Prof Akoh, Dr Debra and the hospital staff

Hernia Training Workshop at Cape Coast Teaching Hospital, Ghana, 17-21 October 2016

Prof Akoh, Dr Debra and the hospital staff

Prof Akoh, Dr Debra and the hospital staff

Itinerary

I arrived Accra on 15 October, spent the night at the Baptist Guest House and was driven to Cape Coast on 16 October. I was housed at the Samrit Hotel about 1.5 km from the hospital for the duration of my stay and had breakfast and dinner there every day. Lunch was usually provided in the operating theatre. I returned to Accra airport on 21 October and to the UK thereafter.

Activity

Table 1

Table 1

Prior to our arrival, 25 patients were organised for surgery. Attempts to recruit more patients during the week were only partially successful. The majority of the procedures were performed under local anaesthesia, with a few under spinal and two incisional hernias under general anaesthesia.

Training

1. The lectures were well attended by trainees, senior hospital doctors and medical students. The academic morning on Friday was well appreciated and turned out to be an effective use of the “surplus” day due to our clearing the surgical list by Thursday afternoon.

2. The theatre facilities were excellent with a team that was well motivated and hard-working. Theatre efficiency could be improved by developing standard operating pathways involving ward preparation, theatre reception and recovery of both inpatient and day case patients.

3. There were approximately ten trainees (including one who travelled ten hours to attend the workshop) who were divided into two groups. Though they were all very keen and they took turns to assist, perform in part and or do the whole procedure, one felt that the opportunities could have been better to allow concentrated training of each candidate as we have done elsewhere.

4. This was very much a joint effort between Operation Hernia and Cape Coast Teaching Hospital (CCTH) as Prof Debra and Dr Morna actively took part in the programme.

5. It is praiseworthy that CCTH surgeons cancelled their elective cases during that week to allow the theatres to be devoted to hernia training.

Recommendations

1. Formally establish CCTH as a centre for Operation Hernia training in Mesh Repair. It may be necessary to involve both the Ghana College of Surgeons and the West African College of Surgeons in this venture.

2. Encourage CCTH to research the effectiveness of prophylactic antibiotics for mesh repair of abdominal wall hernias.

3. Formalise arrangement with Plymouth Hospitals NHS Trust for sterilising “Affordable Mesh” in order to ensure a steady supply to low income countries.

Participant Evaluation

Dr Morna is collating these and will produce a mini-report in due course.

Thank you for the opportunity to contribute in this deeply satisfying way. We owe a depth of gratitude to Dr Mona and Prof Debra and their teams for making the program a great success.

Jacob A Akoh, Consultant Surgeon

Friday 28th October 2016

GHANA CELEBRATION OF 10th ANNIVERSARY OF OPERATION HERNIA

Introduction

On 15th October 2016, Operation Hernia celebrated its 10th Anniversary at the city of its birth, Takoradi in Ghana. It was also a celebration of Ghanaian culture of pomp and pageantry. It was truly, a memorable night. The great and the good in the history of Operation Hernia were present as well as a television crew from the Takoradi Sky TV.

Traditional Dancing

The evening started with traditional drumming and dancing. Drums were played in a coordinated fashion to produce a unique rhythm of authentic Ghanaian music. Energetic traditional dancers performed their complex choreography with grace and passion. They were where clad in very colourful Ghanaian fabric called “kente”. They treated the gathering to an array of mesmerising traditional dances with different themes.

Operation Hernia Exhibition

A photographic exhibition of the Operation Hernia story was opened earlier. It featured the first Operation Hernia team that visited in 2005. On display were photographs of the inauguration by the then British High Commissioner and his deputy, and also the opening of the Hernia Centre at Takoradi Hospital. Photographs of various teams that have visited Takoradi and other centres from 2005 to 2015 were displayed. The series of photographs that stood out depicted the steps in the repair of a large hernia. The use of Operation Hernia Mesh (low cost and affordable) was also highlighted in the exhibition. The picture posters were designed by Mr Bediako, Marketing Manager at Ghana Ports and Harbours Authority (GPHA).

Poster showing details of the first Operation Hernia visit on 2005

Poster showing details of the first Operation Hernia visit on 2005

Main Event

All the attending personalities were acknowledged by Dr Bernard Boateng Duah, local Medical Director of Operation Hernia. We were privileged to have the original group of local doctors and administrators who were instrumental in the nurturing of Operation Hernia. This included the following personalities:-

1. Mr Edwin Philips, a local businessman

2. Mr Philip Nkrumah, the then city manager

3. Dr Kofi Asare, Medical Director of Takoradi Hospital

4. Dr Linda Vanotoo, the then Regional Medical Director

5. Mr Eddie Prah, local businessman and Business Manager of Operation Hernia

The following two personalities were not at the celebration but have been part of the “early brigade” who made substantial contributions to the success of Operation Hernia and deserve our deepest gratitude.

6. Mr Brian Dixon, Ghana Representative for Canadian Natural Resources (CNR) an international oil and gas producer

7. Miss Kate Mensah, our domestic manager. She did not attend but was acknowledged.

The keynote speech was delivered by Chris Oppong, Chairman of Operation Hernia. He emphasised the fact that the success of Operation Hernia is due to the passion and commitment of our selfless volunteers who sacrifice so much for the needy operation hernia patients, and the local doctors, nurses, laboratory technicians, drivers, administrators and the culinary and domestic management skills of Kate and Lilian Mensah and their group of caterers. The pioneering role played by the former CEO Prof Andrew Kingsnorth was recognised both in the keynote speech and in the photographic exhibition. Operation Hernia has treated over 9000 patients and trained several local doctors as well as UK and EU surgical trainees. Emphasis has now shifted to training as exemplified by the recently completed training of ten surgical trainees of the College of Surgeons of East, Central and Southern Africa (COSECSA) in Uganda. Dr Bernard Boateng was given a deserved standing ovation for the tremendous role he has played in sustaining the work of Operation Hernia.

Poster outlining the work of Operation Hernia over the last 10 years

Poster outlining the work of Operation Hernia over the last 10 years

Kosa Beach

Report of the Belgian Team Visit to Takoradi, Ghana March 12–19, 2016

After skipping our 2015 Mission because of the Ebola threat, in March 2016 a Belgian team, consisting of four surgeons (Marc Huyghe, Casper Sommeling, Veronique De Moor and Stijn Heyman) and one resident (Magali Blockhuys) again visited Takoradi in Ghana. Our main financial sponsor still is the Belgian Section of Abdominal Wall Surgery, but also the Lions Club of Waregem supported us financially. We brought meshes (Mr. Oppong meshes aka MROP-meshes from England and BBraun meshes from Belgium), gloves (Medline), disposable drapes (Mölnlycke Belgium and Medline) and suture material (Johnson & Johnson). Local anesthetics were donated by BBraun; this time lidocaine with adrenaline and heavy marcaine were supplied by Operation Hernia.

Kosa Beach

Kosa Beach

Arriving at Kotoka airport with Brussels Airlines on the Saturday, late afternoon, we were pleasantly surprised by the new facilities in the arrival hall, which shortened the check-in procedures. After a 3 hour drive we arrived at the Kosa Beach resort and stayed our first night there.

On the Sunday afternoon we drove to Takoradi, where as in 2014 we stayed in a private house. During the week we again enjoyed the hospitality of Gina Loupiac at her Gilou’s restaurant

Also this year Dr Bernard Boateng-Duah organized the operation programs beforehand in collaboration with the local hospital teams, so we could immediately start our operations early on the Monday morning.

The Belgian Surgical Team at the Hernia Wing of Takoradi Hospital

The Belgian Surgical Team at the Hernia Wing of Takoradi Hospital

During the week we were organised into three teams that rotated in the three different hospitals (Hernia Wing, GPHA and Dixcove). In total 92 patients, of which twelve were children, where operated. Again most of the patients presented with groin hernia.

The first patient operated in the GPHA hospital on Monday morning was the patient in which we performed a Hartmann’s procedure with a temporary colostomy in 2014 due to colonic necrosis. Restoration of the bowel continuity was performed and the postoperative course was uneventfull.

The motivation of the local hospital teams was very good and the level of care of the nurse-anesthetists in the three hospitals was high. The first evening Marc and Magali sustained by the enthusiastic team of Marian at the Hernia Wing worked until 11.00 p.m. to get the selected patients done. The last patient that evening had a giant sliding (sigmoid) hernia, a recurrence after a Lichtenstein procedure some years before.

The equipment in the hospitals is of a reasonable level, but structural changes should be made to the operation theatres. There still is the problem of lack of running water in the Dixcove Hospital.

Our mission was certainly interesting for our resident who could perform several operations in both adults and children.

Visit to the Metropolitan Coordinating Director

Visit to the Metropolitan Coordinating Director

On Saturday morning we first visited the Takoradi harbour currently in a phase of new developments and where big changes are taking place. Then we were received by the Metropolitan Coordinating Director in his private house in the beautiful hills in Sekondi. He thanked us on behalf of the local government for our mission and explained that the local government this year supported us regarding transport and food. Following that we we drove back eastbound to Kotoka airport in Accrea to leave for Europe again.

Conclusion: This was again a very rewarding mission; the future developments will to have be awaited for.

Casper Sommeling, on behalf of the Belgian team

Report of Operation Hernia.nl’s Mission to Ghana, January 2016

Our recent missions to Keta and Sunyani in Ghana took place from 9 – 17 January 2016. They were heart-warming adventures focussing on both treatment and education.

It is a great honour to inform you that the Dutch team of “Operation Hernia” recently finished a successful seventh mission in Ghana. “Dutch Operation Hernia” started in 2009 with three dedicated surgeons and has expanded significantly over the course of the years. This year a team of 15 went to Ghana to use their surgical skills to treat children and adults with inguinal hernias.

The prevalence of inguinal hernias in Ghana is high (7.7% among male citizens) and nearly 25% of patients have to cease professional activities due to their symptoms. Despite these numbers elective hernia surgery is rare in this country. Elective surgical programmes are unusual in Ghana as many regular government hospitals are understaffed (with an average of only nine doctors per 100,000 citizens). Consequently, 80% of patients with a symptomatic inguinal hernia remain untreated. Besides a fundamental effect on daily activities these untreated hernias bear a substantial health risk with mortality rates of up to 80% in case of incarceration and strangulation.

Therefore, the key aims of ‘Operation Hernia’ are treating as many patients as possible and, at least as important, teaching local doctors to perform hernia surgery independently. After having treated 143 patients and having trained nine local doctors we look back on a very successful week in both respects. We are delighted to provide you with some of our impressions.

As soon as we arrived in Ghana, all 15 doctors were divided into two groups; on Sunday the 10th January one group took a short flight to Sunyani whereas the other group went by road to Keta.

Keta mission (8 physicians, supervised by Dr Boerma and Dr Garssen)

As soon as we got out of the car we smelled the African odour of little bonfires and heard warm African music played at the small road-side shops. The weather was beautiful with a warm sun and blue sky. We instantly enjoyed the great beach vibe in town. The beautiful hostel we stayed in, situated along Ghana’s southern coastline, was even more beautiful and relaxing.

The next morning, the hospital bus picked us up from up from our hostel to take us to the hospital. Keta Hospital is a lovely, small and clean provincial hospital with 300 beds and 5 medical officers. After a short walk through the hospital gardens on our way to theatre, we were welcomed by the friendly theatre staff. After a short introduction we started with the operations. A total of 70 hernias were operated by the Keta group. Inguinal hernias (severity grade H1 to H4) were treated with a Lichtenstein procedure, using meshes which were brought from the Netherlands. Although the main focus was inguinal hernias, other hernias such as umbilical and incisional hernias were also operated by the team. Local, spinal and ketamine anaesthesia were used.

The hospital staff and the Dutch Operation Hernia team worked well together. Local doctors were joining the operations to learn and practice Lichtenstein procedures. We were very pleased to hear that one of the medical officers even performed a Lichtenstein procedure on an incarcerated hernia on his own, one week after we left!

In the evening we spent time enjoying real Ghana life. We swam in the sea, listened to music, danced with local people and enjoyed the local food. We had a nice interaction with colleagues from the hospital who we invited for diner on the last night. The hospital administrator gave a beautiful speech and thanked us for all the effort. On Friday afternoon we finished the last surgical procedures and travelled back to Accra. But not before a thousand pictures were taken and all telephone numbers were exchanged.

Sunyani mission (7 physicians, supervised by Dr Simons)

After an impressive flight through inner Ghana we arrived in Sunyani, the capital town of the Brong-Ahafo Region with over 250,000 citizens. We were welcomed by Professor Tabiri, a well-respected surgeon born and bred in Sunyani and one of his residents, Dr Eric Owusu.

We took up residence in a nice lodge after which we were introduced to the team and, more importantly, to our patients in Sunyani Regional Hospital. We were impressed by the warm welcome and by the great facilities including well-maintained surgical theatres in this large teaching hospital.

The next morning, after an inspiring speech by the hospital’s medical director, we started with a fruitful team briefing in which the plans for the upcoming week were discussed.

As soon as everybody was aware of these plans surgery could start. Teams of Dutch surgeons, Ghanaian medical officers and Ghanaian scrub nurses made a great effort to treat all 75 patients who had responded to ‘the call for treatment’. Similar to the Keta mission, the most frequently performed procedure was mesh-based inguinal hernia repair using local anaesthetic. For exceptional cases of irreducible and recurrent hernias spinal anaesthesia was available. Children with inguinal hernias were treated under anaesthesia with Ketamine.

By using instructional videos, lectures, but of course most importantly hands-on-training, local medical officers became familiar with the common surgical procedures. Many of them will work independently in small medical posts throughout the country and we have high hopes that hernia surgery will be part of their ‘arsenal’.

Professor Tabiri proved to be an outstanding host next to an experienced surgeon. He showed us around in his hometown, enabling us to fully absorb the Ghanaian culture. What struck us was the inexhaustible optimism and hospitality that was present everywhere we went. During a memorable final evening local gifts from both Sunyani and Amsterdam were exchanged and inspiring words were spoken. Within one week a solid team had been formed and we all regretted that it already was time to say goodbye.

On Friday evening we were reunited with the Keta group in Accra. We stayed at the lodge close to the beach and shared all experiences of the past week. After some leisure time we had to go back to the airport to catch our flight to Amsterdam. Time had gone by so quickly!

We are very grateful for a fantastic experience and we would like to thank all the sponsors below who have made this journey possible. We are all looking forward to expand our mission with the “Dutch Operation Hernia” team next year!

Dutch Operation Hernia Teams: Maarten Simons, Djemila Boerma, Frank Garssen, Suzanne Gisbertz, Nanette van Geloven, Eddy Hendriks, Jonathan Vas Nunes, Anne Ottenhof, Bert van Ramshorst, Wouter Derksen, Frank IJpma, Theo Wiggers, Ellen Reuling, Charlotte Loozen, Maarten Anderegg

Sponsors & partners: Chris Oppong of Operation Hernia, MRC-Foundation Medline Atrium Medical, Departments of Anaesthesia & Pharmacy of: Academic Medical Center, Amsterdam, Amstelland Hospital, Amstelveen, Flevo Hospital, Almere, OLVG Hospital, Amsterdam, Sint Antonius Hospital, Nieuwegein, Ter Gooi Hospital, Hilversum, University Medical Center Groningen, Groningen

The team prepare to set off from Accra on the journey to Takoradi

Operation Hernia Report: November 2015 Mission to Takoradi, Ghana.

On the 21st November our team of six began our journey to Ghana. We comprised two consultant surgeons, Shina Fawole and Chris Macklin, a consultant anaesthetist, Josie Brown, a paediatric theatre sister, Lisa Macklin and two surgical registrars, Steve Pengelly and myself. We arrived in Accra on Saturday evening and spent the night at the Baptist Guest House before setting off for Takoradi on the Sunday. We managed to sneak in a trip to the beach on the Sunday and prepare for what turned out to be a very busy week of operating.

The team prepare to set off from Accra on the journey to Takoradi

The team prepare to set off from Accra on the journey to Takoradi

We spent the next five days operating at two hospitals in Takoradi; the Hernia Centre and the Ghana Ports and Harbour Authority (GPHA) Hospital, both of which have hosted Operation Hernia teams many times in the past. The patients had been selected prior to our arrival, coordinated by Dr Boateng, Chief Medical Officer of GPHA Hospital, which meant that there was no hanging around on the Monday and we were able to dive straight into work.

Over the 5 days, across the two hospitals, we operated on a total of 83 patients, including 8 children. In total, as a team we fixed 72 inguinal hernias, 7 other hernias (umbilical, epigastric and incisional) and 4 hydroceles. Needless to say, fitting in these numbers meant long and intensive days, and the local theatre staff and nurse anaesthetists worked incredibly hard to ensure we were able to get through all the patients. There was never any question of not sending for the next patient.

The Operation Hernia team plus the local staff at the Hernia Centre in Takoradi

The Operation Hernia team plus the local staff at the Hernia Centre in Takoradi

As previous volunteers have already attested to, the hernias seen were much larger than those commonly seen in the UK, meaning that the operations themselves were more challenging (and fun), particularly given the variability of the instruments as well as the occasional black out. The main difference was seeing the impact that our service had on the patients. With large hernias, many patients were unable to work and thus, a hernia repair can mean a return to work and the opportunity to provide for their families.

Operation hernia was an amazing and invaluable experience. Aside from the operative experience, it provides an opportunity to see and experience a different culture and provide new insights into our own practise. I am grateful to the other members of the Operation Hernia team and the local staff for making the experience so enjoyable and worthwhile. Special thanks has to go to Shina and Chris for their patience in training which enabled me to operate on large and challenging hernia, and to Lillian and her team who fed us remarkably well (considering the lack of electricity at times) during the trip.

Emma Upchurch, General Surgery Registrar

Missions

November 2015 “Operation Hernia” Mission to Bole, Ghana

Visiting Team

John Budd – Team Leader – Vascular and general surgeon

Anna Budd – Theatre nurse

Graham Howell – Urologist and previously a general surgeon

Rosemarie Howell – Theatre nurse

Travel Itinerary

Direct BA flight London Heathrow to Accra arriving 21.30 on 14th November

Overnight stay in Accra at the Baptist Mission Guest House. Meet, greet and brief with Chris Oppong and teams heading for other destinations.

Nissan 4×4 road transfer to Bole: depart Accra 06.00 and arrival at 16.00

Return to Accra by road on 21st November with wash up at the Guest House and return flight to London departing 22.00

Accommodation

The Cocoa Research Institute Guest House ½ mile from the hospital in Bole provided comfortable and clean accommodation with full board and air conditioning if required. Morning pick up was at 07.30 and return at 19.30.

Surgical Achievements

The team carried out 112 elective procedures in 97 patients as follows:

Adult Inguinal hernias 61 Inguinal Herniotomies (children) 15

Femoral hernia 1 Umbilical hernia 1

Hydroceles 18 Epigastric hernia 2

Lumps and bumps 8 Minor ano-rectal surgey 1

Four Emergency procedures were also performed:

Laparotomy and splenectomy for trauma

Appendicectomy for gangrenous appendix

Laparotomy and repair of perforated distal ileum for blunt injury

Caesarean section and tubule ligation

Training

Basic surgical training and some surgical skills were imparted to Dr Asiz and Dr Gerald, two newly qualified general doctors.

Nurse training included theatre skills for the nurses and concept of swab count for laparotomies.

This was a return trip to Ghana for John and Anna and a first visit for Graham and Rosemarie – deferred by the West African Ebola epidemic the previous year. The plan had been to visit Keta on the coast but there was a greater surgical need in Bole despite another teams endeavours the previous week, and we headed up country in the Bole Hospital Nissan pick-up truck on metalled roads. The 50 miles of potholes and craters on first leaving Accra had fortunately been resurfaced since John and Anna’s previous visit 3 years ago. The 10 hour journey was remarkable by its near misses and our passing 19 overturned lorries en route.

We had very comfortable and clean accommodation in the Cocoa research institute guest house and the food was a very pleasing combination of local and European fare.

We were warmly welcomed by the hospital director and the theatre and ward staff. Our surgical day began on the ward each day soon after 7.30 with a pre-operative examination of the day’s patients with surgical marking and a review ward round for those who stayed overnight on day 2 onwards. We used both operating theatres available. Each is now equipped with effective air condition units which made the operating environment quite comfortable. We were most impressed by the ability and humbled by the enthusiasm of all the theatre team.

There were two very capable and experienced nurse anaesthetists – Vitus and Michael. The strategy was to use spinal anaesthesia for the adult patients with very large, irreducible hernia or large bilateral problems whilst the children were given IV Ketamine. There was a modern anaesthetic machine in the main theatre and pulse oximetry and Valley Lab/Eschman diathermy units in both theatres. The laparotomies were done under GA and the Caesarean section under spinal anaesthetic.

John had brought a substantial supply of disposables including mesh, syringes, needles, local anaesthetic, sutures and diathermy pads/pencils. The BMI Bath Clinic had kindly supplied the bulk. It would have been difficult to have managed without the imported supplies and the hospitals own resources were preserved as a result.

We were assisted for some of the operations by Dr’s Asiz and Gerald who were recently qualified doctors with an interest in surgery and there was some time to help them with surgical skills . Dr Joe, the Hospital’s resident doctor, was very supportive and we were fascinated to hear of his WHO secondments to Liberia as part of the Ebola effort and to Ethiopia with the Polio eradication programme.

Some of the hernia repairs were challenging and very worthy of our visit. The diathermy finger switch devices tended to degrade with recycling and we encountered a diathermy pad burn for reasons which weren’t immediately obvious. We had no returns to theatre but disappointingly our splenectomy patient failed to regain renal function post-operatively and died of multi-organ failure within 36 hours. It was a busy week of operating made light by the enthusiasm and hard work of the Bole staff. There was a very positive ambience in theatre and laughter reminding us of the surgical careers of our youth.

Anna and Rosemarie visited the local market on Friday morning kindly escorted by Agatha, one of the theatre nurses, to help with the robust matter of negotiating prices!

We spent our evenings in the guest house discussing how best to resolve the world’s problems but failing somehow to reach a solution. Our final evening in Bole involved a great send off by the theatre team in a down town hostelry and our introduction to BBQ’d chicken gizzards. We were honoured to receive traditional headman’s robes. We renewed and made friendships and look forward keenly to a return visit.

Graham Howell 29/11/2015

Missions

TEAM REPORT FROM NALERIGU MISSION: NOVEMBER 7-14, 2015

This was a good mission to the Baptist Medical Centre at Nalerigu in Northern Ghana. This mission was significant for the fact that the second Guido-Cordula Fellow, Dr Mohammed Bukari was a member of the team.

Team Leader: Chris Oppong

Members: Nazzia Mirza (Consultant Surgeon), Sandra Stanton (Theatre Nurse), Dr Mohammed Bukari (Surgical Registrar at Komfo Anokye Teaching Hospital).

Travel November 7, 2015

The team stayed overnight at the Baptist Guest House in Accra. The hour’s flight to Tamale, Ghana’s northern city, on the following day was seamless. This was followed by a 2-3 hour journey to Nalerigu in a hospital 4Wheel Drive vehicle. The road was in parts very bumpy!!!

Accommodation and food

We were provided with very good accommodation. Food was provided by a local chef who would do extremely well on the UK “master chef” TV programme. The accommodation is set in a leafy area of the hospital compound which also houses hospital staff. The morning walk from our accommodation to the hospital was an enjoyable experience. Wi-Fi was available in the “business office” but there were some issues with the network

Theatre Sessions

We met with the whole of theatre team. This was to affirm each member of the theatre team and share our ethos for the week: team work to deliver quality treatment to as many patients as we can manage with compassion and efficiency. We were all encouraged to wear name bands to help with integration of the team and to break down barriers. The WHO check list was used in parts. The whole team worked as a family. The nurse anaesthetists were excellent. The theatre lead and all the staff were very cooperative.

Training

The Fellow, Dr Bukari, was trained in mesh repair and performed 15 procedures independently in addition to 5 procedure performed assisted by a Consultant as part of his training.

Outcome

Total number of procedures performed was 49 (Hernias 43, including 11 herniotomies in children (26% of hernia patients); Hydrocoeles 4; Lipoma 1; with one return to theatre. Many more patients would have attended for surgery with improved communication and organization.

Post-operative complications

We had only one early complication. A poorly nourished adult male became septic after repair of a large scrotal hernia. He was returned to theatre for evacuation of scrotal haematoma and made a good recovery.

Debrief

A most important final event was a closing debrief meeting of all theatre staff and medical staff, including the Medical Director. There was an open, honest feedback from both the hernia team and the theatre staff. The highlights of the feedback were the following points:

1. The hard work of all team members was acknowledged and commended.

2. There is a need to improve communication with all hospital staff during the planning stages of future missions. This will facilitate better recruitment of patients.

3. Theatre requirements could be more effectively communicated to hernia team.

4. Decontamination and sterilization of diathermy pencils and cables was reviewed. It was agreed the pencils and cables would be cleaned with antiseptic and sterilised in antiseptic solution until required for surgery.

5. The hernia team thanked all the theatre and medical staff for the support received.

6. A group photograph was taken to remember the mission.

Chris Oppong

Consultant Surgeon and Chairman, Operation Hernia

OPERATION HERNIA MISSION: 6TH – 13TH JUNE 2015. KETA, GHANA

So the journey started with three of us meeting at Heathrow Airport on the flight to Ghana; Andy Clarke (Consultant Colorectal Surgeon and team leader), Alex Clarke (A-level student), Dimitri Pournaras (Oesophagogastric Surgical Registrar). A few hours later we landed in Accra. A short taxi drive to our accommodation where we joined Arun Ariyarathenam (Final year Oesophagogastric Registrar) and the team was complete. It was already clear that it was going to be a great week and we were filled with anticipation and excitement as well as apprehension for the unknown for those of us who was doing this for the first time.

The next morning we set of for Keta, having met David, our driver. A man of a few words, but of incredible commitment to the hospital and personally to us. He made it very clear that it was his DUTY to ensure that we were safe and comfortable even if that meant that he would drive us back from the hospital at 22:00 after a long day. But more of this to come…

The route to Keta is scenic and is a great reflection of rural Africa. David’s African music made it even more atmospheric. Having arrived at our accommodation and settled, we went to the hospital for a tour of the facilities and the first introduction with the staff.

Keta Hospital is a local general hospital with three operating theatres. Surgical services are provided on an ad hoc basis with the medical staff being mainly general practitioners with some of them having a special interest in surgery. Caesarean section is the most common operation and other procedures are performed depending on the availability of the more experienced surgeon.

There had already been a campaign on the radio inviting patients with symptoms suggestive of hernia, highlighting the fact that treatment would be provided free of charge by Operation Hernia. The local doctors assessed most of the patients during the previous weeks.

The next morning, after an early breakfast, David drove us to the Hospital. We reviewed the first patients. The challenge was assessing without knowledge of the local language and often using a translator. Considering other types of medical or surgical intervention, hernia is more straightforward to assess in this type of setting where there is a language barrier. The hernias we saw were as expected reflective of rural Africa surgical practice. Very large inguinal and inguinoscrotal hernias in thin individuals, almost exclusively male doing intensive labour work was the most common pathology encountered. It soon became apparent that some of the patients will need to be postponed as they were unfit for surgery mainly due to malaria and uncontrolled hypertension. Knowing that another mission would take place in November and therefore these patients could be safely operated a few weeks later makes the decision-making easier and underlines the importance of establishing recurrent missions in the same region.

The anaesthesia used was either local anaesthetic or spinal anaesthesia provided by the experienced anaesthetic nurses. Their practice was very efficient with a quick turn around and we soon agreed to use spinal anaesthesia more liberally allowing us to take on some more challenging cases and also reducing operating time and maximising our capacity. There was definitely no lack of hernias in Keta!

The apprehension of operating in a different setting, miles away both geographically and culturally from the NHS, faded away at the first “knife to skin moment”. The operating table was low, the operating light was weak and unreliable due to unexpected black outs (we found the headlight used by cyclists very useful!), most of the instruments were worn out and occasionally inappropriate for the type of procedure we were performing with wide variation in the contents of different sets identically labelled. The scrub nurses were extremely keen to help and also learn from our practice. And their enthusiasm made up for any deficiencies.

As soon as we started operating we realised that the operating is pretty similar wherever you are doing it. We tried to use all three operating theatres “taking over” the entire capacity of the hospital and challenging the local team and ourselves. The patients kept coming… We were determined to deal with as many as possible if not all, but keeping safety as our primary concern. On Tuesday we could see that we would be overwhelmed. We performed 20 hernia repairs on that day finishing after 10pm. We had to defer some patients for the next day and we were reassured that the patients would be looked after. What was surprising for all of us was than not a single patient complained. They all stayed, most of them spending the night outside as they were travelling from far, and were very grateful to be operated the next day…

Nights were spent in the local hotel having been driven back by David. Reflection on the day’s activities and plan for the next took place over dinner. A special moment was Andy sharing stories about Shorland Hosking with whom he had a personal and professional relationship.

An effort to include training as an important part of the mission remained a priority. The local doctors found it challenging to attend the operating theatre due to their other clinical duties. However, when they were with us teaching of basic surgical skills, principles of surgery and the technique of tension-free mesh repair of inguinal hernia using were provided. We also used every opportunity to teach the two visiting medical students from Spain, scrub nurses, staff nurses and nursing students.

By the end of the second day the scrub teams were getting used to us, some of the training was paying back and the teams were working as a well-oiled machine. Most of the time… The focus on safety we are accustomed with in the NHS was not the norm in Keta, and this is completely understandable in a healthcare system which is overwhelmed and where the focus is to provide the best possible treatment in the largest number of patients accepting a risk for specific individuals.

What became apparent to us was the desire of members of staff to introduce safety measures, to improve quality, to learn. Doing operations without a WHO checklist felt initially surprising and eventually unsafe. We discussed with different members of the teams and it transpired that they had similar concerns, the most acute being the fact that swabs were not counted. Anecdotes of errors and near misses were shared. We identified the limiting factor was the lack of white boards. Making sure that everyone was in agreement including the management of the hospital we managed to buy three boards on the Friday, our last day. Within minutes they were on the walls with the aid of the estates team. By that time the team were very excited. We did the first procedures using the WHO checklist with needle, instrument and swab count on our last day.

We finished on Friday when all available patients had been operated on. Sixty-five hernia repairs were completed. We left the next day with great memories. We are grateful to the medical and nursing staff of Keta Hospital and Operation Hernia. Special thanks for the Shorland Hosking Fellowship.

Arun Ariyarathenam

Alex Clarke

Andy Clarke

Dimitri Pournaras (Shorland Hosking Fellowship)

Visit to Ho Hospital November 2014

Report about “Operation Hernia” tour to Ho in Ghana from 15/11/2014 to 23/11/2014

This is the second time I have joined a tour for the charity “Operation Hernia”.

The tour was planned well ahead during 2014 with timely reminders about all the practicalities. These preparations were severely disrupted by the Ebola virus outbreak in some West African countries. For safety reasons, the organising team felt it had to cancel the tour. However, I had booked holidays and flights etc, I was looking forward to the tour and I judged that the risk of Ebola outbreaks in Ghana would most likely be minimal and therefore requested to be allowed to go anyway.

I am very grateful that Mr Chris Oppong supported me in my endeavours and worked hard to make my tour possible.

Living in Shetland it is always a gamble to travel in winter from here. The weather was kind to me and my travel arrangements worked out well.

Having arrived in Accra as planned on the evening of 15/11/2014, I was picked up directly at the airport and brought to a guest house for a comfortable overnight stay and rest. The next day, the Ho Hospital send a comfortable SUV car and very friendly and safe driver to take me to my lodgings in a very fine hotel in the outskirts of Ho. The hospital transportation team took great care of transporting me daily to and fro between the hotel and the hospital. The accommodation was extremely comfortable, safe and friendly and had wonderful African food for me.

From Monday morning to Friday lunch time, I worked in the Ho District General Hospital. The team there were very well organised. They had visits from the “Operation Hernia” teams there for a few years running and had put in a lot of effort to make this a success. They opened a special ward with extra staff to look after the patients. In addition they had an operating theatre with extra staff including nurse anaesthetists ready. I had one of the surgical trainees to assist me at all times. He was already experienced in inguinal hernia repairs as obstructed and strangulated hernias are one of the most common surgical emergencies in Ghana. However, they usually have not had access to surgical mesh and therefore do a darn repair. The trainee was very eager to learn the mesh technique and it was wonderful to have his help preparing the patients and getting to grips with the new environment. And it was good that I could show him a different way of treatment and to see him performing mesh repairs independently after a few days. I also encouraged him to contact Mr Oppong to find out about “mosquito net mesh” and the logistics on how to get that set up in Ghana. And I hope that he will be able to use this in his future career.

Overall, I – or rather we – operated on 26 patients, who had 32 hernias, 2 of which were recurrent hernias. Only 2 or 3 of these were of a size that I recognize from my usual practice in the UK. One patient was about the size of a normal weight patient in the U.K. The other patients were all very slim, rather small, with tough muscles and very large hernias which they had to live with for many years. This makes the operations a bit more protracted and challenging. I very much hope there will be not too many seromas…

The patients were admitted the day before surgery. Co-morbidities were few that we knew about. One patient was NIDDM who checked his own BM. We did him early on the list and he was happy to go back on his medication later that day. 2 patients got postponed for a couple of days as they had not taken their anti hypertensives. A common problem, as the patients do not feel better on the tablets and therefore do not understand the sense of taking them. We were able to operate on both of them later in the week.

The patients were discharged the day after the operation if all was well. This was co-ordinated by the junior doctors of the hospital. As far as I was told, no patient needed to stay longer, except for one. This patient had a large, irreducible, sliding right hernia with a fair bit of small bowel, caecum and some ascending colon in the hernia. Furthermore, I found a tumour – most likely testicular in origin – which was invading the mesentery near the ileocaecal valve. So, we ended up doing a limited right hemicolectomy with end-to-end anastomosis and a right radical orchidectomy as well as the hernia repair. This patient was then sent to the normal surgical ward. My local surgical colleagues were happy to take over the post-operative care. They assured me that they would have done the same and that they are very used to looking after patients with bowel resection due to the frequent emergency presentations of hernias. The patient was recovering well when I left.

Of course, operating in a new environment has its challenges for every surgeon. We like to have the security of the known surroundings and our own routines. I was very grateful, that I had the support of a surgical trainee with local knowledge throughout. It must have been difficult to spare him from the routine hospital work which looked very busy for the far too small work force. I appreciate the thoughtfulness of the local colleagues to give me so much support.

I could see that the local resources were stretched by my lists. I had all the meshes for the hernia repairs and left some behind. I had nearly enough suture material. But of course, there is much more involved: extra staffing, re-sterilisation, gowns, masks and hats, air conditioning to keep this northern visitor from collapsing, lunch time feeding for the team… The theatre staff were wonderful. They stayed cheerful until the cases of the day were done. They were patient with all my funny demands. They kept the lists well organised. They warned me in time when we had to improvise so that I could adjust my expectations.

On the last day, after finishing the last scheduled case, I received a warm “thank you” from the hospital management. I thought I had done fairly well. It was humbling to see that they had a much longer list of cases collected earlier in the year. They had hoped for the full team from “operation hernia” to visit which would have allowed for many more patients to get their hernias repaired. I just hope that it will be a good incentive for the charity to organise the next visit for next year.

I am grateful for everybody in Great Britain and Ghana who worked so hard to allow me to visit Ho Hospital.

I wish the trainee, Mr Bosompem all the best for his future career.

Beatrix Weber

Report of Operation Hernia’s Mission to Ho Volta Regional Hospital
November 2013

The Stats!

Location

Volta Regional Hospital in Ho, located in the Volta Region to the west of Ghana
Approximately 3 hours drive from the capital city, Accra

Personnel

From the UK: 3 consultant surgeons, 2 surgical registrars, one scrub nurse
Charge nurse Sister Josephine, who managed everything!
More than 10 theatre staff who rotated between recovery and theatre
Experienced anaesthetic nurses who could give spinals faster than we could scrub!

Patients

98 patients were recruited, 97 patients operated

Facilities

Initially three theatres, with the fourth emergency theatre being made available to us on the final 2 days.

Fixed operating lights and mobile lights
Sutures, gloves, instruments and mesh were brought by the team
2 diathermy machines present from previous trips, we brought a third
Unfortunately no air conditioning was available due to maintenance

Hospitality

We received 5-star treatment from hospital administration and theatre staff
Food and water between cases
Constant care and attention to our every need!

The Story

We congregate at the Baptist Guest house prior to departing to Ho. We meet Mr Oppong who has already arrived early, full of energy and knows everyone’s name. We all feel instantly special. We meet Bernard our hospital representative, who has already been coordinating things behind the scenes. A quick breakfast is followed by us loading up into our respective vehicles and the journey to Ho begins. It a beautiful 2.5hr trip, but one full of contrasts. The beautiful lush landscapes give way all too frequently to little townships, were the even from our vehicle we can see the poverty that so many live in. Grand buildings are side by side with mud huts, small mansions next to tin shacks. Our driver is enthusiastic, and often has to be reminded that we are not thrill seekers. The road is in relatively good condition with the usual perils of overloaded motorcycles, formula one-esque taxi drivers and the ubiquitous tro-tro (public minibus).

Our prayers are answered and we arrive safely at our accommodation. Our residence can only be described as beautiful. To say more would be to tempt you to join the mission for all the wrong reasons!

After a brief lunch we visited the Volta Regional Hospital. We meet the director of surgery, his administrator, head of finance and a senior surgical resident. We are welcomed into a conference room as if we were visiting dignitaries! After introductions and a heartfelt welcome it is time to see the rest of the hospital and staff. It’s a relatively new building, we are told as we walk around. All the buildings are bungalow style sprawling as far as eye can see. Fortunately the walks between the buildings are shaded. The first thing commented on however by our senior visiting surgeon was the ample parking available. I think this alone made his day!

On to the ward to see the patients preoperatively. They have been selected over a period of months, and are eagerly awaiting our arrival. As we enter the ward they have been patiently waiting for us and applaud spontaneously. After a warm welcome by the ward sister, complete with crushing hugs, we begin to see the patients. All the patients are admitted the night before surgery. We reviewed 21 patients, there was only one DNA. What impressed all of us was how organised the nursing and medical teams had been. From blood results to simple clinical notes, everything was in place, and we were able to review and assess all the patients in just over an hour. An impossible feat in the UK! We returned back to our accommodation in the evening, arms full of food that had also been gifted to us.

The week is made up of grueling 15 hours shift days where we operate, ward round, clinics and data collect tirelessly, whilst supported by the brilliant hospital staff, who do overtime to allow us to finish the cases. Our fatigue is quickly forgotten when we see the gratitude of the patients when their operation is completed. Most have travelled many miles to arrive, and wait patiently for their turn with no complaints.

We were pleased to finish all operations successfully on Friday with no complications. We were rewarded with our first social night out where we went for dinner and drinks, dressed in traditional wear that had been gifted to us by the Hospital staff. We left the following day, all of us promising to return the following year!

Special Thanks

To all the theatre staff at Volta Regional Hospital, Bernard, and Mr Chris Oppong.

Miriam Adedibe

Naami McAddy