OPERATION HERNIA TRAINING IN TANZANIA NOV 13-17, 2017

Operation Hernia has completed another Hernia Training Workshop, this time  in Mwanza, Tanzania. This is the first Operation Hernia Training Workshop to be held in Tanzania.

The Faculty was led by Mr Tim Brown, Consultant Surgeon, Swansea in Wales, UK.  Other members of the faculty were Hilde van Susante, a Dutch Consultant Surgeon working in Tanzania and Vihar Kotecha, a local Consultant Surgeon.

Operation Hernia is now recognised as an organisation that effectively trains local doctors in mesh hernia surgery.

INTRODUCTION

This is the first Operation Hernia mission to Botswana. The Operation Hernia team worked at Kanye Seventh Day Adventist Mission Hospital (KSDAH), a district hospital at Kanye. The Botswana mission has been in the planning stages for over a year.  Much credit goes to the CEO, Dr Innocent Mugandi and the local Surgeon, Dr Andrew Ojuka but also to Dr Kabala the CMO, the Hospital Matron Keabitsa Ramatele and Mr Patson Kaumba the Finance Manager who worked in the background to facilitate the process.

Botswana is a beautiful developing country blessed with very welcoming people and adorned by famous nature reserves. Years ago, it was classed among the 10 poorest countries in the world. The diamond and cattle industry have, however, transformed the country and its people. The country is the size of France but has a meagre population of 2 million. The south has vast lands of arid savannah. The north has more tropical weather.

The capital, Gaborone was a very pleasant surprise. It is a modern city with several shopping malls which are all well patronised. There is easy access to ATMs all over the city and even at Kanye.  The streets are clean and the sky is blue with no haze.

KANYE TOWN

Kanye is the capital of the Southern District of Botswana. It is 83 km south of the capital Gaborone. It is served by only one district hospital which is the SDA mission hospital.  Although Botswana is an African country, this time of the year is their winter. We were surprised by the cold nights, when temperatures dropped to 4 degrees centigrade and in the morning.

KANYE SDA HOSPITAL

Kanye hospital is a 167 bed hospital efficiently run by the CEO and his administrative staff. It is relatively well equipped and staffed compared to district hospitals in other developing countries visited by Operation Hernia. The first impression the hospital makes on visitors is its cleanliness.

OPERATION HERNIA TEAM

The team comprised Mr Chris Oppong, Consultant Surgeon (Team leader), Mr Paul Fisher retired Consultant who works part time and Boikhutso Shianaya who is a male nurse at the Nuffield Hospital in Plymouth. He is a Batswanan. He trained and worked at Kanye Hospital before moving to the UK. He was the link between Operation Hernia and Kanye Hospital. He arrived in Botswana 2 days ahead of the rest of the team.

TRAVEL ARRANGEMENTS

All volunteers paid for their travel costs. There is a flight to Johannesburg and a connecting flight to Gaborone, arriving on Sunday June 25, 2017. We were welcomed warmly by a hospital party who also sorted out one luggage that did not arrive on our flight.

ACCOMMODATION

The team was housed in a hospital guest house which was on site. Food was provided by the hospital kitchen.  We were provided with very warm safari blankets to battle the surprisingly extremely cold nights and mornings.  Our jumpers came in handy too!

MEDICAL REGISTRATION

The registration process began well before we left the UK. The licensing authority in Botswana, the Botswana Health Professionals Council (BHPC), were not satisfied with our documentation and therefore we spent the best part of Monday, the first day of the mission, sorting this out. Our hosts were extremely helpful in the negotiations with the BHPC.  Later in the day we met all the operating theatre and ward staff as well as the hospital administration.  Chris Oppong stressed the need for team working and the importance of every member of the team.

PATIENT RECRUITMENT

The mission was promoted in clinics and schools in the KSDAH catchment area. As a result most of the patients were children with large umbilical hernias.  A list of 15 patients was compiled for each of the five days.  All the patients were previously screened by local doctors. The Operation Hernia team examined all the patients either the night before or on the day of surgery.  A few patients who had insignificant hernias were reassured and discharged.

WARD

The ward staff deserve a great deal of credit. They ensured that patients were prepared for theatre in a timely fashion. They were available to return recovered patients to the ward on time and the nurses made themselves readily available to assist the surgeons on ward rounds.

Nurse Boikhutso Shianaya was an effective liaison officer linking the wards and theatre.  He ensured that patients who had their operations under local anaesthetic were managed as day cases where possible.  Preparation of theatre lists appeared to be a novel concept. This seems to be the experience of the Operation Hernia team on our travels. We will suggest ways to facilitate generation of theatre lists.

HOSPITALITY

  1. The loss of activity on Friday provided an opportunity to visit the Mokolodi Nature Reserve. This was generously organised for us by the hospital management and for which we were very grateful. The “rhino trekking” was a most exhilarating and very successful adventure as we were able to get so close to these ferociously massive but at the same time “friendly” beauties of the Mokolodi wild.
  2. On Saturday we toured the Gaborone city centre. The highlight of the tour was the Three Dikgosi Monument, an imposing and a truly fitting monument to the three wise men who rescued the soul of Botswana.

OPERATING THEATRE

The first working day was Tuesday, June 27, 2017 started with a meeting with all theatre staff where the week’s routine, team working and the ethos of the mission was discussed to ensure efficient working.

We were impressed with the theatre organisation and the facilities in each theatre. The two main theatres were used for the mission. They are equipped with anaesthetic machines, monitors and piped gas. There was only one diathermy machine. Operation Hernia provided a diathermy machine and accessories, surgical instruments including five Travers self-retaining retractors, sutures and mesh. Local anaesthetic was freely available although we provided 1% lignocaine donated by the Nuffield Hospital in Plymouth, UK.  The nurses were well motivated and enthusiastic.  Mrs Beatrice Manda, is a competent and well taught manager who coordinated the two theatre lists efficiently and as a result patient turnover was impressive.

The two operating lists run smoothly because every single staff member – from the orderly who cleaned the floor between cases to the anaesthetists –  played their role effectively with little prompting. The team worked like a well-oiled Swiss grandfather clock. This is credit to the theatre manager and the staff who were willing to work for her.  No one wanted to let the team down. The third theatre is for minor cases. It can be used for local anaesthetic hernia repairs.

There is a dedicated two-bed recovery ward equipped with a monitor and a portable oximetry/BP Kit for GA cases for both adults and children. The one-to-one care the patients received was commendable. Each operation started with a stripped down version of the WHO check. It was not as exhaustive but demonstrated the ethos of safety in theatres.

At any one time, we had two anaesthetists who provided GA and spinal anaesthetics when required. The most senior of the anaesthetists, Tim, is very experienced especially in anaesthetising children.  He was very supportive of the other two anaesthetists. The hospital provided gowns and surgical drapes. At the end of each day’s session a debrief session was chaired by the theatre manager and attended by all in theatre.

THEATRE EQUIPMENT

Operation Hernia has donated essential theatre equipment and surgical instruments to KSDAH. The list has been published and is outlined above.

MESH FOR HERNIA REPAIRS

Mesh repair of groin hernias is the standard in the developed world. It produces the best long-term results in terms of recurrence. Most developing countries do not routinely use mesh for inguinal hernia partly because of lack of expertise, but mostly because of the affordability of mesh. Operation Hernia provided a low cost, affordable, polypropylene mesh.  The use of this mesh for hernia surgery was first documented by Dr Tongaonker, an Indian surgeon, and has been popularised by Operation Hernia. The affordable mesh has been used by Operation Hernia on missions to low and middle resource countries since 2006. It was sterilised and packaged in the UK for the training workshop.

The safety profile and outcome of repairs performed with affordable mesh is comparable with results from repairs performed with brand meshes.

OUTCOMES

There were, effectively, 2.5 days of operating.  On Thursday, we had only 4 patients. Although the 15 patients had been recorded for each day only 4 were available for surgery on Thursday and no patients turned up for a Friday operating list. This was due to the fact that a much loved and respected former president of Botswana died the week before mission and his burial was held at Kanye, his hometown on the Thursday to be followed by a long weekend holiday. The funeral was well attended. This and the subsequent bank holiday affected patient attendance.

28 procedures were performed in 27 patients. This was less than half of the planned 70 patients due to reasons outlined above. This was made up of 16 umbilical hernias, 4 epigastric hernias, 1 hydrocoele and only 7 inguinal hernias.  52% of the patients treated were children under 13 years of age.  This is the largest proportion of children in any hernia mission undertaken by Operation Hernia. It is heartening to note that there were no complications.

Table 1: Breakdown of cases.

  No %
Inguinal Hernias 7 25%
Umbilical Hernias 16 57%
Epigastric Hernias 4 14.2%
Hydrocoele 1 3.6%
No of CHILDREN 14 52%

DEBRIEF MEETING WITH MANAGEMENT

  1. The hospital CEO, CMO, Deputy Matron and Finance Manager met with the team to review the mission. As a first mission, we all judged the week as a success in spite of the low patient numbers. There were legitimate contributing factors, which have been alluded to earlier. The success was not only due to the very efficient organisation of the mission, it was because all the operations were performed safely. It was unanimously agreed to organise the 2018 Operation Hernia mission at a time to be decided on later.
  2. The management debrief was followed by a debrief with all hospital staff where the valuable contribution of all the various hospital staff was recognised. The Operation Hernia team were presented with gifts by the management team.

ACHIEVEMENTS

  1. Overall assessment: A well organised and executed programme, proof that KSDAH can organise big international events successfully.
  2. Patient throughput:  27 patients with various hernias were treated safely.
  3. Operating theatres: Very well organised Theatre sessions
  4. Donation: We have donated essential equipment and hernia surgical instruments to KSDAH
  5. Ward management: Well-coordinated ward management of patients.
  6. Team ethos: Recognition of and engagement with the culture of Team Work

ACKNOWLEDGEMENTS

Operation Hernia would like to acknowledge the support of the following:

  1. CEO: Dr Inocent Mugandi
  2. Dr Andrew Ojuka: KSDAH Surgeon
  3. CMO: Dr Hilaire Kabala
  4. Matron: Keabitsa Ramantele
  5. Deputy Matron: Dolly Lekgowe
  6. Theatre-in-charge: Beatrice Manda
  7. Ward-in-charge: Mosibudi Rantadi
  8. The KSDAH Drivers
  9. Mr Tim Rambiki, Senior Anaesthetist, and the two junior anaesthetists
  10. All staff at KSDA

 

Chris Oppong FRCS, Consultant Surgeon

Chairman, Board of Directors of  Operation Hernia

Introduction

The main event was a Hernia Course organised for the Surgical Registrars at the teaching Hospitals at Kigali, Rwanda. This was at the invitation of the Head of Surgery at CHUK Teaching Hospital. In collaboration with Rwanda Legacy of Hope (RLOH) – a Rwandan Charity – an ENT team accompanied the Operation Hernia team.

 CONSOLIDATED PATIENT NUMBERS

 TRAINING OF SURGICAL RESIDENTS

The patients were operated on the two centres as shown below: 

Training Centre Patients Operated On
CHUK 39
Rwamagana 46
TOTAL 85

  SERVICE DELIVERY

  Hernia Surgery 

Hospital Patients Operated On Adults Children
Gahini 45 25 20
Kigeme 21 20 1
Kirinda 6 5 1
TOTAL 72 50 22
       
HERNIA TOTAL 144 100 44

  

 ENT Surgery 

Hospital Patients Operated On Adults Children
CHUK 12 0 0
       
   

  SUCCESSES

  1. Intense training of 14 Surgical Residents in hernia surgery. Most of the trainees were trained to the level of “Able to perform procedure with minimal help”. In the process, 85 patients were offered surgery for their hernias.
  2. Very good feedback from trainees regarding hernia lectures and training in the operating theatre.
  3. Effective collaboration between RLOH ENT surgeon and CHUK ENT surgeons. Plans for the 2018 mission to include training of registrars agreed were agreed.
  4. Equipping Rwandan Hospitals to the tune of over 100,000 Euros.
  5. Successful recruitment of 32 Volunteer Consultant Surgeons and Anaesthetists and Nurses from UK, Germany and Austria. They all funded their own travel and other related costs.

  ACKNOWLEDGEMENTS AND GRATITUDE

1The Government of Rwanda arranged Medical and Nursing Registration for the RLOH Medical Team.

2. The Government of Rwanda waived all Custom and Clearance costs for medical equipment imported by RLOH

3. The Government of Rwanda provided high quality accommodation for RLOH team during their stay in Kigali. The Hospitals provided the accommodation for teams that worked in the district hospitals.

4. The Government of Rwanda funded a Certificates Ceremony.

 

CHRIS OPPONG FRCS, CONSULTANT SURGEON

MEDICAL DIRECTOR RWANDA LEGACY OF HOPE AND CHAIRMAN OPERATION HERNIA

 

In January 2017, the 8th mission of the Dutch team of Operation Hernia took  place. This year a team of eight surgeons and eight residents went to the Ghanaian towns of Keta, Wenchi and Bole. The teams had as goal to treat as many patients as possible.  A second equally important goal was to teach local physicians to perform inguinal hernia surgery with a mesh (Lichtenstein procedure under local anaesthesia), so they would be able to continue performing these operations after the mission had finished, and they eventually can teach others.

On Saturday the 7th January the members of operation hernia arrived in Accra.  The next day 8 surgeons and residents went by car to Takoradi and the other 8 took a domestic flight north to Kumasi.  There they split up and a team of four went by car to Wenchi while the other four drove to Bole in the northwest region of Ghana.

Since elective surgery and in particular hernia surgery is rare in this country, many patients travelled from near and far to be treated by the Dutch team of Operation Hernia.  An untreated inguinal hernia causes, besides effect on daily activities and cessation of professional activities, a substantial health risk.  In case of incarceration, mortality rates up to 80% are not exceptional.  So the goal of our visit is clear: treat as many patients as possible!  And, equally important, teach local physicians and nurses to perform hernia operation and provide care afterwards.

Takoradi team

After a drive of approximately 5 hours we arrived at Takoradi. During the trip we already got to know Ghana a bit and this made us more and more enthusiastic to start our mission. Since Takoradi has a fantastic coastline, we first visited the beach and ended the day with a dive and some drinks over there.  We speculated what the week would bring us.

The next morning, after the delicious Ghanaian breakfast, with Dutch peanut butter, we were split in three groups since we were working in three totally different hospitals.

GPHA is a private hospital.  Dr Bernard Boateng is the leading doctor in this beautiful hospital with even a CT-scan.  The theatre staff were friendly and very capable. Rapidly, an inguinal hernia was followed by a giant hydrocele alternated by an emergency Caesarean section. Days flew by, in total 27 operations were performed in this hospital.  The medical staff were well trained and a pleasure to work with.

The largest hospital, Takoradi hospital has its own hernia wing. The head of theatre there is Marian.  A great personality, she and her team made our mission even more special. Time flew, while working hard in the wing there was a lot of fun! In the Hernia Wing, a total of 29 surgical procedures were successfully performed.  The majority were adult male patients with inguinal hernias treated with a Lichtenstein procedure under local anaesthesia. The severity varied from H1 to H4 (large scrotal hernias), all treated with a mesh brought from the Netherlands. The Takoradi group operated on 9 children under the age of 9.  A herniotomy was performed with general anaesthesia.  In both the Hernia Wing and GPHA, young doctors were joining us to be taught about the Lichtenstein procedure. It was great to see their enthusiasm and we were convinced of their surgical skills.

Dixcove, a small hospital in the more rural area outside of Takoradi, was a great place to visit.  In this hospital, with an anesthetist known for his fast spinal anaesthesia technique, working was extraordinary. The theatre was used optimally, a Lichtenstein procedure was performed while a Caesarean section had to start.  No problem, in Dixcove they perform this at the same time in the same room!  A great experience!  We were very happy to work with the medical staff and hopefully the same applies for them. Working in this hospital was sometimes even a real party, especially when the scrub nurse started to dance to our music in between the surgeries.  The fact that we worked hard besides the fun is shown in the total of 20 surgeries performed. In total 76 patients were treated by the Takoradi group.

 

Bole team

Together with the Wenchi group we took an inland flight north to Kumasi. From there our groups split and the four of us were picked up by Baba, the Bole hospital ambulance driver. All the equipment we brought was loaded in the back of his pick-up truck and off we went. Our six hour drive was interrupted only for a short introduction to the Ghanaian cuisine: banku! (a mixture of fermented corn and cassava dough in hot water).  Along the way the setting changed into more rural scenery.  While listening to the car radio we heard a broadcast to invite patients with inguinal hernia to register for surgery at the Bole Hospital. This way, Dr. Josephat Nyuzaghl (Dr. Joe), one of the two local doctors of the Bole hospital and our contact person, had efficiently recruited patients for surgery!

After a long day of travelling we were welcomed by the hospital administrator and the medical director of the Bole hospital, and Dr. Joe kindly showed us around.  Many patients had responded to the radio broadcasts, so our days started early with the screening of patients that had queued up in front of the male ward.  After this we started surgery and worked together with the enthusiastic local operation team until all patients, that were put on the list that morning, were operated on.  The hospital has two functioning operating rooms and we therefore divided into two teams of a surgeon and a resident mixing the pairings. The vast majority of patients were operated on under local anesthetic, only some patients had a spinal anesthetic. We had the opportunity to use sterilized mosquito net meshes that worked very well.

Vitus, the pragmatic nurse anesthetist, organized the operation list and made sure everyone of the team knew exactly what to do.  Not a minute of our time there was lost. The whole team worked extremely hard, sometimes until late in the evening!  We had little chance to work together with Dr. Jatuat, the young local surgeon, who was kept busy with other patients since he and Dr. Joe are the only physicians in this region.  In total over the week we carried out 83 procedures in 74 men, women and children.  All patients stayed in the ward the night postoperatively and were discharged the next morning.

As a special treat after we finished Dr. Joe had kindly organized a send-off party with drinks and food (guinea fowl). We had the chance to thank the Bole Hospital staff for making us feel so welcome. We were presented with custom made smock, worn on special occasions. We would all like to reiterate our thanks to Dr Joe, Vitus and the staff at Bole Hospital. Finally we would also like to thank the Ghana Government for facilitating our mission. We will be visiting again.

Wenchi team

At Kumasi airport we were welcomed by Dr. Bibi Bosomtwe who took us on a 2.5 hour drive north through the beautiful Ghanaian landscape to the town of Wenchi.  Wenchi is the capital of Wenchi Municipal of the Brong-Ahafo Region in South Ghana with a population of around 40,000 people. On arrival we were greeted by Bernard Clement Botwe, the charismatic CEO of the Wenchi Methodist Hospital.  Afterwards we were brought to our accommodation for the upcoming week, a nice guesthouse just outside Wenchi. Here we were joined by Sarah, a Ghanaian scrub nurse with experience in assisting during the Operation Hernia Missions. She was asked specifically for this mission to come and assist, and to teach the scrub nurses of Wenchi Methodist Hospital.

On Monday morning we were picked up by the hospital bus and were taken to the Methodist Hospital.  It is a lovely typical Ghanaian hospital with approximately 300 beds. We met the anaesthesia medical officers, scrub nurses and the local physician we were going to train, Bismark Kubi.  After discussing our plans for the week we got acquainted with the two small but adequate operating theatres, which were going to be our work environment. The enthusiasm of the complete operating room (OR) personnel and everyone at the Wenchi hospital from the first second of our visit was impressive.

Every day started with screening of the potential patients. Numerous patients from the whole region surrounding the hospital had responded to the call for treatment. After screening, eligible patients were seated outside the operation theatres until surgery. Most patients were treated under local anaesthesia; they walked into the OR, underwent inguinal hernia correction with a mesh, and afterwards walked out of the OR by themselves. For exceptional cases, such as irreducible and bilateral hernias, spinal anaesthesia was available. Children with inguinal hernias were treated under general anaesthesia with Ketamine.

During our stay at Wenchi Methodist hospital, 45 patients with a total of 52 hernias were operated. Doctor Bismark Kubi, who was already well acquainted with hernia surgery but did not have any experience with the use of a mesh, was trained in performing the Lichtenstein procedure.  He proved to be a very skilled, kind and enthusiastic doctor who learned quickly. At end of the week, he was able to safely perform the procedure by himself. As we were able to donate a significant number of surgical meshes, adequate care of inguinal hernias at the Wenchi Methodist hospital can be continued.

We ended the week with a party on the final evening, which we organized to thank the staff of for their kind hospitality. Together with the OR personnel we looked back at a successful and enjoyable week. Kind words were spoken both from the Ghanaian and the Dutch side, and mutual hopes for future collaborations were expressed.

Acknowledgements

The Dutch Operation Hernia team gratefully acknowledges the MRC foundation for providing the necessary funds in order to be able to treat so many patients with such a large team.

Also the hospital staff of the anaesthesia, pharmacy and surgery departments of the Hospitals OLVG, St Antonius and Tergooi are gratefully acknowledged for providing materials and medication.

The surgeons performed the surgery on a voluntary basis in their own time.

Team Ghana 2017

Maarten Simons, Frank Ijpma, Eddy Hendriks, Nanette van Geloven, Bert van Ramshorst, Djamila Boerma, Wouter te Riele, Daphne Roos, Ernst Steller, Jasper Atema, Tjibbe Gardenbroek, Jip Tolenaar, Charlotte Loozen, Anne Loes van den Boom, Marjolein Leeuwenburgh, Joost Hoekstra

The Dutch Operation Hernia Foundation

Maarten Simons, Frank Garssen, Djamila Boerma, Nanette van Geloven and Eddy Hendriks

TRIBUTE TO PROFESSOR GUIDO SCHURMANN (1956-2017)

Operation Hernia is mourning the painful loss of one of our long-time volunteer surgeons, an Operation Hernia Ambassador, Prof Guido Schurmann, 61.  He died unexpectedly on 24 October in Bielefeld, Germany.  He had been due to go to Ghana on another humanitarian mission, 11 days later on November 4, 2017.   He is survived by his wife, Cordula and children.

Prof Schurmann was the Chief Physician and Medical Director at the Clinic for General and Visceral Surgery at the Klinikum Bielefeld Mitte.

An important part of his life was his deep passion about provision of quality medical care for the less privileged.  He volunteered for several Operation Hernia missions to Ghana where he provided a superb hernia service to needy patients as well as training local doctors and surgical registrars.  He and his wife, Cordula, funded an Operation Hernia Ghana Fellowship.   This was set up to provide Ghanaian surgical registrars intensive training in Mesh Hernia surgery. The Fellowship was named the “Guido-Cordula Fellowship”Operation Hernia will continue to run the fellowship in honour of his memory.  Prof Schurmann also went on other humanitarian mission organised by other charities.

Guido was a warm, and a very friendly colleague.  He had a sympathetic heart for the needy.  He will be fondly remembered by Operation Hernia and all the volunteers who had the privilege to work with him.  Hernia patients in Ghana and other countries will be tremendously grateful for the treatment they received from Guido.  He repaired their very large, disabling hernias, improving their quality of life.  Many more patients will benefit from the training received by Ghanaian surgeons who trained with Operation Hernia as Guido-Cordula Fellows.

His funeral was held at Bielefeld on November 2, 2017, an occasion that was attended by Chris Oppong, Chairman of Operation Hernia.   It was very fitting that our organisation was represented at Guido’s funeral and all those who new Guido join the trustees of Operation Hernia in sending sincere condolences to his family.

MAY HE REST IN PEACE AND MAY GOD COMFORT HIS WIFE, CORDULA, CHILDREN AND FAMILY