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

Tuesday 25th November 2014

UPDATE ON ESSENTIAL (GLOBAL) SURGERY – NOVEMBER 2014

Chris Oppong, Chairman of Operation Hernia, attended the Netherlands Society for International Surgery Symposium on “Surgery in Low Resource Settings” in Amsterdam from November 14th to 16th, 2014.

There were some important highlights that may be of interest to Operation Hernia partners.

1. International Collaboration for Essential Surgery: 15 x 15 Campaign

15 x 15 is a campaign by the International Collaboration for Essential Surgery (ICES) http://www.essentialsurgery.com/ and Operation Hernia is a Supporting Body of ICES. Hernia Surgery is one of the 15 Essential Surgical Procedures. The ICES website explains that the campaign focuses on promoting the 15 essential interventions that can take care of the basic surgical needs of any community. 15 x 15’s overarching goal is to ensure that Essential Surgery is recognized as a priority for primary care policies, practice, and research by 2015. The 15 x 15 campaign aims to increase access to Essential Surgery through:

Piloting — innovative models for task shifting and training non-MDs to perform surgery
Advocating — for essential surgeries to be integrated into existing health systems
Informing — the field through research, publications, and screenings of The Right to Heal

The Right to Heal is a film that sheds light on the neglected issues of surgical care globally, and the need for organizations and individuals to unite in bringing essential surgery to poorly-served areas of the world. Please visit the ICES website (http://www.essentialsurgery.com/the-right-to-heal/) to watch a trailer of The Right to Heal or http://vimeo.com/91687421 to watch the full film.

2. The Role of the World Health Organisation (WHO) in Global Surgery

This was the keynote lecture delivered by Dr Meena Cherian who leads the WHO Global Initiative for Emergency and Essential Surgical Care. She is a Professor of Anaesthesia, having originally graduated from a University in India.

Dr Cherian announced that the WHO will at its meeting in May 2015 formally approve of Essential Surgery as part of its Global Health agenda. This will be preceded by approval by the WHO Executive Board at their meeting in January 2015 and will bring hope to the 2 billion people who lack access to basic surgical care. It will be the culmination of years of campaigning by various bodies and individuals to persuade the WHO to end years of neglect of basic surgery as an essential part of the WHO programme to improve global health.

3. Edna Adan University Hospital, Somaliland www.ednahospital.org

Edna Adan thrilled the meeting with her eloquent presentation of her achievement in establishing a successful healthcare system in Somaliland from the ruins of a war. Born in Hargeisa in1937, she was trained as nurse and midwife in the UK. In 1961 she returned home becoming the first qualified midwife in Somaliland. Her career for the WHO started in 1965. In 1991 she became WHO Representative in the Republic of Djibouti where she served until retirement in 1997. In 2002 she became the first and only woman Minister in the Government of Somaliland when she served as Minister of Social Affairs, and between 2003 and 2006, she was Somaliland’s Foreign Minister. For her impressive work she has received numerous awards and she has been invited to several international conferences, like the Lancet Commission of Safe Surgery. In order to reduce the high maternal mortality rate of the women in her country, her lifetime goal is to train 1,000 midwives to work in remote areas in Somaliland and encourages other countries in Africa to train one million midwives to work in African countries with similar harsh conditions for women like Somaliland.

Dr. Shukri is a remarkable young doctor. She became one of two first female doctors in Somaliland. First she graduated as a midwife at the Edna Adan Hospital. Due to her talent and motivation she received sponsorship to go to medical school. After graduation in 2011 she was one of the first female medical staff members of the Edna Adan hospital. This ambitious lady is still improving her skills. She became the first national trainer on infant resuscitation. Dr Shukri is currently focusing on surgery and recently performed her first obstetric fistula operations.

4. E-Learning with 3D visualisation for training

Theo Wiggers a retired surgeon presented a novel e-learning module with 3D visualisation for training surgeons. This will be piloted in Ghana during an Operation Hernia mission led by Dutch surgeon, Maarten Simons.

5. College of Surgeons of East, Central and Southern Africa

The College of Surgeons of East, Central and Southern Africa (COSECSA) is an independent body that fosters postgraduate education in surgery and provides surgical training throughout the region of East, Central and Southern Africa. COSECSA is a non-profit making body that currently operates in 10 countries in sub-Saharan Africa: Burundi, Ethiopia, Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe.

Prof Jani, Secretary General of COCSECA, presented the innovative model for training of surgeons in the COSECA region to improve the critical shortage of trained surgeons. Operation Hernia is now exploring possible collaboration with COSECSA to be involved in training in hernia surgery.

Chris Oppong,

Chairman, Operation Hernia

November 24, 2014

Grace, Lilian, Kate and Brian

Dutch Team, Takoradi, Ghana 10-19 JANUARY 2009

The Dutch team consisting of Maarten Simons (consultant), Frank Garssen (experienced tropical doctor and surgical resident) and Astrid Huiberts (surgical resident) operated at in Takoradi from January 10-19.

Grace, Lilian, Kate and Brian

Grace, Lilian, Kate and Brian

We had a wonderful time thoroughly enjoying performing the operations, meeting Ghanaians and visiting parts of the country. After arrival we drove to Takoradi arriving there at 2 a.m. being welcomed at the guest house by Brian Dixon and our hosts for the week Kate, Lilian and Grace. We are very grateful for all the effort that was put into making our trip a success. Brian was closing down his office but this did not stop him from worrying about our wellbeing 24 hours a day. On our final day when we were traveling back to Accra he called us 23 times informing whether the drive was OK, if we had found Rebecca our guide, if the lunch was OK and if enough salt was added to Frank’s sandwich. The girls were a delight. Cooking wonderful meals and joining us for trips to the market and the beach. We will not forget their singing on the way from the beach back to Takoradi. Beautiful songs and beautiful voices. We were sad the car drive was over. We hope that the girls will continue being part of Operation Hernia and certainly that Brian will stay involved. It is hard to imagine the stay without his help.

Sunday we met Bernhard Boateng and discussed the week. He thought we were with two teams and had planned 40 patients; 25 in the hernia wing and 15 in the Ghana Ports and Harbour Authority hospital. We agreed to try to help all the patients by spreading them over the week and working in two teams on the last day. In 5 days we managed to perform 40 operations in 38 patients. We had taken material for 40, so our suitcases were empty at the end of the week. Everything went very well. The Hernia Wing and GPHA are well equipped. The nursing staff are well trained and fun to work with. They work very hard without complaining and put the wellbeing of their patients first. We operated on five children, two women, two bilateral, two recurrences and almost all hernias were scrotal. Very educating for the two residents! We performed one orchidectomy for an ectopic testis and scrotal hernia and for a huge hydrocele a hemiscrotectomy in an old man. With Bernard the residents performed drainage and excision of an infected mesh with a fistula of two months. The patient had come quite late with this complication. This is of course the nightmare of operating with mesh and everything must be done to keep the complication rate at an acceptable low percentage. We gave prophylactic antibiotics and Bernard had chosen to give all a 5 day cure of Stafoxil. Sterility in the OR is good. Rules are abided by although lack of enough drapes and running water can be a disadvantage. We used large meshes that before the first patient were cut into 8 smaller meshes and kept them under a sterile drape during the day. Dr Frank and Dr Bernhard deserved and received our deep respect for their work in Takoradi. Running a hospital and being a generalist physician who treats all patients (children and adult) with all diseases (as surgeon, obstetrician etc) with relatively little is an immense responsibility. They deserve as much support as we can give.

We truly hope to hear if there are complications of our work. The infected mesh that we had to remove in a young adult was hopefully an exception and infrequent complication. It would be a good idea to have all patients put into a databank so that results can be monitored more closely. We spoke about this with Bernhard and he would come with a proposal for some research in this area.

We performed a small study into the EHS classification system. All hernias were independently by the three of us scored for type of hernia preoperatively (H classification) and peroperatively (EHS). We hope to publish the results in 2009-10.

The second weekend we stayed at Axim beach. Very relaxing. We played soccer with the local kids, swam in the wonderful sea and enjoyed the sunshine. Sunday we were picked up by Brian and the crew that sang us back to Takoradi. Monday we visited the rain forest, Hans Cottage and Elmina. Finally on Monday evening we were on our way home. We will be back.

Maarten Simons
Frank Garssen
Astrid Huiberts