyre puncture included in the middle of nowhere. At the airport they open all the packages before entering and check all the material, despite having all our permits in order.

Finally we arrived in Madrid after 10 days of travel, with a strange feeling. Maybe we could have done better, maybe we could have operated more, but the conditions were what there were, and things don´t change in one day. I hope that in future campaigns, all the problems that were presented to us in this first mission in Shinyanga, can be solved and thus be able to carry out more useful campaigns in a hospital with a lot of potential.

After a month of our return, after which I had contradictory feelings regarding this mission, I only have in mind the good things, the smile of the children when giving them a toy or a simple caress, with their parents grateful for our help, and all the patients that we have improved their quality of life after our passage through Shinyanga. In the end this is the essence of this work. And of course, in my mind there is always the team spirit, the union that occurs between the group, especially in the difficult situations that have been presented to us. Without a doubt, this has been essential for the development of this mission and the reason why there is always a desire to repeat a mission . ASANTE SANA.

TECHNICAL MEMORY:

 PARTICIPANTS:

Ana María Gay Fernández, general surgeon Álvaro Cunqueiro Hospital, Vigo

Pablo Lozano Lominchar, general surgeon Gregorio Marañón Hospital, Madrid

Lucía Garrido López, 4th year resident of general surgery Álvaro Cunqueiro Hospital, Vigo

José Miguel Morán Penco, pediatric surgeon, Quirón Salud Hospital, Cáceres and Badajoz

Beatriz Revuelta Alonso, anesthesiologist, University Healthcare Complex of León

Almudena Ceballos Ruano, nurse, Poniente Hospital, Almería

Sergio Sánchez Agullo, photographer

DURATION: Departure from Madrid 9^th March 2018, arrival in Madrid 19^th March 2018.

RESULTS OF THE CAMPAIGN:

Adult surgeries: 44 patients. 50 procedures.

Inguinal hernias: 34

Eventrations: 3

Hydroceles: 5

Epigastric hernias: 5

Sigma volvulus: 1

2 reinterventions for hematoma.

Pediatric surgeries: 34 patients, 41 procedures

Inguinal hernias: 15

Umbilical hernias: 5

Cryptorchid: 4

Phimosis: 5

Hydroceles: 1

Burn Cures: 3

Other procedures: 8

THE HOSPITAL:

It´s a large hospital, with 3 operating rooms and several rooms for hospitalized patients, for men, women and children separately. They have a sterilization room with an autoclave. The cleaning of the hospital and specifically the operating room area is very poor. In addition, the operating room area has many windows, which are permanently open, with the consequent entry of insects and dirt from the street.

SURGICAL MATERIAL:

-They don´t have any electric scalpel generator that works correctly, neither terminals and plates.

– They have a lot of surgical equipment, although quite old and rusty. Some boxes for laparotomy are in good condition, but the material for hernia surgery is very poor. They don´t have specific material for pediatric surgery, because children are not routinely operated in this hospital.

-they have gowns and surgical covers, but not enough for daily surgeries that are performed in this type of campaigns, so it´s convenient to include gowns and surgical fields, as well as gauzes and antiseptics.

-they have a lamp on each operating table, but light cuts due to overload are frequent, so it is advisable to wear a frontal light.

– Pediatric patients with severe burns are taken care of daily, so it´s important to take material to make cures of this type

ANESTHESIA MATERIAL:

-The hospital is equipped with a modern anesthesia machine and an older one, one in each operating room. We used the most modern one, to be able to do pediatric anesthesia. It consists of two vaporizers: one of halothane and the other of sevorane. They only have halothane, but for future missions it is good to know, for the possibility of getting sevorane and use it. The oxygen was in bottles, and they have enough for surgeries that were performed

-With regard to the medication for general anesthesia, there are muscle relaxants such as succinylcholine, ketamine and little else, so it is important to carry everything we consider necessary.

– Endotracheal tubes, aspiration probes, after being asked repeatedly, appear. There aren´t laryngeal masks.

-Fluids, systems for intravenous lines are available,

-We work in two tables in the same operating room, as already mentioned. At one table we made adults and in the other one children with the respirator. There are also several oxygen concentrators, so it is possible to use them if necessary.

-Staff local, there are no anesthetists trained as such. They are anesthetic technicians, who perform mainly spinal anesthesia, but also general anesthesia when surgery requires it. They have a great capacity to adapt to the situations that are presented to them, taking into account the means at their disposal and the little accessibility to the best in our speciality. They listen everything we told them and try to use devices like masks, which they have heard but have never seen. Their collaboration was essential to carry out the mission given the large volume of patients we had.

In summary, and although there are some material and medication, it´s preferable to take anything that we can think we need. In addition to this, the expense that we can cause over the days is diminished.

ASPECTS TO IMPROVE:

-cleaning  conditions of the operating rooms. It is necessary to place mosquito nets in all the windows.

– train local staff in asepsis and antisepsis, as there are many aspects that are unknown or poorly practiced. 

– help from local staff to expedite the entry and exit of patients to the operating room and then to the room. 

-correct identification of patients and their clinical history.

-include patients who don´t have the financial resources that have been required in this campaign.

 Ana Gay

Team Leader

CAMPAIGN IN FARAFENNI (GAMBIA), MARCH 2018.

After months of preparation and bureaucracy, on Saturday March 10, We, the Spanish team of “Cirujanos en Acción” in collaboration with Hernia International, started our mission in Farafenni (The Gambia). Two groups of people travelled to Banjul from Barcelona and Madrid: Pepa Fornier (nurse at the Hospital Materno-Infantil, Badajoz) and Inmaculada Vílchez (nurse at Hospital Universitario La Fe de Valencia), Ana Arnalich (anesthesist at Hospital Universitario Gregorio Marañón, Madrid), Asuncion Azpeitia and Nagore Solaetxe (paediatric surgeons at Hospital Universitario de Cruces de Barakaldo) and Antonio Satorras (general surgeon, Hospital da Costa, Lugo).  We arrived in Banjul at night. Once there, we could enjoy the smell of Africa and see an incomparable starry sky. We were received by Mr Sainey Dibba (the public relations officer of the Farafenni General Hospital) and by Amadou (our driver). We spent our first night at Grand Villa Guest House, a nice colonial style place near the airport.

After a short night, only altered by the imam calling to prayer, we met Mr Wandifa Samateh, Chief Executive Officer of the FGH, and we set off to our destination. We travelled along the Gambia river in a crowded old ferry. The trip lasted over two hours due to the blowout of a wheel. Eventually, we arrived at the AFPRC Farafenni General Hospital, where we were introduced to part of the local team. There are no local doctors there. That is why nurses and technicians as well as a few doctors from Cuba are responsible for the things done there. It was in that place where we had our first hot meal. As regards the facilities in the hospital, I would like to highlight the fact that there are 160 beds available, as well as two poorly equipped operating rooms. We had at our disposal the biggest one, in which there was enough room for three tables. However, there was only a real surgical table and there were just two stretchers. There was only a surgical light and an old anesthesia machine, which worked with Halothane. There was only one oxygen tank and power cuts were very frequent, so we needed to make use of our front lights.

Near two hundred kilos of materials and drugs were brought by us, including a diathermy. I would like to mention that on the one hand, we could use another local Valleylab. On the other hand, intravenous fluids were provided by the hospital. Anyway, the equipment and materials were not in good condition either (gowns, sheets and gauzes were sterilized in an autoclave there, and were often wet).

After a tiring day, we went to our hotel, the Mone Berre Lodge, near the hospital. Its spartan rooms did not comply with the minimum hygienic conditions. However, there was air-conditioning, Wi-fi connection, there were also mosquito nets and cold beers. Anyway, Rastaman (the owner) made an effort to make our stay enjoyable speaking to us and playing Reggae music.The next day, we had breakfast at the hospital at 7.30 a.m. and at 8.00 a.m. we began to work. The Spanish campaign had been announced by the media, then a lot of patients, without previous selection, started arriving at the hospital. Some of them had to be refused. Nobody had gone through a preoperative study, and there was no time nor a possibility to do so. Almost nobody spoke English, but we had Mandinga and Wolof (the main local languages) translators at our disposal. Finally, after doing a first selection and solving some new technical problems, we could start with the surgery. Yudelines Denis (a Cuban General Surgeon) and Luís Anglada (a Cuban Anesthetist Technician) who work at the Medical Centre, were of great help for us as they started working partially as part of our team. They explained to us about the local idiosyncrasy and the African way of doing things. Thanks to their help, we could operate eleven patients (both adults and children) who were suffering from a total of 13 pathologies. This way, we put an end to the first but exhausting working day. It was a bit later that we were told those patients had to stay at a recovery room without any monitoring system and without any qualified medical staff. That is why while we stayed there we tried to teach the local staff as much as we could though the results were not as good as expected.

At cockcrow and the call to prayer we began a new working day. We were picked up and driven to the hospital at the fixed time. The meals were made by a local cook. Breakfast and lunch at the hospital and dinner at the hotel were served for six euros per person a day. We could eat rice with vegetables and a different side dish every day. The food was very tasteful. But the hygienic food storage and preparation was not the best.

We decided to establish some rules so that the patients who were going to be operated had to arrive shaved and washed to the surgery. The working pace, there, is different from the one we are used to and for that reason only a maximum of twelve patients could be operated a day (3 per turn and team). Those were from Gambia and Senegal. They were mostly men. It seemed to us that women did not require our services… Nevertheless, women came to bring their children (who usually suffered from malnutrition). Medical treatments were cheaper than usual there but not free; and almost everybody had to remain hospitalized for a night. In case any of them required a check-up to remove the drain, they had to stay at one of their relatives’ house and could come back to see us two days later.

We had to be really careful in order not to be infected with AIDS or hepatitis. Then, wearing double gloving was recommended by local doctors.Despite having informed the Head of the hospital about the members of our team thoroughly, the number of pediatric patients was very low. It was a pity they missed the opportunity of being helped by the two experienced and available pediatric surgeons. On Thursday, we were astounded as only a few people attended the medical practice. There were only six people to be operated, so we had a free afternoon and we could visit the Farafenni’s market.

Although they had organized surgical activity for us to do until Friday morning, we decided to work later the last afternoon to help as many patients as possible before we left. On Friday night, they celebrated a farewell dinner (both surgery staff and management staff attended it). They were very grateful to us and so they gave some speeches to let us know.

On Saturday just before coming back, we visited the Wassu Stone Circles, a megalithic and world heritage monument of the UNESCO, and the old slavery place of Jamjamboreh. On the road, our van broke down and we had to wait four hours for another one to arrive. Then, the trip lasted 3 hours at night. The cars had no lights. We travelled in a crowded ambulance along dark roads. On the way, we met risky pedestrians, free animals (a run-over sheep), and dozens of police controls. Luckily, in the end we arrived at Leybato Beach Hotel where we were able to rest in appropriate conditions. On Sunday we could visit a crocodile pool at Kachikaly, we could also see monkeys at the Banji National Park, we could go on a boat ride through the mangroves and to the fish market in Tanji. At night we took our flight. A stopover at the airport in Casablanca allowed us to visit the city for a while. Finally, we arrived in Madrid save and sound.

The final result of the campaign has been very positive. We assisted fifty-three patients in total with sixty-one processes due to double pathologies. I would like to highlight not only the number of patients we had assisted (41 adults and 12 children, aged between 1 and 5. Most of them (48) were male) but also the human and technical quality we could offer with the limited resources we had. Regional anesthesia was used in 35, general in 14 and 4 were done under local anesthesia. Inguinal hernia, some of them giant, was operated in 38 patients; mesh hernioplasty was done in all adults. 12 hydroceles, 4 umbilical hernia, a non-descended testicle and 6 lipoma were also treated. Only one hydrocele patient needed a review after early hematoma. All the others went right.

Expenses other than plane tickets were 16€ for accommodation and 8€ for meals per person and day. Lots of water bottles were included. We had no other expenses apart from tips, excursions and last-minute gifts.Once the mission has finished, we think that it would have been better a duration of two weeks, because when things started to work well, we had to go. Perhaps, with more time we could have taught better to the local staff, some of whom were very willing and eager to learn. But this will be on future visits.

 Antonio Satorras

Report UGANDA Campaign 2017

Holy Innocents Health center – Kamuturu  

Bukedea  

Kamuturu, Mbale – Uganda

1-10 December/2017: Uganda Campaign

(COLLABORATION: SURGEONS-in-ACTION and HERNIA INTERNATIONAL)  

Team leader: T. Butrón

Team:

General surgeons: Teresa Butrón, Sebastián Fernández Arias, Francesc Marsal, Sol Villar.

Anaesthetist: Beatriz Revuelta, Blanca de Prada

Nurse: Manuela Dorado

After a year of uncertainty and cancellation of the mission, on the month of October, with Hernia International in Sodo (Ethiopia), Cirujanos en Acción together with Hernia International organizes the first mission for Kamuturu (Uganda).

The references of the hospital where we are going to work imply that it is a rural center under construction, with a project for extension, about which the director provides information, situated at the North-East of the country and, according to the information given by Sister Clare Nantandwe, in charge of the centre, is about 4 hours by road from the Entebbe airport.

The seven members of the group, 4 surgeons, two anaesthetists and one nurse, planned out in a short time the trip to Uganda. Finally for several reasons we decided to travel with the company Emirates via Dubai till the Entebbe airport, situated at about 40 km from Kampala, capital of Uganda. The Emirates company told us that the total weight accepted without pay would be 30 kg per person, so that we reduced our luggage to 210 kg without any extra kilograms.

On December 1^st the group started from Spain with a short stop in Dubai till Entebbe, to Entebbe, Uganda’s international airport. More than 11 hours flight.

Customs were not more complicated than those in other African countries, and our having our visa in advance, having got it through Internet, facilitated our way without any complication, with all our luggage book out previously.

In the airport we were received by the driver who took us to our destination. Our surprise, after our long trip to Uganda, begins with the slowness in traffic, as we had to cross Kampala, the capital of the country, on Saturday evening and from West to East, without any round way that would avoid the heavy traffic in the city. Getting out of the capital took us more than two hours of heavy traffic till we got to the road that links Kampala to Mbale more than 300km ahead. Since in Uganda night comes at 06:30 pm our journey took place mostly at night, through a very poor road with too much traffic and through cities where speed should be diminished, but the Uganda drivers never did that. This gave us, Europeans, a very bad impression.

After more than 8 hours travelling, with the last part of the way (about 40km) through a rural path, our driver decides not to go ahead because of the bad state of the road, so that we had to finish our way walking with our luggage in hand and with lights on our foreheads. The whole team took the situation as part of our adventure, and finally about 01:00 am on Sunday December 3rd we arrived at our destination. Moses and his helpers shifted all the material in our trips on a motorcycle without any problem.

After settling down in our rooms, which were comfortable African shacks with beds, sheets and mosquito nets, we took the supper the Sisters had prepared for us.

On Sunday December 3^rd we woke up at 06:00, and after an African shower and breakfast we began to organize the operation theatre where we were going to work, unpacking the more than 200kg of luggage identified as “Cirujanos en Acción”. At the same time two members of our team examined the patients to be treated. Given that the center has not a sufficient infrastructure, particularly from the anaesthetical point of view, we did not operate upon children, so that all our patients were adults.

The provisional operation theatre of the Holy Innocents Health Center, is found in one of the pavilions in which a room was made into an operation theater. Two table-stretchers in a place that was meant for other uses would be our operation theatre where we began our work at once. The first two patients, under local anaesthetics, were operated upon for two subcutaneous lipomas, and later we went on to operate upon a total of 14 patients, where the most complex case of an intraumbilical eventration required a Stoppa reparation.

On the whole we operated upon 46 patients in five days, with the further complication that one of the members of our team had to return home for a serious family problem. We decided to go back to the airport, given the difficulties of the journey, on Thursday evening so as to make sure of our arrival with sufficient time for the return flight to Europe.

The Holy Innocents Health, a general hospital of 57 beds with an 80% occupation of beds, situated in a very remote zone to the East of Uganda, with rural centers of difficult access, started about a year ago with the idea to cater to a poor population in remote places towards the East in Uganda. Its director and founder, Moses Aisia together with his wife Sister Clare Nantandwe, administrator of the centre, manage the centre. Two family doctors control the patients for infectious sicknesses together with maternity and labour since the main aim of the founders is the reduce the number of child mortality, attack VIH/SIDA and malaria. In the staff there are also four nurses, three midwifes, two technical laboratory helpers, as well as maintenance, cleaning and security staff.

As Moses Aisia says, with the improvement in basic sanitary attention through education, formation and information, the changes will become permanent and deeper with a great impact in future generations. The patients came mainly from Bukedea (53,2%), Sironco and part of the Balubuli districts. Children under 5 years represent 30% of the patients, and approximately 64,7% are women. Moses informs that 89% of the mothers in the community give birth in the centre. It is important to mention that Bukedea was the centre of the civil was in Uganda from 1980 to 1993.

The mission that we in “Cirujanos en Acción” and “Hernia International” carry out had, among other aims, to initiate surgical assistance with the starting of an operation theatre and the postoperation control of our patients by part of staff in the centre with the idea to start new cooperation missions in Kamuturu.

We could observe that there are new pavilions being built for the new operation theater, which with the recommendations of our team and the monetary help they hope to get, could have a better infrastructure and material more complete and in a better condition if possible. The lack of ceiling lamp, plugs for connexions and respirator with oxygen concentrator, make it impossible for now to have some type of interventions and to attend to some kind of patients. Still, our team carried out with good results all the interventions that were programmed after the selection of patients.

In later conversations with Moses we have seen hoy our proposals have been carried out. First, we proposed the possibility of shifting from Entebbe to an airport close to the hospital centre so that we diminished the hours of our way by road, which according to Moses would be possible with local flights with important discounts as it was a cooperation humanitarian mission. Installation of running water in the surgical pavilion is another of the improvements foreseen by the direction of the centre in the new pavilions under construction.

In conclusion, the experience of our camp in Kamuturu, Uganda, has been very positive. The centre and the needs of its extensive population to which it reaches (more than 101.999 persons) can benefit from future missions by surgical groups or voluntaries who may like to live for some months in the hospital centre and, as its director Moses Aisia says, through a process of strategic planning they can attend to all those who may need it at their homes or in the hospital.

Dr Francesc Marsal  

Schweizerische Sektion

Section Suisse – Sezione Svizzera – Swiss Section

                                          Mission report ICS Training team, Okpoga, Nigeria,

November 2017

From November 4^th to 17^th the first mission by a training team of the Swiss section of the International College of Surgeons (ICS) was undertaken to St. Mary’s Hospital in Okpoga, Nigeria. Previously the missions were carried out by Swiss Surgical Teams, but this organisation decided to abort the project after 6 years. This years team included two surgeons (Peter Nussbaumer & Florian Oehme), an anaesthetist (Thomas Stoinski) and gynaecologist (Katrin Ochs) and a scrub nurse (Sanne van Rijn).

After an uneventful flight from Zurich to London and Abuja the first challenge was Nigerian Immigration. Thanks to our partners from the hospital and a very helpful note verbal by the Swiss Embassy in Abuja our passing through Immigration and Customs was smooth, despite the multiple boxes filled with medical equipment and consumables. Various medical companies in Switzerland donated the material. 

Immediately we continued our journey by minibus. On the road we passed cities, marketplaces, cattle and landscapes with a few huts, some made of stone some made of clay. Due to the bad condition of the usual route we had to take the long road through Lafia. After 8 hours and 450 km of pothole ridden driving we arrived at St. Mary’s hospital just before dusk. There the staff with singing and dancing warmly welcomed us.

To ensure an early start the next morning we decided to unpack our boxes and set up the theatre the same evening. This activity was interrupted by the first emergency case, a 7-year-old girl with a perforated typhoid ulcer. After a successful operation the patient was discharged a week later.

The next morning we started with a lecture* in the meeting hall. About 40 staff joined and participated in the discussion. Afterwards there was a ward round together and then work in theatre started. 60 patients were ready for screening and confirmation of the diagnosis. Some were operated on the same day, others planned for the following days. Everybody agreed to have a short list on Sunday, so we could schedule patients for 10 days. Soon we had adjusted to our day -to-day routine, the only interruption being the many emergency cases. With 6 cases of typhoid perforations we could put a focal point on teaching the concept of emergency laparotomies including staged procedures and the equally important postop care.

Sunday was the only day with some recreation, first by visiting the catholic mass in the village and later in the afternoon the get-together with traditional dancing, singing, speeches and traditional clothes for each team member.

Unfortunately one of our diathermy machines, necessary for haemostasis during surgery, was blown. The second one mal-functioned and so we were left with only one functioning machine. This slowed down work considerably and the operations went on late into the night. Never the less we were able to treat 130 patients and perform 143 operations; including 24 children aged 3 to 7 years. Despite very limited recourses and without the accustomed standard equipment our anaesthetist contributed significantly to the successful outcome of these interventions.

Once again the hospitality of the Matron Sister Christiane and her team was overwhelming. They went out of their way to make our stay relaxed and convenient.

Time flies by and already we had to say farewell. Altogether the team spent an amazing, extraordinary and unforgettable time in St. Mary’s Hospital, and we thank everyone involved for their help and support.

*The following topics were covered during the lectures:

Postpartum haemorrhage

Pre-ecclampsia

Thoracic trauma & drainage (2 parts)

Sutures: material & technique (2 parts)

Hygiene & asepsis

Inguinal hernias

Dr. Peter Nussbaumer, MD

2nd Vice President Swiss section

International College of Surgeons

Project coordinator

Hernia International: Korogwe, Tanzania November 2017 Report

This mission was the 10^th  Hernia International team to visit Korogwe and the welcome and support that we received from Sister Avelina (lead surgeon) and all the staff was heart-warming. The team comprised Katharina (anaesthetist and excellent team leader from Switzerland), Michael (medical engineer from Switzerland), Margaret (RN from Great Britain), and the surgeons Christoph (from Switzerland), Stefan and Nico (from Germany). Most of the team had previously worked together on another mission so there was a nice feeling of ‘re-union’.

The custom check at Tanzania airport is quite strict especially for the (X-Ray-dense) surgical equipment.It was very helpful that Christoph was able to show the invitation letter from the ministry of health.

Coming from different destinations we met at the Trinity Airport Hotel and spend our first night there, and at 8am the following morning our transport arrived accompanied by Justin our escort (Korogwe dentist). The Land rover roof was packed high with our luggage and supplies and secured with a much needed tarpaulin to cover. There had been heavy rains the day of our arrival and the rain continued for most of our 7 hour journey to Korgowe (Michael likened it to a cloud hernia!). The traffic was pretty dense for the first hour until we hit the outskirts of Dar es Salaam, and the rains hampered our progress somewhat but we eventually arrived at the hospital at 4pm.

We were greeted by Sister Avelina and her team and without much delay taken to the ward where 30 patients waited patiently for review and assessment for surgery. The Korogwe staff had worked hard with their preparations and recruiting of hernia patients, and were very well organised. The next day’s operating schedule was agreed and we then unpacked our supplies and set up the 3 operating rooms ready for work the next day. 

Our operating days started at 8am and usually finished by 6pm. We had superb hospital staff to work with, and the efficiency of the sterilising team was amazing – keeping up with supplying a stream of instruments and gowns throughout the day was constant work.

We completed 85 hernia procedures on 72 patients (19 female, 53 male). There were 18 children under 12 years (all had general anaesthesia). Most patients had inguinal or umbilical hernias, we operated 10 epigastric/incisional hernias, mainly in women. 7 adults had general anaesthesia. 27 adults had spinal anaesthesia and 21 had local anaesthesia. There were 6 particularly large/complicated hernias – one of which comprised a mini laparotomy and could be regarded as bordering on major surgery.

There were occasions during the week that we had to stand aside and make available the operating rooms for local emergency surgery that occurred. And it was impressive to observe quite complex surgery and clinical decisions being undertaken with such limited equipment and resources. The learning was endless, along with adapting to new ways of working

– but it has to be said that the connections with the people deepened the whole experience and made it so meaningful. Sister Avelina had invited a junior doctor in surgical training and we are happy to have taught her some hernia operation techniques for further benefit.

Michael, our medical engineer, worked unrelentingly alongside the local engineer/technician. His knowledge, expertise and educational input was invaluable. Infusion and syringe pumps were cleaned and resurrected; anaesthetic machines checked and repaired; theatre tables adjusted; diathermy machines repaired; the steam steriliser serviced and repaired; and fridges in the mortuary attended to………….. and much, much more. Michael was a real asset. If the option was available, every mission could do with having a medical engineer! 

Mid-week we changed our accommodation to the `Magnificent Korogwe Hotel (due to ongoing building work and noise at the “White Parrot” Hotel). The title probably does not capture accurately how delightfully quiet it was on an unsealed road, providing comfortable rooms and open court yards in which to relax in the evenings – all a 15 minute walk away from the hospital. The morning and evening walk to and from the hospital on a path through the villages gave insight into daily living – free roaming chickens and goats, small plantations/crops, and children going to school in immaculate uniforms. The hotel provided good food and we would recommend this accommodation for future missions. 

All too quickly the week came to an end, but it was not before experiencing (on our last afternoon) the hospitality of Sister Avelina and other nuns at the St Joseph’s convent, a 45 minute drive from Korogwe. It was a most serene setting of landscaped buildings and gardens. On our arrival the local choir was practising under the trees – and it was quite atmospheric to hear the beautiful African harmonies wafting in the evening breeze. Before we left we enjoyed lovely afternoon drinks and food, along with interesting conversations with the nuns about spiritual life in the convent, and education opportunities for the novices in local universities and colleges.

Huge thanks goes to Sister Avelina and all the staff – we have left with great memories and unforgettable experiences that live on and influence our professional practices.

For the whole team: Margaret

Hernia International

Gambia Farafenni November 2017

Three experienced surgeons, Jane from UK, Fernando from Spain and me, Leo from Austria, arrived on 18. November 2017 in Banjul and were picked up at the airport. We were taken to a hotel (woodpecker) where we stayed overnight. On Sunday, 19. November 2017 we arrived in Farafenni early in the afternoon having been welcomed by the medical director Dr. Wandifa Samateh and the hospital staff. We became acquainted with the building and especially with the theatre.

Then we checked in in Eddies hotel which was very low standard except for the garden where we spent our evenings “under the mango trees”.

On Monday we started working and operated on 78 patients until Friday night. Our working days were usually from 8:30 a.m. until 8 or 9 p.m. We did not just operate on grown-ups but also on many children, who even came from Senegal.

The anesthesia for our youngest patients was a challenge but perfectly done.

Apart from our medical work we could experience the hospitality and friendliness of our hosts. I am sure we would not have succeeded that much if the hospital staff had not collaborated with us in such a wonderful way.

After our mission was finished we returned to Banjul on Sunday, where my colleagues flew home and I stayed another three days in the capital city.

Our stay in Gambia was a chance to experience medical treatment from another point of view.

The team: Fernando from Spain Jane from UK, Leo from Austria.

Jane screens patients

Every child received a soft toy as a present

 Patients staying overnight, waiting for getting screened

After work “under the mango trees”

 Leo Mitteregger

December 2017

HERNIA INTERNATIONAL MISSION TO BENIN

28 OCTOBER – 3 NOVEMBER 2017

 On 29^th October a team built by Professor Campanelli reached the “Hopital la Croix” in Zinvie, a compound managed by Fathers Camilliani. Over the past years, the efforts of Professor Campanelli have addressed the problem of the treatment of abdominal wall defects in under-developed countries and on this special occasion, with the help of Day Surgery Onlus Foundation and Gruppo San Donato.

For the very first time, the group was nearly all composed of Italian professionals, with only an American nurse. Three general surgeons, two anesthetists, one resident in general surgery, two scrub nurses, four nurses and one medical student compose the team.

The arrival of the team had been announced during the previous days so that every patient complaining of symptoms regarding the abdominal wall had been visited and successfully treated. From 30^th October to 3^rd November, 45 patientes, both adults and children had been operated on. Not only open inguinal and umbilical hernia repair had been pergormed, but also complex incisional hernia repair and pediatric hernia repair under  general anesthesia.

The team was warmly welcomed by Padre Mario, who with his constant support and sensibility made the work possible and rewarding. The entire team was well integrated thanks to the local staff which made easy the perioperative management of the patients. The well-known continuous research for improvements in abdominal wall surgery of Professor Campanelli, perfectly matched with professionalism of the team, reaching nearly the same results as performed in Italy.

Padre Mario made the team’s stay possible and comfortable; a apartment was offered and there was a place for the surgeons to relax and enjoy the local culture and dishes at the end of the day’s work. That made the team stronger and involved in their work.

The unique experience will last for years in the heart of the surgical team and the patients who were able to benefit from such expert surgeons. On the other hand, the work for the surgeon had been widely rewarded by the patient’s simple smiles and enthusiasm.

A very special thank to whom made this experience possible

Professor Giampiero Campenelli

L I B E R I A    2 0 1 7

2^nd Slovenian “Hernia International Foundation” Expedition

Ghanta City, November 11^th – 19 ^th 2017

This year’s planned charity mission led the Slovenian national team to Liberia, to Ghanta City and to Ghanta’s “Esther and Jereline Koung Medical Centre” (E&J MC).Our team consisted of 10 members: 3 surgeons, 3 assistants, 2 anaesthesiologists, 1 radiologist and 1 nurse.

We travelled to Monrovia with the dutch airline KLM via Munich and Amsterdam, with a short stop in Freetown. In the capital,  Dr. George’s team picked us up in the middle of the night with a couple of powerful 4-wheel-drive vehicles. There were two reasons for a one hour delay at the airport in Monrovia: 1 piece of lost bagagge and a missing customs’ approval for importing the goods into the country. When the person authorized to “approve” the import of medical equipment to Liberia was finally reached over the telephone, we hit the road. The good thing about the 4 hour drive to Ghanta at night was the reasonable traffic conditions. On the way back we needed more than 5 hours. The road, built recently by Chinese, was a very good one and made travelling much easier.  

The weather during the week was quite good: partly cloudy with frequent afternoon/night showers that we only heard because of the thin metal rooftops. The temperature of 30°C felt like 35°C and morebecause of the humidity. Accomodation at Jackies Guest House was a good decision (privacy, airconditioning, WiFi with some interruptions, a restaurant with reliable food and a minishop with all the essentials that one needs, even in the case of lost luggage). Some members decided to share a room to minimize the costs, which exceeded the costs of  some airport hotels in Europe (USD 50, dinner about USD 20, breakfast about USD 10). Jackies Guest house was built and first owned by  a local politician Mr. Koung and has now a new owner.

After some hours rest upon arrival, the welcoming ceremony in the hospital started with a prayer and speeches by Dr. Peter Mathew George and the hospital director. The hospital was constructed in July 2016 and was built by Mr. Koung.

All the patients for the week gathered in a big hall. The decision for the mission to start the next day was well accepted among all team members, although it was Sunday.

  Short instructions to well educated  local team

 Ultrasound is allways welcome

All OT’s (0perating theatres) in the hospital were airconditioned. We had to use head lamps in just one of them, the other OT lamps functioned well. The tables were adjustable for height, which was not expected. 2 OT’s were close to each other, which made any interventions easier, especially for anasthesia. Two diathermies were working properly, there had been some trouble with the one that we brought with us. Before it is finally donated to the E&J hospital, it will be rechecked in Europe. Many thanks to Sister McDermot  from  South  West  Acute  Hospital  in  Enniskillen,  for this donation.

For the first three days, the work in all three operation theatres (OTs) ran smoothly. A special thanks goes to Dr. George, who selected the patients personally. On day four, a huge number of patients who had been waiting for surgery (almost 200) forced Dr. George to start operating himself in OT Nr. 4. This was not a very good idea from the organizational point of view as his hospital colleagues were (not yet) fully capable of recruiting and diagnosing patients for 3 or 4 OTs. Our radiologist with the ultrasound was a great help, excluding some patients (with enlarged lymph nodes, other swellings, etc.), who initially expected to be operated on.

On day four we stopped operating on children, as one of them had aspirated just recently breastfed milk during an anaesthesia induction (it took some time for the mother to understand that milk is considered as a food and not just a simple liquid). Our anaesthesiologists and the nurse managed to solve the situation skilfully with emergency drugs, an improvised aspirator and an oxygen concentrator. Under self-built intensive care, supplying antibiotics and oxygen over the following days, the aspiration pneumonia was managed and the child was saved. After this event, Dr. George took over the patient recruitment again and the mission continued smoothly. Dr. George, MD, PhD is basically an obstetrician and gynaecologist with the good skills of a general physician and is capable of performing hernia surgery, including Lichtenstein mesh repair. And of course, with organizational talent. One of his reliable co-workers, Dr. Charles might also be an important link for future missions. Emanuel, an anaesthesiology assistant, showed a lot of readiness to upgrade his anaesthesiological skills. In the absence of HI teams, the whole anaesthesia issues in the hospital depend on him                      

 »Talking« to pediatric patients before surgery

  During narcosis induction

We worked daily from 9am to 7pm, sometimes even longer. The local staff were always ready to work, even late into the evening. Lunch break (chicken gyros sandwicheslike doner kebabs, sometimes French fries with fish) was also an opportunity for briefing the morning patients and planning the rest of the day.

The good thing of having a self sufficient team (surgeons, assistants, anaesthesia,..) was to work with people that one knew from hospitals at home and that were used to working as a team. Anyway, we educated the local staff as well, among them were many very motivated volunteers who applied to work for free during the week and helped so that the mission could succeed.

As we did not have enough gloves to fully suport all the teams in 4 operation theatres in the sense of double gloving (as a Spanish team had done some months earlier), we used single gloves because of the expectation  that all patients were HIV and Hepatitis B tested. As this was only possible for 2 days from the side of the hospital and further on against additional payment, we paid for the tests for the rest of the patients ourselves. It was not realistic to expect that the patients should cover these costs as they expected that the management would be free of charge. Covering some minimal costs from the side of the patients (or the hospital) is an issue that can be discussed in the future.

Anyway, the best surgical infection prophylaxis is a considerate and careful operating technique.

A good decision was to bring along over 300 disposable sterile gowns and sterile hole-drapes to ensure the sterility of the operative field. With additional education of the scrub-teams, we were more and more satisfied with the preparation of the operative field. One of the suggestions to the new hospital director Mr. Victor W. Kpaiseh (the general directors of the hospital had changed during our mission) was providing cloth gowns at least for the scrub personnel. This would demand improving the sterilization capacities (buying the second charcoal-run autoclave pot), which are one of the bottle-necks of the process. This idea is probably not immediately applicable, but might be solved in the future.

 One of the incisional hernias with  praeperitoneal repair

In 6 working days (4 full days, 2 half days) we performed 103 procedures on 86 patients (14 female, 72 male). The average age of the patients was 36.5 years. The oldest patient was 89 years, the youngest 1 year. The majority of patients had inguinal and large inguinoscrotal hernias (71).

Predominantly we repaired inguinals using the Lichtenstein (>95%) and sometimes the Shouldice technque with young patients (<5%). In 14 pediatric patients with inguinal hernia, the Mitchell Banks and Ferguson techniques were used. We performed 2 incisional repairs (retromuscular), 17 umbilical repairs, 2 undescended testicle repairs, 1 femoral hernia repair and 1 hemorrhoids operation (acute). We performed 2 revisions, 1 due to a postoperative haemathoma, 1 for a suspicious haemathoma (negative revision). As we had a reliable anaesthesia team, the anaesthesia was predominantly spinal (72), general (13) and local in only 2 cases.

The presence of a radiologist on such a mission was a very good idea: 70 performed ultrasound diagnostic checks preoperatively, 3 postoperative ultrasound checks, 12 pregnant women with ultrasound (education of midwives), 16 emergency ultrasounds.

 Our team with the medical director of »E&J MEDICAL CENTRE«      

                 Dr. Peter Mathew George

At the end of the team work, we agreed with Dr. George, that it was a good mission. The farewell ceremony was much more a cultural event than just saying thanks and we were thankful to be able to be in Ghanta City, Liberia, together with the local hospital staff for their patients.

All this would not be possible without a skilled, experienced and enthusiastic team:

–     Tomaž Benedik (consultant, surgeon, 2^nd mission)

–         Maria Greiner (consultant, surgeon, 1^st mission)

–         Marija Jekovec (consultant, radiologist, 1^st mission)

–         Irena Urbancic (consultant, anaesthesiologist, 1^st mission)

–         Katarina Primožic (registrar, anaesthesiology, 1^st mission)

–         Katja Carli (registrar, surgery, 1^st mission)

–         Luka Kovac (registrar, gynaecology and obstetrics, 2^nd mission)

–         Selena Benedik (medical student, 2^nd mission)

–         Mateja Selic (scrub nurse, acted as an anaesthesiological nurse, Hernia International mesh sterilizing support)

–         Jurij Gorjanc (consultant, surgeon, team leader, 7^th mission)

Report of Hernia International Mission

to Chittagong, Bangladesh

20-27 November 2017, 2017

The team consisted of the following individuals:

Dr. Petr Bystricky, General Surgeon (Czech Republic)

Dr. Stepan Matoska, General Surgeon (Czech Republic)

Dr. Paulina Mysliwy, Anesthesiologist (Poland)

Dr. Parafull Bohra, General Surgeon (U.K.)

Dr. Usha Bohra, Anesthesiologist (U.K.)

Dr. Meena Agrawl, Pediatric Surgeon (U.K.)

Dr. Scott Leckman, General Surgeon, Team Leader (U.S.A.)

We operated for eight straight days, 20-27 November, at the Nuture General Hospital. During this time, we did the following:

Total patients operated: 83

Including 15 Pediatric patients

Total procedures on 83 patients: 94

Special thanks goes to Nasreen Baqui and her team of volunteers. The hospitality shown to us was extraordinary. Contributing greatly to the mission were the many volunteers including Bangladeshi medical students and residents.

The vast majority of cases were inguinal or inguinal-scrotal hernias, unilateral or bilateral. In addition to these, there were hydroceles, lipomas, umbilical hernias, an epididymal cyst, inclusion cyst of the scalp and one of the scrotum and an abscess of the scrotum. After three weeks, complications noted were three cases of post-operative urinary retention requiring catheterization after bilateral hernia repairs and one case of a deep surgical site infection treated non-operatively.

Scott A. Leckman, MD, FACS

MEMORY OF THE “SURGEONS IN ACTION” and “HERNIA INTERNATIONAL” MISSION IN THE GUSTAVO DOMINGO RODRIGUEZ ZAMBRANA HOSPITAL OF SANTO DOMINGO DE LOS COLORADOS (ECUADOR)

After several months organizing everything by mail, and having had to change some members of the original team (almost up to 59%) that left at the last moment, the date to start for Ecuador came at last. The team was made up finally by 7 members: Cesar Ramirez (surgeon and team coordinator), Antonio Satorras (surgeon), Ana Belén Fajardo (surgeon) Alejandro Unda (paediatric surgeon), Paco Gomez (nurse), Isabel Moreno (anaesthetist) and Yolanda Cabrero (anaesthetist).

Except for Alejandro, who is from Ecuador and had been there for some time visiting his family and working in other missions as he does every year, and for Yolanda Cabrero who was on guard duty and came a day later, all the other team members met to get acquainted with each other on Friday 29^th September in Terminal 4 of Barajas in order to book our luggage in our Madrid-Quito flight at 12.35 p.m. After the first awkwardness in our introductions everything went very well so that with the help of Paloma Gonzalez (of the “Mano a Mano” NGO who works with Iberia) we had not to pay for any extra luggage and we could   book without any problem our own bags and the almost 120 kg of medical and surgical material we were bringing for our mission. For Antonio, Ana Belén and Isabel this was their first mission with “Cirujanos en Acción” with this kind of collaboration, as we all the others had already being in previous campaigns.

After an 11 hours flight Madrid-Quito flight we landed without problems (at 16.35 p.m. local tme) and passed through customs without any problem. At the terminal Dr. Kathia Tinizaray, who is the second director of the Hospital Gustavo Dominguez Zambrana of Santo Domingo de los Tsáchilas, the centre where we were going to carry out our mission. Kathia is a faithful coworker of the “Cirujanos en Acción” campaigns (or rather their very soul) and is always seeing to it that we are as comfortable as possible from the start. She placed all our luggage in a van and took us to our hotels in the colonial centre of Quito. Just as last year, I decided we would spend the weekend in Quito so as to start for Santo Domingo the day before the mission in order to share walks, meals and suppers those two days so as to be able to meet and get acquainted for the 10 days of intense work waiting for us.

We used the weekend to visit in detail the center of Quito and all its wonderful churches (there is no capital in the world with so many churches so great and beautiful, in such a small place, particularly the churches of the Society of Jesus, the one of St Francis, Carmen Alto, and the spectacular and gothic “Basílica del Voto Nacional”), and the “Virgen del Panecillo” who from its height contemplates, guides and cares for the whole city of Quito. On Sunday October 1^st,and after a tiring 4 hours journey by van to Santo Domingo, we arrived at our hotel (the modest Hotel Santander in the outer city neighbourhood) where Dr Kathia Tinizaray and Dr Lenin Falcones, who is Medical Director of the Hospital and surgery chief who has been our most constant and important logistic help during these two weeks in Ecuador.

The same Sunday night we went to the Hospital, we unpacked and placed all the material in the operation theater that had been us for our work and, besides, we revised the operation theatre programation that Dr Falcones has prepared for our two weeks. The Gustavo Dominguez Zambrana is a relatively new hospital, but it suffers from the miseries of a health system which is deficient and very badly run from the central administration, so that there are no resources to operate the patients (no laparascopy, and the patients have to buy for themselves even the most basic material to be operated upon,the famous “insumos”, they have no meshes, neither any suture material of the lowest quality) and the waiting lists for the most basic processes lengthen to eternity.

In the morning of October 2^nd we were able to begin operating thanks to the great effort of DrFalcones and Francisco, the Anaesthetics coordinator of the Hospital, who had taken care that all patients were programmed with their pre-operatory examination carried out and with the approval for surgery. Every day the patients were given an appointment for 7 in the morning in a room next to the operation theater where part of our team carried out a quick evaluation of all the cases so as to be able to begin operations as soon as possible. We are grateful for the excellent organization at this level, thanks to which many patients have been operated upon easily.

Thus on the first day we operated upon 19 patients, which can be taken as a great success and which shows how well organized everything was. On the whole we have operated upon 119 patients with 149 processes, which means that up to 25% of the patients have been operated upon for more than one process in the same act. All the cases in CMA regime were discharged without problems or post-operation complications immediately noticed. Since in “Cirujanos en Acción” we consider that our missions also help formation,

I organized with Dr Falcones a programme of clinical sessions each morning from 10 a.m. to 10.30 a.m. for the whole staff connected with the Surgery Service and the Surgical Block; we also collaborated in cases of a special difficulty and complex abdominal wall, so that we carried out 11 giant eventrations (two associated with right colectomy), one coledoco-duodenostomy and 8 colecistectomies by laparoscopic way, all successful except for one patient with a deep infection which was treated in a conservative way without any difficulty. At each moment we have had exact information as to how the patients were doing, so that we visited them at their places on admission and each day whether any patient operated by us under CMA regime or visited in Urgencies; when this has happened it has been due to minor complications.

If there is something I have learned in these 3 missions is the key role of the infirmary. The all out work of Paco, who places the material or takes out the patient or works as surgical helper, and I don’t want to leave out the roll of the licensed Marlene and Liliana, and of all their students who have worked with us all this time and have been essential for the operation of so many patients.

In order to get the most from our work the time for meals was 30-45 minutes in some of the small bars around or in the “shopping” in front of the Hospital. We also operated on Friday October 6^th in the evening and on Saturday October 7^th in the morning. The moment to relax each day was always theend of the work, never before 20-21 p.m., which allowed us in some of the multiple “burger pubs” of Santo Domingo to share with the whole team gossip, laughter and refreshments (local beers chiefly) often accompanied by Dr Falcones and our local anaesthetists, the popular Francisco and Raúl Castillo.

Sunday October 8 was really our only full rest day, and we went to see the community of Red Indians (or Tsáchilas) who have lived historically in that zone, and who since a few years form part of the social and political activities. The last night was special as we decided to invite for supper all the directors of the Hospital, the infirmary staff and the surgeons from the Hospital Surgery Service, so that we all enjoyed ourselves in a very good way. We enjoyed local gastronomy and the ceviches, meats, “guata”, and other typical dishes from Ecuador.

     To say goodbye, and coinciding with some acts commemorating the 40 anniversary of the creation of the hospital, Dr. Kathia Tinizaray on behalf of the hospital Gustavo Domínguez Zambrana gave us this plaque-trophy recognition of our work that we Honor and finish giving full meaning to the work that we have done there.

Cesar Ramirez