Plymouth team, Takoradi 15-22 NOVEMBER 2009

On the 15th of November at 4am a team of 9 arrived in Takoradi, Ghana. 101 procedures, 3 c-sections and one neonatal resuscitation later they returned. After a comfortable flight for some more than others we arrived at Accra airport to be greeted by Mr Oppong and a team ready to get us to Takoradi. After a bumpy few hours we reached the Villa and the smiling faces of the indispensible girls that would look after us for the next week.

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We brought with us surgical equipment and also clothing- football shirts, chalk, maps. Coffee and cereals are very expensive there and I d recommend bring your own if you can t do without. After some rest we were taken out to see some of the surrounding area and stopped by a village in which a young boy had been diagnosed with talipes last year. This time a girl in her early 20s was brought to our attention she was unable to walk due to a gibbus. We later got her to Dixcove hospital where they commenced her on TB treatment which is free.

We worked from 3 centres; in Takoradi the Hernia centre and Ghana Health Ports Authority Hospital (GPHA) and for the first time the more rural Dixcove. I had the pleasure of visiting all 3 places. We were also joined by 4 surgical senior registrars from the Teaching Hospital in Kumasi, Ghana s second Medical School. This training was arranged by Mr Oppong and Prof Michael Ohene Yeboah.

My first day was at the hernia centre I walked in to theatre (the only place with air-con) and within the first few hours I had encountered the biggest hernia I had ever seen (that is till the next day). Over at GPHA there is only one theatre and one man and I finally had the pleasure of meeting the infamous Dr Bernard Boateng-Duah who was responsible for the smooth running of our stay. His unassuming manner belies the fact that he is responsible for all the cases at GPHA. I would also like to thank him for finding all the hernias and the t-shirt! My day at Dixcove started with a bumpy 45 minute journey in a version of an ambulance and I was sat on a seat. There one doctor covers the hospital and a population of 20,000 and he had a smile to greet us. His skills like many doctors in Ghana ranged from medicine to appendicectomies and caesareans. One theatre meant that occasionally lists were interrupted for emergencies. At all the theatres equipment was basic but the staff expertise made up for it. The sets presented to us were variable in terms of quality and quantity and required an open mind. We often didn t arrive home till gone 7 and my hat goes off to Mr Oppong who did 3 days at Dixcove arriving home at near 10 each night with his team.

If you have never experienced living in a developing country it may not be what you expect. However, I found the villa comfortable and welcoming and it added to the experience. We had air conditioning and running water though I must admit we did have a few power cuts. But who can deny the pleasure of being spoilt every evening with a freshly cooked meal and greeted with true Ghanaian hospitality and warm enquiries as to your day. I have never seen such food and the presentation, thanks to Bridget, it was often spectacular. In addition there was Lillian, Kate and Bernadette who made our stay as stress free as they could. Not only did they help with money changing but also shopping! We finished early on Friday and had an hour by a pool before a celebration meal at a local Ghanaian restaurant.

Our special treat for the weekend was a visit to the stilt village and then on to Green Turtle lodge for a night staying in huts on the beach. On the way to Accra to catch our flight we visited El Mina Fort for a sobering tour of the slave trade. The journey was broken for lunch overlooking the sea at Biriwa resort. After freshening up and a meal we left Accra

Although the system is sometimes frustrating there are many battling to try and make a change. Catching a group of children share one sweet without a second thought and the smiles and laughter brought by simply having their picture taken was a lesson in humility. This was probably the hardest week of work I have done. The days were long and we operated non stop. Also we had to contend with a different environment and were constantly challenged in one way or another – be it a loss of electricity, unfamiliar equipment and the language barrier. But the staff friendly and I had to marvel at their innovation and way they worked to minimise waste. It was physically, mentally and emotionally hard at times but would I do it again- of course!!

I would like to thank all those who supported us in various ways from donations of their time, money, equipment or clothing that made this a special trip possible for us and the people we managed to meet along the way.

Eiling Wu
Surgical registrar

Spanish Team

Spanish Team Group 3, Eruwa, Nigeria 21-28 NOVEMBER 2009

This is the first Spanish Group to come to Nigeria. In spite of only a month´s notice, the preparations for the trip came along very well.

Spanish Team

Spanish Team

Within four weeks of knowing about the trip, the team of six (Teresa Butrón, Raquel Delestal, J.A. Pascual from 12 de Octubre University Hospital, Aleidis Caro, Carles Olona from Joan XXIII University Hospital Tarragona, Áurea Tartas from Getafe University Hospital Madrid) was assembled with financial aide and the necessary equipment. We want to thank Caja Madrid, the branch in 12 Octubre Hospital, Obra Social Caja Madrid, Ethicon, Smith and Nephew and Viajes Atlanta. We also want to thank the people in our hospitals, and Ethicon for collecting and handing over to us a good amount of materials.

The first time our team met was at the Madrid airport, hours before leaving. We brought 17 large bags of sanitary equipment. It took us a long time to wrap all of the materials in plastic wrap, and marked everything with red crosses. We want to thank Mano a Mano NGO for letting us each check one bag extra per person.

After a long flight, we arrived at the Lagos airport. Thankfully there were no problems with customs and we met Dr. Awojobi Yombo , who was very surprised to see 17 large bags. When we got outside, we weren´t sure if the bus would fit us, much less our bags, but there was no problem as the minibus was only for us.

The first night of our journey was spent in Lagos. The next morning, we awoke to loud music and singing. It turned out that a local Pentecostal church was having service with dancing and singing. What an experience! After this visit to the church and breakfast, we took a three hour bus ride to Eruwa.

On arrival we took a tour of the clinic we would be working at. When we arrived at the supply room, we found it was empty. Our first task was to stock an entire supply room. Fortunately with 17 large bags of medical material (two bags with toys and stationary for children), the room filled quickly and we had enough supplies. That night we had dinner in Dr. Awojobi´s house, and went back to the hotel to relax. We thought the next day would be a routine day in the operating room. But it was a learning experience that helped us to adapt quickly.

Spanish Team Operating

Spanish Team Operating

 

Spanish Team Operating

Spanish Team Operating

We started operating at sunrise because most of the light filtered through the windows. Our ´surgical light´ was four low-energy lightbulbs in an upside-down kitchen bowl, a felicitous local invention. The patients came to the clinic on foot, sometimes walking for miles to get there. There were two surgical tables in the operation room. From sunrise until well after sunset we operated on patient after patient. Finally, at 9pm, we finished our last operation for the day.

The following days became easier and easier as we adapted, and we began to finish earlier and earlier. From boys to old men, we worked on many different patterns. Some hernias were small, and others were quite large. After the spinal anaesthetic, they would stay for a day in our makeshift ward. We received quite competent help from the young doctors who have come from different places in the country to learn and practice new skills.

In our entire week of working with the patients, we never heard one complain or talk about their discomfort. They thanked us often and were heartily. By the end of the week, we were able to finish the surgeries quickly enough to walk around the community at the end of each day. We visited a school, where we distributed toys, pens and other writing materials. Another day, we visited different installations around the clinic. Dr Awojobi utilizes the local resources to function as autoclaves, a manual hematocrit centrifuge, patient trolleys, pedal suction pumps, water distiller, intravenous fluid and Histopathology service. The last day we visited the public General Hospital of Eruwa. We found that the installations needed updating. There was no water nor electricity in the whole hospital, and there was great lack of cleanliness everywhere except in the odontology section which the nurse in charge kept very clean, and we were told the lack of cleanliness was due to lack of official means or financial resources, but we also thought that in a great part this situation was due to carelessness on the part of the people in charge in the hospital.

The week was a very eye opening experience for us. We saw the difficult conditions that the Nigerian people live and work in, and we also saw the adaptability and ingenuity that can overcome many obstacles. We will never forget the people here, and thank everyone for their contribution in this great project.

We also give thanks to Peter John Acceturo whom we met at the airport and who helped us polish this English report.

The Leighton & Derriford team

Leighton & Derriford Hospital Team, Carpenter 1-14 NOVEMBER 2009

Magdi Hanafy, reporting.

The Leighton & Derriford team

The Leighton & Derriford team

On the last day of October 2009 the Leighton Hospital team arrived at 7:00 am to my house in two mini-buses. I opened my garage and we shifted all 22 boxes and bags filled with our and medical equipments to one of the buses, and headed off to Manchester Airport. We took turn, transporting our luggage, upstairs to departures, where BA opened a check-in counter especially for us. 22 luggage counted and checked- in without problems. We flew to Heathrow, terminal 5. Janet and I noticed people walking around wearing a T shirt with GHANA written on it. She went and talked to some of the ladies and we discovered they were the Canadian team who have just arrived from Toronto on their way to Accra and then Carpenter. We introduced ourselves and met with Dr. Jennifer Wilson their team Leader. She explained to us the way they were introduced to Carpenter through Mrs Mensah, who is originally from Canada. The Canadian group have met Prof Kingsnorth two years ago when they were travelling to Ghana, and a new destination for Operation Hernia was born. We had a potential problem with Ginny s ticket as it was a free ticket donated by British Airways. We were told that if the plane was full she would have to wait for the next available place which could be the next day. That could cause a problem as we had to travel by land to Carpenter the next day. I could not have left her to travel alone the day after. Luckily there were enough spaces on the plane and we boarded together to Accra.

In Accra airport we made a long queue (at least two hundred meters) extending from customs and excise to the trucks and buses waiting for us outside the terminal. People with their trolleys loaded with boxes, hockey bags full of medicines etc… (Total of 102 pieces of luggage). We went to the hotel in Accra where we spent the night after meeting with the Plymouth team and Prof Kingsnorth who arrived on Ghana Airlines two hours beforehand.

The next morning we were waken up at six a.m. had a breakfast and off we started our journey to Carpenter. That took 12 hours, including three stops. We arrived in a big compound next to the village. Mr and Mrs Mensah have prepared our accommodation AND OUR DINNER. We were accommodated in a large compound with security and all facilities in constant supply, electricity, water, transport.etc. We were told about the project they are running and the efforts they are doing in sustaining this community. We went to our rooms. Each room had from one to three beds, each with mosquito net and a washing bag. Rooms and toilets are clean. The area is calm. It rained twice on that day.

The next day we woke up early in the morning, warm weather. We went early to operating theatres (which were empty rooms) and started opening the boxes and distributing the equipment on both theatres, knowing what is available and what is not. Craig, Ali, Helen, Dee, Janet, Ginny worked hard mobilising heavy equipment into both theatres with the help of the local boys. We gave Brenda, three bags of children school equipment we brought as a gift to the community. By the middle of the day it became very hot, and we became tired. We started screening patients for HIV and listing them for an appropriate operation, i.e. local or general. We did not have enough nurses, but a surplus of surgeons. We had to sit down in the night and arrange a rotating list between us to see who is doing what, when. We all had lunch together. The Canadians started work already, screening people from the compound. We started operating at three o clock, finished two operations in each theatre, and had to stop when night fell down, due to inability to work with only headlight, and insect s invasion. We had dinner and Prof started to organise our list for the next day. With that number of surgeons and staff the work had to be organised so that nobody would be left out, and others would not feel tired. We listed ten patients per theatre for the whole day, a big task. We had to go early to bed as we decided to start at first light, to reduce the likelihood of working in the dark, at the end of the day.

One of many operations performed each day

One of many operations performed each day

 

Patient care

Patient care

Tuesday 03 November 2009

Woke up early at six a.m. Perry Board before me. A quick shower before everybody else and off we went to theatre. Patients were there waiting for us. A quick ward round, yesterday’s patients were seen and discharged, new patients were allocated to their rooms, Ali started to excel, in organising the local helpers and the flow of patients. Theatres were prepared by Craig, Ginny, Dee and Janet, and we started one after the other. We performed 20 patients with 26 procedures. We finished late after sunset. When all the insects concentrate where light is shining (i.e. the wound). The air-conditioners started to fail. We started screening for the next day and allocated lists for both theatres. I was asked to go to the community with the Canadian team. I had dinner and went to bed early.

Wednesday 04 November 2009

Off with the Canadian team to the nearest village one hour away. A big organised place was set up for us. Chiefs waiting to great us, and each medical, nursing and pharmacy group was allocated a room. The Canadian team was prepared for the invasion by all the local population with and without any illnesses. But many of them have already been triaged by David Mensah, so those with genuine complaints were allowed to be examined. The day started very busy, and we had lots of surgical referrals until things started to calm down by 2:00 pm and I managed to see medical conditions as well, bringing me back to the old days in medical school. I have diagnosed malaria, yaws, and chest problems. I was very happy with the experience. At the end of the day, we gathered to be greeted by the chiefs who offered us gifts of vegetables and a ram as a token of gratitude. We went on to our vehicles for the long trip home which we had to reach before sunset.

Thursday 05 November 2009

Raj’s day out in the villages today. I have had a whole list on my own and managed to finish five cases in the morning. Prof did many cases as well, in the afternoon Richard managed a list on his own while we were seeing new cases and making the lists for tomorrow. Ginny did not feel well and had to retire. Many of us have been falling for slight diarrhoea, and exhaustion from heat. Especially when the air conditioners in Brenda operating room packed up and the room turned into a sauna. We had dinner together that was followed by a speech of thank you for Prof Kingsnorth, Jane and Ginny before their leaving home on the next day. They were thanked and praised.

Friday 06 November 2009

I started a GA list after Breakfast. Prof Kingsnorth and Ginny said their Good byes and left for Accra. Richard was out in the villages today. Raj went on to do the local anaesthetics list in Brenda s theatre when the A/C packed up again. But he continued operating. The last patient on my list was Kunako Koene a 120 years old man. We do not know whether this is true or not but he was very old. He had bilateral inguinal hernias. He was booked for general anaesthetic. He weighed 32 kgs. Walked with a light stick. We helped him up to the table, Perry started his anaesthesia and I performed the two operations. We decided to wake him up and recover him in theatre where the A/C is still working. When he woke up he asked the interpreter to tell us. I pray to God for all those people who came from far away, leaving their families, and jobs and countries to treat us for free, may God may bless you all. May God reward you and give you all the money that you need and more, not only you, but your children as well during and after a long life. Most of us started crying as we were very touched. He continued praising us while we all stood surrounding the operating table looking at him. The interpreter was quick and flawless. We were amazed at his way of thinking and talking, the way he realises all what is happening to him, the confidence that he had, the strength to go through such an operation at such an age, the wisdom and presence of mind. We helped him down from the table, gave him water to drink, and walked him to his room. The same evening at dinner David asked me to say what happened. In the middle of the talk I was so emotional I had to stop.

Saturday 07 November 2009

Raj was exhausted yesterday and took the morning off. I started the GA list and Richard the LA list. We went to see all the Patients and the old man Kunako Koene was doing very well. We kept both lists light, but still finished at 8:00 o clock. We managed to see all the patients for Monday s lists. At the evening we had dinner together and went to Brenda and David s house for tea and had a lovely evening with Craig s magic and a nice game. We went to sleep late.

Sunday 08 November 2009. Our Day off.

After a late breakfast we went to the buses heading for the church. While driving we found Richard s (one of our theatre helper staff) motor bike on the road with him standing with a piece of cloth against his head, full of blood. He had a fall while driving to Church. He sustained a small laceration to the scalp and a deep wound to the left knee that was bleeding profusely. I decided to take him back to the theatre in the compound and Janet offered to come with me. We cleaned his wounds, infiltrated them with Local anaesthetics and prepared our instruments. All the wounds were debrided, edges freshened, foreign bodies removed. The scalp wound was easily closed with sutures. The knee injury was deep reaching the patella. The quadriceps tendon was torn in two. I had to suture the tendon with interrupted number 1 ethilon. Then subcutaneous tissue than skin, with silk. We bandaged the wound for the day and provided antibiotics, pain killers etc.

In the afternoon David took us in a tour around the compound. Not known to us, there were fish farm and an ostrich farm as well. Nice big trees surrounding the farm from its fruits the ladies extract oil that is sent to Body Shops around the UK.

Bernard came to visit us on his way to Takoradi from the North. During the evening meal Chris Oppong arrived as well. We had dinner together. And sat down to chat over a cup of tea, discussed the next morning list before retiring.

Part of the Leighton & Derriford team

Part of the Leighton & Derriford team

Tuesday 10 November 2009

We woke up early and did a ward round, changed the dressings, and prepared the rooms to accommodate today s patients. I went for breakfast and followed the Canadian team to the school in Carpenter. On that day there was a queue of patients with only hernias. I examined and listed 61 hernia patients and examined 16 non hernia patients.

I operated on a patient under local anaesthetic and evacuated two abscesses from her neck and her pubis. A man came back two days after a hydrocoele operation, with melena and fainting attacks, I examined him and found no problem with the scrotal wound. I decided to resuscitate him on the floor in the clinic, with fluids first. Followed by transfer to the compound. He felt much better after the fluid load and proton pump inhibitors he was given. There was some confusion about whether to send him to a nearby hospital or to continue treating him in the compound. I heard that Raj is not feeling well and decided to come back around 3:30 to the compound and theatres. I managed to help with two cases on Brenda s list. Finished at 9:00 o clock pm and went for dinner. Than a shower and sleep.

Wednesday 11th November 2009

I had a whole day list. Started by a large irreducible indirect inguinal hernia under GA that did not have any contents in the thickened hernia sac. But there were a large prolapsed diverticulum of the bladder sliding with the sac that I could not identify. I injured the bladder and corrected the whole with two layers of viryl. I finished the repair and inserted a urinary catheter. The patient did very well. I operated on two children afterwards followed by adults. We finished the day at 8:00 pm, having hit more than 140 patients.

We had a nice dinner together, had a nice chat and were congratulated by the team on the achievement. By that time 146 patients and 186 procedures.

Thursday 12th November 2009

I woke early as usual went and packed two boxes full of sutures and gloves and the remaining medicines. After Breakfast we had a meeting down in the garden, when the old man Kunako Koene came with David to give us a speech, thanking all of us on the care that he had received and giving us praise and praying for us. Brought few more tears down. Jennifer controlled her tears while giving a speech. The Canadian team gave the man a small gift, and we thanked him for his kind words.

I felt tired and left theatre to have a quick siesta. Janet, Craig, Perry, Helen, Sarah and Ali all were in theatre logging numbers of meshes left (95), packing the instruments, theatre furniture and equipment in one room and closing the doors for next year.

We still had to operated on some facial lumps, clean wounds, change dressings and evacuate abscesses. The final count was 191 procedures on 151 patients. The next day we said Good bye and travelled home on a long trip of 11 hours inland drive, six hours overnight flight and one hour internal flight to arrive home 28 hours afterwards on Saturday 14th November 2009. Still much quicker than our Canadians colleagues.

Conclusions: This mission was exceptional, our achievements were as follows
– 191 surgical procedures in 151 patients in 8 ½ days.
– Collection, packing and transportation of 16 bags of medical equipment.
– Listing patients with hernias for next year. (60 pts/day)
– Helping support the Canadian Medical Team. Canadian team supporting us with medications, bandages, dressings etc.
– All in all, a Life Changing Experience!

Leighton Team: Mr Magdi Hanafy (Surgeon), Dr Perry Board ( Anaesthetist), Dr John Kerslake (General Practitioner), Dr Helen Simpson (Trainee surgeon), Sister Virginia Long (Theatre Manager) Sister Janet Burrows (Theatre Sister).

Plymouth Team: Professor Andrew Kingsnorth (Surgeon), Dr Jane Kingsnorth (General Practitioner), Mr Raj Dhumale (Surgeon), Mr Richard Dalton (Surgeon), Mr Craig Brown (Theatre Manager) Sister Dee Richards (Theatre Sister), Miss Sarah Hasted (Volunteer), Sister Alison Stout (Ward Sister), Dr Stephen Lewis ( Consultant Gastro-enterologist).

Site visit to Awojobi Clinic, Eruwa

Eruwa, Nigeria

Nigeria has an intimidating reputation with concerns about security, corruption, traffic chaos, economic nihilism and unfathomable bureaucracy.

Site visit to Awojobi Clinic, Eruwa

Site visit to Awojobi Clinic, Eruwa

However, carefully following all protocols and negotiating the hawkers at Lagos airport, I struggled into the tropical humidity of the arrivals lounge at Lagos airport and instantly found my host Dr Oluyombo Awojobi with his son, Yombo Jnr and our friend from Takoradi Dr Charles Sagua. We headed north into the night for a 150km drive to Eruwa. The journey of 6 hours took us through shanty towns and slums, over potted and non-existent roads, districts teaming with road-side traders and the general crush of humanity, until at midnight we arrived to the relative rural tranquillity in the tropical savannah at Eruwa.

After a good nights rest Yombo Snr took me on a tour of the Eruwa community. Beginning at the primary school, we watched the assembly, including joyous singing and I gave a small invited speech of encouragement. Ward rounds began at 8am and 40 patients were assessed. The Awojobi clinic is a miracle in the midst of the failing state of Nigeria which can no longer deliver fresh water or electricity to its towns or the hospitals within them. In the Awojobi clinic water is pumped up from dams fashioned by hand. Electricity is provided from cheap generators. All hospital equipment is cheaply produced including Heath Robinson autoclaves, a water distiller, intravenous fluid production, surgical gowns, drapes and materials. Yombo is able to provide comprehensive surgical services for all members of this community at a very low price. At the same time he is dealing with end stage pathology, which requires a large breadth of experience and surgical skill.

During the day we had discussions about how to enter a partnership between Operation Hernia and Awojobi clinic beginning within the next few months.

The following day Saturday 7th March, Yombo took me on a tour of the town which was amongst the poorest I have seen in Africa. There is virtually no visible input from government services. The District Hospital was in a state of desolation and decay with rusting beds and equipment and filthy conditions. Following a traditional lunch of palm nut soup, ground cassava, smoked catfish and a fiery, peppery stew, we visited Igba-Ora District Hospital, which was little improvement on the hospital in Eruwa, although there were some signs of surgical activity, which occurs when there is an electricity supply provided erratically during a random four hours each day.

The following day, which was my day of departure, I was taken to the Ibadan University and the University College Hospital, which had an air of majestic and faded neglect, and where we observed enthusiastic trainee doctors and surgeons. Finally before departure to the airport I visited Layo Model hospital at Ikire in Osun state which is run by Dr Tunji Adenuga. He has built a small medical facility in an isolated rural area together with a school and community based projects. This site may become a second place in Nigeria for Operation Hernia.

Nigeria offers exciting possibilities for Operation Hernia where in spite of the problems, there exists a nucleus of surgeons determined to provide a service for their communities and willing to work with outside agencies. We look forward to our next visit to the Awojobi clinic.

Andrew Kingsnorth

In surgery, Eruwa, Nigeria

Leighton Hospital Team with others, Eruwa, Nigeria 8-14 AUGUST 2009

 Arriving in Nigeria with all our luggage

Arriving in Nigeria with all our luggage

MY DIARY: Saturday 8 August

I (Nicola Eardley) arrived at Magdi Hanafi’s house at 6:00 am to find him still asleep! After he hurriedly got dressed, we packed the car and set off for Manchester Airport with our luggage and three boxes full of medical equipment. We met Ginny Long (theatre sister) at the airport, and checked in without any problems, although some swapping of contents between bags was needed to ensure that we didn’t exceed our weight allowance! We flew to Heathrow airport where we met up with Professor Kingsnorth and Eyston Vaughan-Huxley, a surgical trainee who had just finished his F2 year. We boarded the plane and unfortunately were delayed for an hour on a hot day without air conditioning (hotter than we were in Nigeria!), but eventually we took off and had a smooth flight to Lagos.

When we arrived at Lagos Airport, we were relieved to see that our luggage had also arrived, having survived the transfer at Heathrow’s Terminal 5. Customs questioned their contents, but allowed us to pass without any problems. We were warmly met by Dr Oluyombo Awojobi and his son at the airport. From there they took us to a hotel near the airport where we were able to wash (in the dark due to a power cut!) and have dinner. Over dinner we briefly discussed the following day’s itinerary before heading to bed (again in the dark due to another power cut!). Many of us were then woken with a start during the night when the electricity came back on and so did the lights and television!

Sunday 9 August

We had an early start with breakfast at 7:00 am. We checked out and packed the cars and off we went. Dr Awojobi had a busy day planned for us. We drove through the traffic of Lagos and once we were at the periphery of the city we stopped to visit the town where Dr Awojobi grew up. He told us all about his family and visited the grave of his elder brother, a respected engineer. We then went to a church, which had been built by his grandfather, and visited his grave. We then travelled for another hour to visit Dr Awojobi’s mentor and teacher, Professor Ajayi. He made us feel very welcome, discussing with us the difference between the old and new schools of medical education, over a cup of tea whilst sat on the front lawn of his house. After an hour or so we set off again and then stopped at his brother s house where we had a fantastic lunch. We thanked him and his wife and then set off to go and pay a visit to Dr Awojobi’s mother-in-law before the last leg of our journey to Eruwa. It was a long journey and we could see why it was best to travel during daylight hours as some of the roads were in very poor condition. Ten hours after we set off from our hotel in Lagos we arrived at Dr Awojobi’s home. We were warmly greeted by Tinu, his wife, and the rest of the family, and sat down to a nice dinner before heading back to our hotel to rest before our work was to begin the next day.

The Leighton Hospital team

The Leighton Hospital Team

In surgery, Eruwa, Nigeria

In surgery, Eruwa, Nigeria

Monday 10 August

Another early start, meeting at 7am (apart from Magdi who overslept again and met us at 7.15!). We had met Richard Salam, an anaesthetist, at the hotel on the previous night and that morning he told us how he had crashed his car on the journey from Lagos to Eruwa. We were amazed when we saw the photograph of his wrecked car that he had managed to escape with only minor cuts and bruises! We were driven to Dr Awojobi’s house and had breakfast before walking across the fields to the clinic. We were introduced to Kareem, the operating theatre supervisor, whom we were to find invaluable over the forthcoming days, and also some junior theatre helpers. In the operating theatre we found two operating tables for twin operating. We unpacked our boxes of supplies, which included gowns, gloves, local anaesthetic, antibiotics, analgesia, sutures, dressings, finger-switch diathermy, diathermy plates, sharps boxes and surgical scrub fluid and skin prep, in fact pretty much everything we needed to repair the hernias!

We met up with some Nigerian doctors, surgeons and GPs, who had come along to get some experience of performing hernia repairs with mesh. Professor Kingsnorth gave a lecture to the local doctors about the Lichtenstein repair and then we set to work. We examined the patients in the consulting room (2 patients at a time stood in the room, naked except for a sheet which they wrapped themselves in) and then they walked into theatre and climbed onto the table. Here they were given oral antibiotics and analgesics before lying down.

The vast majority of our operations were adult inguinal hernia repairs and all but the biggest (and I mean big!) were performed under local anaesthetic. Even the bilateral hernias could easily be repaired under local anaesthetic as our patients were, on the whole, nice and slim. We starting operating, assisted by the Nigerian doctors who were keen to learn. They had varying skills and all had differing aims and objectives of what they wanted to learn from us. For some it was how to perform a Lichtenstein hernia repair well, for some it was simply a matter of learning all about aseptic technique, tissue and instrument handling and effective suturing and knot tying. We kept working like a conveyor belt, interrupted only by lunch which was brought to us in lunch boxes. After only a 30 minute break we were operating again! All in all in the first day we performed thirteen procedures on ten patients. During the course of the day and also at the end of the day we visited the patients in the ward area, where they were usually surrounded by many family members before we discharged them home. Many travelled home on a motorbike just a few hours after their surgery! After a long day we walked back to the house and sat drinking tea and talking about our day until dinner was served. We then headed back to the hotel to rest before another busy day.

Tuesday 11 August

Another early start. Professor Kingsnorth and Dr Awojobi headed off on a trip to look at potential locations in Nigeria for further Operation Hernia missions. Today was to turn out to be slightly more adrenaline filled! Magdi Hanafi had to deal with a patient who had a right neck swelling and bilateral inguinal hernias. He started with the neck swelling and immediately encountered a difficult dissection and lots of pus. The internal jugular vein was injured and he found himself in a situation where he had to control venous bleeding with no suction, bad light, pus filling the wound, no provision for extra swabs and as an assistant, a GP who had very little operative experience. Fortunately he managed to get control, suture the tear in the vein, dissect out and excise the cyst, all under local anaesthetic and sedation! The second case was no easier, a 40 year old lady with the build of Magdi and an incisional hernia from a lower midline caesarean section. After a failed spinal she had to have a general anaesthetic with ketamine. It proved to be another difficult procedure as bowel was immediately underneath the skin with no peritoneal covering. There were several Nigerian doctors around who wanted to learn and scrubbed with each case. It was a relief to all that the remaining cases for the day were relatively straight forward.

Wednesday 12 August

An early wake up call this morning as they decided to turn the generator on at the hotel at 5am. Another busy day in theatre. We saw a 65 years old man with a scrotal swelling reaching down to his knees. This didn’t appear to be a hernia as it was very hard in some areas and cystic in others and he had only had an inguino-scrotal hernia repair a month before. It turned out to be a giant haematoma which was evacuated and included an orchidecomy.

Thursday 13 August

Slight stress this morning as the patient who had had the giant haematoma evacuation was nowhere to be seen, He has already gone home, even though he had a drain in situ (the finger of a glove acting as a drain!). Other patients relatives chased him up in a car and brought him back from the road. We were able to remove the drain and redress his wound. Professor Kingsnorth and Dr Alowojobi arrived back this morning and operated with us. They operated together on another giant inguinal hernia. After another long day we had a tour of Eruwa and got to see the original clinic before it moved to its current site. We were also fortunate enough to meet the chief (Oba) of Eruwa in his palace.

Friday 14 August

All packed and ready to go but a few more operations to perform before we left. Our tally for the week was 49 operations, the vast majority being performed under local anaesthetic, and no major complications. We set off for the airport, thanking everyone for their hospitality and a few hours later we arrived at Lagos airport. A long journey back home and plenty of time to think about the next mission

Leighton Hospital Team: Magdi Hanafy, Nicola Eardley and Virginia Long.
Others: Andrew Kingsnorth, Eyston Vaughan-Huxley (surgical trainee), Richard Salam (anaesthetist)

Theatre Superviser Kareem

Theatre Superviser Kareem

Adhoc Team – Eruwa, Nigeria 27 JUNE – 3 JULY 2009

Servaise de Kock; South Africa, Ramon Vilallonga; Spain, Andrew Kingsnorth; UK

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Operation Hernia’s first outreach to Awojobi Clinic Eruwa (ACE), Oyo State in Nigeria (26 June 3 July) has been a remarkable experience. The outreach followed Professor Andrew Kingsnorth’s site visit to Eruwa earlier this year (see report). Nigerian visa complications at the eleventh hour unfortunately prevented Dr Dave Sanders (from Plymouth, UK, but at the time doing voluntary work in South Africa) from joining the project. The final team consisted of team leader and very able teacher Prof Kingsnorth, charismatic Spanish surgeon Dr Ramon Villalonga and myself from South Africa.

On arrival at Murtala Mohammed International Airport in Lagos on Friday evening I was met by Prof Kingsnorth and our Nigerian host, Dr Yombo Awojobi. We stayed over at the Lasos Hotel where we could discuss the week s programme over supper. Breakfast the next morning was had amidst at least five power cuts. Later we learned that the power has been off in Eruwa for 2 months and most houses have their own generators. Coming from South Africa, the Nigerian environment was not that much different from home. The lack of proper infrastructure for such a rich country as Nigeria came as a shock though!

Traffic in Nigeria is simply chaotic and I was extremely thankful that I did not have to drive myself. Motorbikes carried up to six people and South African potholes suddenly seemed very small to me. Dr Awojobi kindly took us on a sight seeing trip to his alma mater school, Lagos University (where a monument was put up for his late brother, Prof Ayodele O Awojobi, a distinguished lecturer in Engineering). We also visited the Olabisi Onabanjo University Teaching Hospital. We then headed to Eruwa where Mrs Tinu Awojobi and the rest of the family welcomed us and cared for our needs in a very special way throughout the week, including cooking special meals for us.

That evening we unpacked the new Codman surgical instruments donated by Atrium, the mesh donated by Atrium, the Valley Lab diathermy machines from Covidien and the suture material donated by BBraun. Thanks also to Ethicon SA and other sponsors for having made this project possible.

Over the next few days we operated happily using the AM Eye Clinic Theatre on the ACE premises (where beds, gowns and theatre lights are locally made!). Forty-four patients underwent surgery and 52 hernias were repaired, including bilateral femoral hernias in a male patient and a lumbar hernia. We also trained 24 local surgeons, resident surgeons and family practitioners in performing the Lichtenstein Mesh Repair. Most of them still do a modified Basinni repair for lack of mesh availability at a reasonable cost. Most of the trainees could get hands-on experience. We were kindly assisted by Dr Awojobi s staff and his clinic supplied most of the reusable equipment.

We were most impressed with Dr Awojobi s ingenuity in his hospital. His cleverly devised inventions include an autoclave machine, locally produced intravenous fluids, a self-made washing machine, a bicycle wheel driven centrifuge, etc. He is also producing interlocking bricks that are used for building an auditorium to host the 2011 Rural Surgeons World Congress. Rural surgery at ACE is practiced at its best. Much can be learnt from Dr Awojobi s resourcefulness. One gets the impression that patients are cared for in a special way.

Special events included a visit to the local king, an evening party with a live band and neighbours attending in their typical Nigerian attire, visiting a local school and just walking around the village streets. Nigerians are very hospitable and we were always greeted with a You’re welcome!

ADVICE to future teams:

1. Do take operative protective clothing (theatre shoes, plastic aprons and eye protection).

2. Take Malaria prophylaxis and Yellow Fever immunisation.

3. Make sure you have enough memory/batteries for your camera.

4. You will need lots of energy the working days can be long.

In conclusion, taking part in Operation Hernia was an enriching experience for me. I found Prof Kingsnorth’s input especially inspiring. Ramon Villalonga also proved to be a particularly pleasant team mate. I wish Dr Awojobi and the ACE all the best for the future. May Operation Hernia continue to contribute meaningfully to rural surgery.

Servaise de Kock
Surgeon, Ngwelezane Hospital, Empangeni, KwaZulu-Natal, South Africa.

German Team, Takoradi, Ghana 13-21 JUNE 2009

First of all I would like to thank everybody who was involved in establishing Operation Hernia, those who took part in our mission and all the companies and private donators who granted financial and material support.

wolfgang_reinpold

Without their help and sacrifice the mission would not have been possible and successful. A (hopefully) complete list is at the end of this short report. My special thanks go to Dr. Chris Oppong for helping us preparing and organizing the mission; lovely and warm hearted Lilian and Kate for cooking excellent Ghanaian food, brilliant housekeeping and making us feel at home in our accommodation, Dr. Bernard Boateng and Dr. Frank for their excellent patient selection, patient preparation and their support and help during our stay; the outstanding staff of nurses at Port Authority Hospital and Takoradi Hospital and last but not least the excellent team from Hamburg and Gifhorn that accompanied me: Veronika von Blücher, Hilde Kuiken, Janine Priebe and Ingo Leiser (OR-and anaesthesiology technicians), Dr. Corinna Meissner-Kuck and Dr. Rüdiger Lohr (anaesthetists), Dr. Ute Harte (general practitioner), Dr. Matthias Rohr (surgeon).

Our team arrived at Accra airport Saturday evening. We were happy that all 32 boxes with medical goods and equipment had made the trip without damage. It is absolutely advisable to bring medical goods and equipment with the same flight. We had marked the boxes clearly with a red cross. Our flight company had kindly agreed beforehand not to charge extra weight charges.After a short delay due to a traffic congestion in Accra our bus arrived and we had a safe 4 hour trip to Takoradi.

On Sunday Lilian and Kate took us to beautiful tropical Green turtle beach where we had a very pleasant, sunny, and relaxing afternoon. We swam in the Atlantic Ocean and took a short beach walk to a nearby village of fishermen.

In the evening Bernard took us and our equipment to Takoradi- and Port Authority Hospital. We decided that Matthias, Rüdiger, Hilde and Janine would operate in Port Authority Hospital while Corinna, Ute, Veronika, Ingo and I would work in Takoradi Hospital. The operating rooms of both hospitals are sufficiently equipped according to European standards. During most of our operating time we had no running water in Takoradi hospital. Clean water was stored in plastic buckets and tubs. For future missions I would recommend to bring alcohol-based skin disinfection agents. There is always a shortage of drapes and gowns. We brought only 40 sets of drapes, thus we had to use one set for two patients. The nurses were well trained separating a set of drapes in two while maintaining sterility.

From Monday to Friday we performed 65 operations on 61 patients. The vast majority were indirect scrotal hernias, some of them very big. About one third of the operations were performed under local anaesthesia. There was one emergency of a strangulated massive scrotal hernia which required a large omentum resection. Fortunately, a bowel resection was not necessary in any of the cases. We operated on 4 children who all got a high hernia sac ligation. There were 8 ventral hernias, some of them very big. The big ventral hernias were fixed with an open sublay repair, while small umbilical hernias were operated on with a nonabsorbable suture repair. All groin and scrotal hernias had Lichtenstein repair with polypropylene mesh. We had to operate on 4 hydroceles. There were no major complications. Recently Bernard told me on the phone that all patients were followed up and that fortunately there were no wound infections only some minor hematomas and seromas which resolved spontaneously.
The patients were all very well selected and well prepared by the local medical staff. The patients and their relatives were all very thankful, patient and pleasant. Most of them spoke only very little English but the nurses helped us to communicate. We learned some expressions of the local languages and some of the patients laughed about our wrong pronunciation.

Despite the fact that hernia repair is only one of many health issues in Africa, we feel that Operation hernia is an important project that is worth being supported in the future. For all of us the hernia mission was not only an outstanding and heart touching experience which we will never forget, but also a mission of friendship and partnership between Africa and Europe. We are all looking forward to come back to Ghana in the future.

Dr. med Wolfgang Reinpold
Surgeon from Hamburg, Germany

The first German Hernia mission to Takoradi was kindly supported by donations from:
Dieter Adelwarth, Anästhesie Zentrum Hamburg, Jeanette Azzaloni, Sigrid and Hans-Jürgen Beinhorn, Otto Binkele, Praxis Dres. Elke Brüning, Matthias Ewe and Petra Köster-Meyer, Wilhelmsburg, Covidien Deutschland GmbH, Irma Deschka, Deutsche Lufthansa AG, Fa. Freizeit & Hobby, Anita and Fred Gohle, Renate und Ingo Grundmann, Dr. Horst Haeberlin, Johnson & Johnson Medical GmbH (formerly Ethicon), Katholische Kirchengemeinde St. Bonifatius Wilhelmsburg, Margret Kaczmarek, Erika and Kevin Kilpatrick, Brunhilde Kirsch, Lohmann & Rauscher GmbH & Co.KG, Anke and Bernd Malik, Elke Matuszczak, Fa. Medic Zeitarbeit, Dr. Ute Moje, Marianne and Gerhard Nöthlich, Dr. Gerald Paschen, Hans-Jürgen Peschel, Anja Petersen, Ilona Reichwald, Semperit Technische Produkte, Anna Schilling, Thomas Schmidt, Martha and Johann Swoboda, Dietgard Ude-Zalik, Sabrina Wehrmeyer und Frau Wittneben (Reisebüro Wittneben, Gifhorn), Dr. Anke Witte, Barbara and Norbert Wolpers, Christel Wowtscherk, and many others who either didn´t want to be listed or donated anonymously.

Spanish Team, Takoradi, Ghana 16-23 MAY 2009

The Spanish mission 2009 is done!!!! Lots of satisfactions and lots of difficulties, but we feel again that our support to the people in Ghana is important and highly-valued by the Ghanaians.

Spanish Team 2009

Spanish Team 2009

Large hernias, hydroceles and different emergencies were treated by a very well-balanced team of nurses, anaesthesiologists, general surgeons and paediatric surgeons. Spain is excited about the Operation Hernia Project and about having the chance to help people in developing countries. In fact many professionals asked about the possibilities of going to Ghana and so we ended up by creating two teams, the first one being composed of 14 professionals, including 3 nurses, 4 anaesthesiologists, 1 paediatric surgeon, 5 general surgeons and 1 allergist who supported the local doctors and nurses as a general doctor.

First of all, we would like to thanks our institutions who supported the project with drugs and equipment and specially by letting 14 professionals leave for Ghana in the middle of the local situation in which we live nowadays in our hospitals, the University Hopsital Virgen del Rocío (Sevilla), USP-Clínica Sagrado Corazón (Sevilla), Hospital Rio Tinto (Huelva), Hospital Infanta Elena (Huelva) and Hospital del Mar (Barcelona). A total of 11 people from Sevilla, 2 from Huelva and 1 from Barcelona who were locally also supported with an investment of money for surgical equipment, air tickets, toys and cloth for the children by Diputación de Sevilla, Ludociencia, Viajes Atlanta, Sevilla FC, Ecija Balompié, Betis Moda, La Caixa, Fundación Roviralta and los amigos de Juan .

Secondly, we would especially like to thank the local people who looked after us, Dr Bernard Boateng-Duah for organizing everything in the three hospital were we worked, we are aware of the amount of extra work for him that means such a large group such as the Spanish one going to Takoradi: Michael Danso, by giving the support of the Takoradi hospital to the project and taking care of the luggage that did not arrive in Accra with us; the girls that looked after us at the house, the lovely Kate, Lilian and Barbara, who are inside everyone s hearts; and of course, to the local professionals of the health systems of Ghana, the nurses, who works together with us these days to perform 100 surgical procedures, always happy and making things easier for us, and to the two local doctors who were involves in the project, Ernest and our friend Dr Frank, who we are going to miss next year in case he move to other part of the country.

This year we had the chance to work in four operating rooms, at the two surgical theatre of Takoradi hospital, at GAPOA and at Nana´s hospital, a small rural hospital surrounded by the jungle with no running water in which doctors are able to help people with very low resources. One hundred surgical procedures in 83 patients were performed in 5 days by a team of Spanish professionals who are very involved in this project. We all are happy to hear that the number or giant hernias are decreasing in the area since the project starts in 2005, which means that things are working and that it is very important to keep supporting the project next years.

This is an analysis of what we did, what we saw and what we think about this year mission, but overall what it is in the deep of our hearts is two basic things: the face of the Ghanaians giving us thanks, with a smile in their face, after the surgery when they were still having pain; and the spirit of friendship of a group of 14 people who leave their family for 8 days and their hospitals and spend an important amount of money out of their own pocket to try to solve a situation to someone who s it. Ana, Fran, Miguel and Hilario, our 4 anaesthesiologists did an extra excellent work by handling very difficulties situations, especially with the little children since they did not have the anaesthetic drugs and only a oxygen needed for a general anaesthesia in these cases, it took more than five hours for a little child to wake up from a general anaesthesia, but they are top professionals and they know how to handle themselves in these situations. Paco, our paediatric surgeons, running from one hospital to another during these days, covering the cases scheduled in each operating theatres, performing the largest hernias he has ever seen, and showing the humanity with children of an experienced surgeon. Manolo, Rosa and Patricia, our 3 nurses, teaching the local nurses how to treat difficult wounds, assistant the surgeons in the OR, supporting the anaesthesiologists during the local, spinal and general anaesthesias and during the advanced cardiopulmonary resuscitation needed in some cases to solve very difficulties situations, especially with little children. Salva, Antonio, Juan, María, Marisol, the 5 surgeons, the ones always ready to operate any complex case, like the re-recurrent and giants Ghanaian hernias, and always ready to solve any surgical emergency during these days. And the lovely Virginia, who supported Dr Frank during these days by offering him different solutions to the different cases with the support of the drugs that we brought with us.

Everyone of them had an important mission, the only thing we missed was that it was an important group of professional that could support local nurses and doctors to teach them our knowledge to be adapted to what they have here, but we hope to do it next year, because our dream is to keep being involved in this project and continue our support for the people who need it.

Salvador Morales-Conde

Swedish team, Takoradi, Ghana 20-25 APRIL 2009

Members of the team were Par Nordin (surgeon), Eva Nordin (operation nurse), and Erik Nilsson (surgeon).

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We were kindly received by Martin, a co-worker of Graham Bell, when we arrived at Accra airport Friday evening. On Saturday Martin took us to Takoradi, with a stop at a crocodile park! Anita and Graham Bell were our hosts in Takoradi, and they showed us hospitality beyond imagination.

On Sunday we met Dr Bernard Boateng-Duah, who in his gentle manner supported us throughout the hernia week. He and his surgical colleagues had selected patients for surgery. On Monday morning we started operating at the Hernia Wing in Takoradi Hospital, and at the end of the week we had operated 33 patients from 8 to 75 years old, three with epigastric/umbilical hernia, one with incisional hernia, and 29 patients with groin hernia (three with bilateral hernias).

As expected, hernias in Ghana were more advanced compared to what we usually see in at home. However, all but four patients could be treated in local anesthesia. We had the possibility of using to operation theaters. It was a delight to work with the well trained nursing staff. The anesthesiology nurses were very efficient and managed to get an intravenous needle in the right place in a minimum of time. As the mission of “Operation Hernia” is to teach hernia surgery as well as to treat patients, we would have appreciated the attendance of a local trainee surgeon. However, it is easy to understand the difficulty in organizing surgical education in a country like Ghana, which has suffered an enormous brain drain in recent years.

After the hernia days we saw the local market and had a swimming tour in a wonderful beach west of Takoradi. On our way back to Accra we visited the Elmina Castle and considered dark history. As none of us had been to Ghana before, we took the opportunity to see the surroundings of Accra, including National Parks with animals we had read about, but never seen before.

We thank Operation Hernia for giving us the opportunity to work inside health care in Ghana. We met friends in a culture with colours and flavors more intense than at home. And surely, we want to return.

Par Nordin
Erik Nilsson
Ewa Nordin

Team Ghana 2009

Hispano-Belgian Team, Takoradi, Ghana 14-22 FEBRUARY 2009

The Hispano-Belgian team consisting of Ramon Vilallonga (consultant from Spain), Pina Orlando (experienced nurse from Belgium) operated at in Takoradi from February 14-22. Unfortunately, Dr. Casper Sommeling, Dr. Martin Ruppert and the rest of the Belgian team couldn’t come and we had a very busy time in the theatre. We personally finished exhausted every day.

Team Ghana 2009

Team Ghana 2009

After arrival we drove to Takoradi in a raining night. We were welcomed at the guest house by Grace, Lillian and Kate, our hosts for the week who had a lot of pleasure in meeting again Pina because it was her second year.

Sunday we met Dr. Bernhard Boateng and discussed the surgical week . He had planned about 29 patients; 22 in the hernia wing and 7 in the Ghana Ports and Harbour Authority hospital. We underwent for incisional hernias, mango, pineapple and one watermelon hernia repair. Also we had two cases of testicular hydrocoele and a testicular tumour. We performed also and emergency surgery in a patient with a strangulated hernia.

We had a very nice time with all the team there. The operation nurses helped a lot that everything was well organised, especially at the GPHA hospital. Everybody treated us very well and we danced even a lot, sandwiches were very nice

Dr. Bernhard Boateng spend a lot of precious time for us, in keeping us with some activities, even in the late afternoon. However we had time for visiting the harbour, play a game of golf with Georgina (The best golf player in Ghana) and some other activities. We even plan to organize a Golf tournament the next time we will go.

Local Children

Local Children

 

Part of the Team

Part of the Team

The last day in the hospital we were gratefully thanked by the team of nurses for the good works we did with presents. We got a special T-shirt of the hospital and lovely team pictures where taken. We also got one for our own album.

Also Dr Boateng and his team did think about our curves! Special Ghanaian chocolates where given to us by hart. We both were very touched with these gifts !

On Sunday after our arrival, we were taken to the beach and the last Saturday we visited the National Park of Kakum with the lovely guide Rebecca. Finally we went to Cape Coast and Accra where I was dropped to fly back to Spain and Pina picked up her whole family for another nice vacation trip around Ghana.

The Foundation Dr. Vilallonga www.fundacioramonvilallonga.org had taken material for 40 patients, including meshes, 200 bottles of local anaesthesia and Pina took plenty of presents for the kids but also for the friends. So our suitcases were empty at the end of the week. Everything went very well.

Dr Frank and Dr Bernhard deserved and received our deep respect for their work in Takoradi for treating all patients (children and adult) with all diseases (as surgeon, obstetrician etc) with relatively little is an immense responsibility. Also the nurses who we cannot forget because without their organisation we were able to operate. We hope we will be able to support them again.

We are keeping in touch with everybody, and all patients are going fine and will be followed up thru next teams and the local doctors .

The Hernia Wing and GPHA are well equipped but in the Ghana Ports and Harbour Authority hospital theatre we ran out of electricity for 30 minutes and we performed the surgery with a lamp. The nurse asked me Aren t you going to continue, doctor?, I answered after some reflection Of Course . Than we used the flashy glasses whit led lights on who Pina took with her. We, the young surgeons have grown with the electrical cut. The nursing staff are well trained and fun to work with. They work very hard without complaining and put the well-being of their patients first. Dr Frank and Dr Bernard 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 had a wonderful time thoroughly enjoying performing the operations, meeting Ghanaians and visiting parts of the country.

We will be back!

Ramon Vilallonga
Pina Orlando

Operating Ghana 2009

Operating Ghana 2009