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

 

Surgical trainees with Mr Chris Oppong and other faculty members

A Multinational Operation Hernia Team, led by Mr Chris Oppong, Consultant Surgeon and Chairman of Operation Hernia, have just returned from Rwanda.

Surgical trainees with Mr Chris Oppong and other faculty members

Surgical trainees with Mr Chris Oppong and other faculty members

The course faculty drawn from the UK, Germany and Austria trained 14 first year Surgical Residents in both mesh and tissue repair of groin hernias.

Lectures on almost all aspects of groin hernia surgery were delivered on the first two days of the training course. The most important lecture, on the anatomy of the groin, was delivered by Dr Ralph Lorenz, Consultant Surgeon from Germany. The lectures were followed by hands-on, one-to-one Operating Theatre training at the Central Teaching University Hospital of Kigali (CHUK) and Rwamagana Hospitals. This occupied the next 5 days.

Overall it was a very successful programme which provided essential, high quality training to Rwandan postgraduate surgical trainees. Operation Hernia is most grateful to the other members of course faculty; Mr David Sedgwick (UK), Dr Maik Lechner (Austria), Dr Albrecht Frunder (Germany) and Dr George Ntakiyiruta from Rwanda.

Lecture on the anatomy of the groin

Lecture on the anatomy of the groin

Inguinal hernia repair with affordable (low-cost) polypropylene mesh

Inguinal hernia repair with affordable (low-cost) polypropylene mesh

For this important surgical training course Operation Hernia was in partnership with the Rwanda Legacy of Hope charity. Operation Hernia is also extremely grateful for the enormous support and hospitality received from the Rwandan Ministry of Health and the Government of Rwanda.

Following the visit by the Operation Hernia Team an article outlining the visit and its achievements was publishd in the New Times, Rwanda’s Leading English Daily Newspaper:

http://www.newtimes.co.rw/section/article/2017-03-14/208886/

Chris Oppong

Surgical trainees in the operating theatre. The "Safe Surgery Checklist" can be seen in the background.

Surgical trainees in the operating theatre. The “Safe Surgery Checklist” can be seen in the background.

Operationn Hernia team in Rwanda

OPERATION HERNIA MISSION TO RWANDA – FEBRUARY 2014 REPORT BY CHRIS OPPONG, CHAIRMAN OF OPERATION HERNIA

INTRODUCTION

The OPERATION HERNIA/LEGACY OF HOPE MEDICAL MISSION to Rwanda 2014 was the largest this year. It was led by Chris Oppong, a UK Consultant Surgeon who is the Medical Director of Operation Hernia. A UK medical team of four teamed up with a team of 13 from Germany, led by Ralph Lorenz. We were attracted back to Rwanda by the burden of need but also by the legendary warm welcome which awaits volunteers and visitors.

Operationn Hernia team in Rwanda

Operationn Hernia team in Rwanda

We linked up with LEGACY OF HOPE for the RWANDA Project. Legacy of Hope is a church-based registered UK Charity. They operate from Plymouth which is also the base of Operation Hernia. Operation hernia provided the UK and Germany teams. This year we had a solo Plastic Surgeon who works in the UK. Ralph Lorenz, a Consultant Surgeon, is the Operation Hernia Ambassador in Germany.

The aim of OPERATION HERNIA/LEGACY OF HOPE MEDICAL MISSION is to deliver sustainable, high quality medical care to relieve suffering from burden of disease in Rwanda and to train local doctors, nurses and other healthcare workers.

BURDEN OF HERNIA DISEASE IN RWANDA

Hernias are more common in Rwanda than is commonly thought. In fact the estimated burden (prevalence) of hernias in Rwanda is 5.78%3. This compares with 5.36% in Tanzania1 and 3.15% in Ghana in West Africa.2 Repair of Hernias with polypropylene mesh (Lichtenstein technique) has become the standard in high income countries. In low resourced countries high tension, sutured repair is standard because of cost of branded mesh and lack of skill. Resultant high recurrence rates increase the total cost of treatment of hernias. Mesh repair of hernias averts significant number of disability adjusted life years (DALY)4.

HOSPITALS

Last year, OPERATION HERNIA/LEGACY OF HOPE MEDICAL teams worked in two mission hospitals: Nyamata and Remera-Rukoma hospitals. This year we worked in two additional mission hospitals: Kirindi and Gahini hospitals. The new Hospitals were represented by the Medical Director of the Association of Presbyterian Hospitals, Dr Esperance. Nyamata, Kirindi and Gahini hospitals hosted Hernia surgery. Remera-Rukoma hospital hosted hernia surgery and plastic surgery. The latter is an expansion of the medical programme of LEGACY OF HOPE. Training of local doctor was a high priority and this was provided in Kirindi and Gahini hospitals.

PATIENT RECRUITMENT

This year’s recruitment was a massive success. The publicity for the programme was mounted by the Rwandan Ministry of Health for all the four hospitals involved in the project. This is because of the vital link established between the project and the Rwandan Ministry of Health. This link was negotiated by LEGACY OF HOPE (LOH), led by Pastor Osee Ntavuka. Legacy of Hope is officially recognised by the Rwandan government and OPERATION HERNIA (OH) is a partner of LOH.

The success of recruitment was in part due to the involvement of Dr Esperance, the Medical Director of the Presbyterian Hospitals.

A young boy with an inguinal hernia being assessed prior to surgery

A young boy with an inguinal hernia being assessed prior to surgery

TRAVEL AND CUSTOMS

All equipment brought by the teams were cleared for customs by the Ministry of Health because of the official recognition given to LOH.

MEDICAL REGISTRATION

The OPERATION HERNIA/LEGACY OF HOPE MEDICAL team is in a unique position in Rwanda regarding registration of the medical team by the Rwanda Medical Council (RMC). We are grateful to Pastor Osee through whose efforts, all the doctors on the project have been given a 5-year registration by the RMC. This includes registration as Continuing Professional Development (CPD) providers. This is an invaluable platform on which to expand the work of OPERATION HERNIA/LEGACY OF HOPE MEDICAL team in Rwanda.

ACCOMMODATION

The teams stayed overnight in Kigali, the capital. Accommodation in Kigali was in a hotel. During the week, all volunteers were accommodated by the hospitals who also provided subsistence. Volunteers paid for their hotel accommodation in Kigali.

TRAINING OF DOCTORS

This training programme was registered by the Rwandan Medical Council for CPD points. A total of 13 local doctors received training in two hospitals. All but one of the doctors had skills in hernia surgery. The training programme included formal teaching on anatomy and the essentials of mesh hernia repair. This was delivered by PowerPoint. Trainees then had hands-on training –

Assisting OH surgeons
Assisted to insert mesh in at least two cases.
A few had opportunity to do more cases.

At Gahini hospital, trainees were presented with certificates to recognise their attendance at the training sessions. Five doctors adjudged to be competent at the end of the 5 days were given mesh to use in their hospitals. All the cases they perform will be documented for review when the team visits in 2015.

Chris Oppong presenting a certificate of attendance at a training session to one of the local doctors

Chris Oppong presenting a certificate of attendance at a training session to one of the local doctors

CLINICAL OUTCOME

A grand total of 166 operations were performed in all 4 hospitals.

A total of 132 cases of hernias and hydrocoeles were performed in all centres. 33 plastic surgery operations were performed at Remera Hospital.

Table 1

Table 1

CLINICAL OUTCOME

A grand total of 166 operations were performed in all 4 hospitals.

A total of 132 cases of hernias and hydrocoeles were performed in all centres. 33 plastic surgery operations were performed at Remera Hospital.

Table 2

Table 2

Change of policy.

Because of the complication in the 5 year old, it was decided at Gahini hospital to postpone surgery in all children under 9 until 2015 when hopefully a consultant anaesthetist would be part of the team.

MEDICAL EQUPIMENT DONATED

OH/LOH provided and donated a large amount of medical equipment to the various hospitals.

The total estimated cost of medical equipment was £39,000.

ACKNOWLEDGEMENTS

Ministry of Health

Our prime thanks go to God who is the provider of all goodness.

We would like to register our profound gratitude to the Minister of Health for the tremendous support the team has received. Our thanks also go to François Habiyaremye and all the other officials.

Medical Teams

It is appropriate to acknowledge and congratulate the effort of all the medical team for volunteering significant financial resources, annual leave and other resources to provide the people of Rwanda with such excellent medical care. All team members are motivated by a passion to care by employing their clinical skills to provide relief of suffering and transfer of their skills to the local healthcare stakeholders.

The Medical Team would like to express sincere thanks to the following stakeholders.

Minister of Health
Ministry of Health officials
Rwanda Medical Council
All Medical Directors
Staff of all hospitals
The Head of the Presbyterian Church
Dr Esperance, Medical Director of Association of Presbyterian Hospitals

FUTURE PLANS

The OPERATION HERNIA/LEGACY OF HOPE MEDICAL MISSION will continue to cooperate with the RWANDA MINISTRY OF HEALTH to expand the coverage of our care. This will be clearly detailed in our Plan of Action for 2015.

CHRIS OPPONG, CHAIRMAN OPERATION HERNIA

REFERENCES
1. Beard JH, Oresanya LB, Akoko L, Mwanga A, Dicker RA, Harris HW
An estimation of inguinal hernia epidemiology adjusted for population age structure in Tanzania.
Hernia 2014: 18: 289-95

2. Beard JH, Oresanya LB, Ohene-Yeboah M, Dicker RA, Harris HW
Characterizing the global burden of surgical disease: a method to estimate inguinal hernia epidemiology in Ghana.
World J Surg 2013; 37: 498-503

3. Beard JH, Oppong FC
Epidemiology of Inguinal Hernias in Rwanda.
(To be published)

4. Shillcutt SD, Clarke MG, Kingsnorth AN
Cost-effectiveness of groin hernia surgery in the Western Region of Ghana.
Arch Surg 2010; 145: 954-61

The Team

Report from a German-British Mission in Rwanda, February 2013

The Team

The Team

Background

Rwanda – a country on the move: after the genocide with up to 1 million victims almost 2 decades ago Rwanda has evolved rapidly. As one of the countries with the lowest corruption index Rwanda announces an accelerated growth and has established a compulsory school attendance for children free of charge. The government with president Kagame undertakes great efforts in the future program 2020 in the field of birth control, generation of energy and environment. In recent years a revolutionary health system was established: every citizen of Rwanda pays a very low contribution for a health insurance and every citizen gets a primary health care. But there are still a lot of problems: for example there are only 221 physicians for 12 million inhabitants available in Rwanda (0.2 per 10 000 inhabitants comparing to Germany 36.0 per 10 000) and 4050 nurses (*World Health Statistics 2012).

Dr Ralph Lorenz & Dr Dr Elda Balikwisha

Dr Ralph Lorenz & Dr Dr Elda Balikwisha

Dr Maral Miller

Dr Maral Miller

The Mission

After the exploratory mission by Chris Oppong in February 2012 a plan to come back with a big operating team of 12 German and British Healthcare-Professionals could be realized: this bi-national team stayed from 08th to 18th February in two regional hospitals in Nyamata and Remera Rukoma.

The first team from Berlin consisted of two surgeons, Dr. Ralph Lorenz and Dr. Jens Heidel and the anesthetists Dr. Maral Miller as well as and two theatre nurses, Ines Kuhl and Peggy Grassmann.

The second international team consisted of the three surgeons MD Chris Oppong from Plymouth, Dr. Karl Spitzer from Munich and Dr. Christine Kosch from Berlin, the anesthetist Dr. Petra Wölkerling from Berlin, the theatre nurses Helena Azevedo und Sandra Gess from Plymouth and the anesthetic nurse Carolin Dauksch from Berlin.

The expected problems with the excess baggage (24 boxes with more than 500 kg) on the check in desk where fortunately absent as well as any kind of conflict with the customs in Rwanda. The only surprise in Kigali was that we had to remove all plastic film from the boxes, since Rwanda’s law has placed a ban on imports of any plastic bags and packing. So Kigali is a very clean city with no plastic waste at the roadside – what a difference that makes!

Pastor Osee from the Legacy of Hope aid organization had prepared everything perfectly: not only did he organize a really warm welcome at the airport in Kigali with temperatures of 25 degrees Celsius after a long flight from freezing Germany – he also arranged a beautiful accommodation in a nice guesthouse in Kigali.

A big heartfelt thanks to Pastor Osee with his team!

After the first two days for acclimation and team-building, we already visited on Saturday both hospitals for the last preparations. On the following day, the whole teams visited the King Faisal hospital, the biggest and model-hospital in Rwanda by invitation of the CEO Dr. Jean Bosco Butera. We were deeply impressed about the perfectly equipped facilities.

On Monday 11th February we began with our work with two teams in both hospitals, performing surgery from 8 am to 8 pm with as many patients as we could. Still, there were many patients on the waiting list.

At this point we would like to say a deep-felt thank you to the regional persons in charge as well as to nurses and attendants in the two hospitals under the supervision of Dr. Alfred Rutagengwa (medical director of the Nyamata Hospital) and Dr. Kalinda Viateur (medical director of the Remera Rukoma Hospital) for their perfect preparation and coordination!

Resume

The statistics added up to 95 operations on 78 patients within five days:

All together 72 inguinal hernias were operated, including 20 hernias in children and 17 inguinoscrotal hernias. In one case of an incarcerated hernia with chronic abscess formation there was a need for an emergent resection of the small bowel.

Furthermore 10 ventral hernias (epigastric, umbilical and incisional hernias) as well as 14 hydroceles were operated.

Nearly all patients apart of the younger patients were supplied with a mesh. Thanks to the generosity of companies’ donations in all cases original meshes could be used instead of mosquito-nets. All currently possible open operation-techniques like SHOULDICE, LICHTENSTEIN, Plug and Patch and TIPP were applied. The diagnostic findings however cannot be compared to European standards. Nearly all hernias were indirect, mostly with a small defect but with a large hernia sac. In certain cases there was additional a hydrocele.

As anesthetic methods we used mostly general anesthesia with laryngeal masks, in certain cases also local anesthesia and spinal anesthesia. The majority of Patients stayed for one or two nights in the hospital since their journey home would have been too long.

All operations were successful without complications and all patients were discharged from the hospitals during our stay.

The long-term sustainability of this mission resulted not only in giving away a lot of medical equipment the surgeons are now able to use, but also in educating the local Professionals. The surgeons were trained step-by-step in doing Hernia repair with meshes and the local anesthetists received supervision by our anesthetists Marla and Petra. Last and not least our nurses gave a lot of advice and techniques to the nurses in charge. It was an excellent team-work in these mixed teams from Rwanda-Germany and UK. After one week of training Dr. Elda Balikwisha – a young surgical resident at Nyamata hospital has perfectly performed a Lichtenstein Repair by himself – a big success!

Dr Jens Heidel & Dr Nzeyimana Jean Berchmans

Dr Jens Heidel & Dr Nzeyimana Jean Berchmans

After the return to Kigali we got two more personal contacts with people. A Meeting with the president of the Surgical Society of Rwanda Dr. Emile Rwamasirabo has developed a vision of a closer collaboration in case of education. So it might be possible to organize a hernia workshop for all surgeons during a next mission in Rwanda.

A very ceremonial and emotional finish of our humanitarian mission was a church service on Sunday in Kigali with Pastor Osee and a congregation that cheerfully welcomed the European visitors. And after this stressful working week the German team travelled through this beautiful country with its breathtaking landscapes.

Without the generous support of numerous private and company donations as well as the unselfish commitment of all team members this mission would not have been thinkable. The great success of that mission was mainly possible because of the distinguished capacity for teamwork of every participant.

We have gained a lot of positive insights through this humanitarian mission. Emotionally most touching was the deep thankfulness and appreciation of the patients, and last but not least of the nurses and hospital workers. During one week an outstanding personal and cooperative partnership had developed.

All team-members expressed their wish to participate on the next humanitarian mission.

We are deeply thankful and we look forward meeting again in Rwanda!

Ralph Lorenz für das Team Germany /U.K.

February 2013

Nyamata Hospital

Rwanda was a very pleasant surprise. The country has recovered from the genocide that ravaged the country 20 years ago. The people are very welcoming. I felt I could easily make Kigali my second home in Africa, after Ghana.

Nyamata Hospital

Nyamata Hospital

The capital Kigali has been rebuilt. It is a very clean city. Commerce is booming. French used to be the lingua franca until after the genocide. English is now taught in schools. We were so embraced by the city I have already started planning a return in 2013!!

A visit to the Genocide Memorial was both emotionally challenging and hugely instructive.

The surgical team comprised one Consultant Surgeon and a nurse. This was meant to be an exploratory visit. For that reason we planned to perform only 25 cases.

Travel

We travelled on Kenya Airlines and stopped over in Nairobi before connecting to Kigali, capital of Rwanda. We were met at the airport and transported to our accommodation.

Hospitality

We were very warmly welcome by the Medical Director Dr Alfred Rutagengwa ( Dr Alfred) and by the General Manager. They offered us the best hospitality they could offer from the resources they had. Our accommodation was in the hospital guest house. It was basic but included en-suite facilities. The team was grateful for the care and attention we received in the guest house. We were adequately fed, probably overfed!

Dr Alfred is very enthusiastic about establishing NYAMATA HOSPITAL as a Hernia Centre. Operation Hernia is keen to make this happen.

Chris & Helena

Chris & Helena

Chris & Dr Alfreda

Chris & Dr Alfreda

Theatre Staff

There were 2 trained nurses, one student nurse and 2 auxiliaries. We had 2 anaesthetist each day. They offered a superb service. One doctor was assigned to help us. The staff nurses were competent. The Anaesthetist were skilled in Spinal anaesthesia and committed to best patient care. Staff were helpful. The intensity of work we required was not the norm but they coped reasonably well. No cases were cancelled due to lack of theatre tome or staff. All our full days ended after 7pm.

Patient Screening

Not all had had their pre-operative investigations. Some of them had not been fully registered. This delayed the start of surgery on 2 days. That will be improved for the 2013 visit.

Facilities

2 Theatres, one Recovery room, one Minor surgery room, 2 Changing rooms, Doctors office equipped with a computer connected to the internet, Theatre Sister’s office; Stock / Nurses room with a PC; Sterilisation Room with 2 autoclaves.

Theatre facilities

Each theatre had the following facilities:-
Theatre table: This was old but functional
Anaesthetic machine which was modern
Monitor which was also modern
Ceiling theatre Lamp. Functional in only one theatre.
Standing lamps which had poor focus.
Air conditioner worked in one theatre.
Diathermy machine: We provided and donated a refurbished Eschmann’s diathermy machine complete with accessories- patient plates, diathermy pencils, foot pads. This was a donation from TORBAY HOSPITAL.

Surgical Instruments and supplies

They had enough instruments to perform 7 procedures a day. Most of these should be replaced. We can do with Travers / West/Weislander retractors, decent needle holders, scissors. These instruments would have been provided had our order arrived on time!! They coped with the rapid turnover. Theatre gowns and drapes were provided for all. Autoclaving of kit kept pace with the relative rapid turnover of patients. Some theatre gowns showed their age but did not affect sterility.

Outcome

25 patients were originally booked for surgery. We operated on 29 patients and performed 33 procedures. This is a credit to the theatre staff for being willing to work hard on our full days to ensure that no patients were cancelled because of theatre time. All hernias were graded using Kingsnorth Grading. All operations were entered into Operation Hernia Database.

Apart from 2 patient excluded on clinical grounds, all hernia repairs were performed with Mesh. This was a complete novelty at Nyamata Hospital and was well received.

A major breakthrough was introduction of Hernia Repair under Local Anaesthetic infiltration. There was initial resistance from patients, anaesthetists and nursing staff. This has never been practiced. All hernias had hitherto been performed under spinal anaesthetic. Success of this “new ” technique was welcomed enthusiastically by all staff. The advantages over spinal anaesthetic were swiftly recognised by the Chief anaesthetist:- safety, day case surgery, no family visits, less cost.

From a genocide orphan

From a genocide orphan

Training

One of the local doctors assisted me and was trained to insert mesh in 3 patients. The need was expressed to train more local doctors in both mesh repair and local anaesthetic surgery.

Commendation

1. Enthusiastic and hardworking staff

2. Skilled Anaesthetists

3. Keenness to learn new techniques.

Achievements

1. 33 procedures performed in 4.5 working days

2. Introduction of Mesh Repair of Hernias – a more effective treatment.

3. Introduction of Hernia Repair performed with Safe Local Anaesthetic Infiltration

4. Training one surgeon in Mesh Repair.

Recommendation for future Visits

1. CME on theatre management

2. Workshop to train doctors – Mesh repair and LA infiltration

3. Require new surgical instruments

4. New Air conditioner

5. Possible New Theatre Table

6. Possible New Theatre Lamps