Welcome to Operation Hernia

Welcome to Operation Hernia

Welcome to Operation Hernia

Following a really successful trip to Farafenni in January 2011 an enlarged team comprised of the original group from Estonia led once again by Surgeon Juri Teras and a new team from the UK lead by Surgical Registrar Michelle Tipping ventured once again into the depths of Africa to build on the valiant efforts of the Estonians earlier in the year.

Having linked up with the Estonian team via e-mail before departure our UK contingent was large: 1 consultant anaesthetist – Scott Farmery, 2 consultant surgeons – Mr Andrew Wan (UGI) & Mr Andy Ramwell (Colorectal), 1 senior scrub nurse Adrian Kasparian, 2 surgical trainees Hannah Wright (FY2) and myself (ST4), and two general volunteers Christopher Mason and Helen Durance.

We arrived a day after the Estonians which was lucky as they were able to organise transport for us to the hospital, even then, the amount of supplies we had managed to secure seemed to take our hosts by surprise! 100kg of drapes, a surgical operating table, 1 portable ultrasound machine, 8 volunteers, 10 bulging bags and a huge box of donated vacuum packed teddy bears. One small hospital ambulance and half the length of the country along a pot-holed African road later, we all knew each other much better than when we set off! The adventure had officially started.

We found the hospital and the breath-taking hospitality exactly as described by the Estonian team. Baboucarr Saine, Mr Bondi and Sainey Dibba once again went out of their way to make us feel at home and we stayed in the same accommodation they had used previously.

As the Estonian team had made a head-start we were already almost up & running on arrival. The plan was to get three theatre teams working so we could maximise the work we could do. We managed to get enough resources together to get two theatres running simultaneously and got started with the first patients. The UK team had discussed our long-term mission prior to arrival as well as our immediate objectives. We left the UK with aspirations to help train local people to start doing their own hernia repairs. Once we started we realised that the needs of the hospital were a lot more basic. It became apparent very quickly that basic theatre practice & education was desperately needed. Basic knowledge regarding concepts of sterility and instrument handling were just unknown. So, we started at the beginning. Luckily due to the size of our team we could educate and develop practice as we went along and by the end of our time things were much improved although it will take time and effort to train surgical nurse practitioners to the standards required to complete their own repairs.

Another basic concept which needed addressing was the organisation of supplies in the hospital. As we explored we found lots of locked rooms containing boxes & boxes of donated supplies but no-one seemed to know what was in them! This was where our extra non-clinical volunteers made a huge impact. Using a lot of elbow grease and any of the surgical team not currently operating they re-organised the whole of the hospital surgical supplies into 2 labelled rooms so that everyone knew what was there and how to find everything. This also came in extremely handy when we were asked to see other surgical problems that didn’t involve hernias but needed treatment! Safe to say the hospital does not need any more urinary catheters or neonatal ITU equipment!!!

This was a great hospital to visit and the enthusiasm they have as hosts clearly shows they appreciate the efforts of the volunteers who give up their time to go. It is a place where people are keen to improve and develop to offer the best possible for their patients. We see a long-term future for Operation Hernia in this hospital although the two things I would recommend as vital for future teams (apart from all your surgical kit) . CO2 monitors for the anaesthetist to assist with childrens hernias and head torches; some-things never change!

Inguinal hernia repair under local anaesthesia

Inguinal hernia repair under local anaesthesia

The local market

The local market

Rural Gambia

Rural Gambia

Welcome at the gates

Welcome at the gates

Welcome at the gates

Report by Francesc Marsal: St Vincent’s Hospital, Aliade. Nigeria. Spanish Team

Last 26th November 2011 we left from Barcelona airport to our destination in Nigeria.

The whole team met up at Heathrow Airport. We took 14 boxes each weighing 23 kilos. The boxes contained surgical material and presents for the local people. In Barcelona, British Airways helped us a lot with the customs issues and didn’t charge any extra weight.

We arrived at Abuja International Airport at 05:35 on the 27th where Dr Austin Ella was waiting for us. The procedure through customs was long but fairly agile. We then loaded the boxes and our luggage into a Toyota pick-up and a mini-bus and set off. After a 6-hour trip with many police controls, we arrived safety at St Vincent´s Hospital in Aliade.

Waiting

Waiting

2 tables operating

2 tables operating

We were received by the local team, headed by Peter. We met the Sisters of Nativity (Sister Helen and Sister Rose) and we were welcomed by the performance of a welcome tribal dance by the local residents. That afternoon the team set to work to prepare the theatres for the operations the next day.

We had brought new bulbs for the theatre lamps and two new boxes of surgical material for hernia repair. We had also brought a two new pulse oximeter which they didn’t have. We started to operate at 07:00 every morning after a good breakfast prepared by Sister Rose.

For 5 days the Spanish team of 5 surgeons and 2 nurses, together with the local team operated on 78 patients with 110 procedures.

Spanish Team and our hosts

Spanish Team and our hosts

The results were very satisfactory and for the first time ever we used “mosquito mesh” (59 cases). Friday was the hardest day when we operated on 24 patients. In all we experienced complex cases (14 bilateral hernia) and 9 large hydrocele. We used loco-regional anaesthesia in 57 cases, and the rest cases with local anaesthesia.

When we lefts Aliade on 3th December we felt very satisfied with our work and the friends we had made.

The team members were: Enrique Navarrete, Maria del Pilar Consejo, Juan Manuel Moreno, Francesc Marsal, Riverola Aso, Blanco Rodriguez, Arantave Caravaca, Candeal Haro.

Team members

Leighton, UK Magdi Hanafy, Paul Sutton, Janet Burrows, Jackie, Sara Watson

Northampton, Rob Hicks, Sue Johnson

Canada Lawrence Turner, Ira Bloom, Teresa Buckley

Inverness Morag Hogg

Germany- Antje Haupt

Southampton Sarah Hasted

Operation Hernia to Carpenter, Northern Ghana. November 2011

One of my most rewarding experiences -this trip should be recommended to everyone. As a Consultant Surgeon, I joined the Operation Hernia Team for the trip to Carpenter in Northern Ghana. The trip is organised to coincide with the visit of a Canadian Team , called Ghana Health Team and together we spent two weeks away. We operated for 10 days and during our time in Ghana; together with the Ghana Health team we screened 10,000 patients, treated 5000 patients and repaired 290 hernias.

The Operation Hernia team comprised of 5 surgeons, 1 anaesthetist, an anaesthetists assistant, 4 nurses and Sarah our non-medic. Magdi Hanafy, a Consultant Surgeon from Leighton was our Leader. This is his 5th trip to Carpenter, and on this occasion Magdi and Andrew Kingsnorth had recruited a team from far and wide. Lawrence Turner from Vancouver, Paul from Manchester, Morag from Inverness, Sarah from Southampton, Sara, Jackie and Janet from Leighton, Antje from Germany and Sue and myself from Northampton.

There is a lot of planning required fro a successful trip. Behind the scenes, Magdi had been busy chasing sponsors, begging, borrowing and collecting equipment and supplies, which we would need. Prior to leaving all the required equipment was checked and packed into boxes, each weighing 23kgs. In addition there were all sorts of fundraising activities to help support this and future Operation Hernia trips.

It was with some trepidation that I headed to Heathrow with Sue to meet the team. I had no real idea of what was in store. We all met on Saturday morning in Terminal 5 Heathrow and after a hearty lunch took off for Accra. The plan was to stay the night in Accra and then take a 12-hour drive north to Carpenter. There was great excitement as all of our kit was loaded onto a lorry for the journey north. The 60 Canadian hockey bags all filled with essential medical supplies overshadowed our 24 cardboard boxes.

Carpenter is a small village in Northern Ghana. The village comprises of a few houses (mud huts with thatched roofs), a water pump, a primary school, and the church. We were staying on a compound run by the NEA – Northern Empowerment Association. This is an organization whose aims are to improve health, nutrition and water supply, improve education, reduce local conflict and improve farming techniques (grid-nea.org/). It is led by Dr David Mensah and his wife Brenda, who organize the local aspects of our visit. The logistics of 60 healthcare professionals from Canada and the UK, coming to work for 2 weeks, not to mentions the organization of seeing 10000 patients cannot be underestimated. For anyone concerned we were looked after extremely well and a considerable amount of effort had been put into ensuring that our accommodation and food would enable us to maintain the hard work over the 2 week period.

We arrived on Sunday evening and our first hernia patients were scheduled for surgery on Monday morning. These were patients whom had been listed for surgery the previous year by last years Operation Hernia Team. The morning was spent unpacking. This year we had 3 operating theatres to use, David’s theatre, Brenda’s theatre and a newly prepared room called Moses theatre, named in memory of David’s father who died of a strangulated hernia when David was a boy. Each theatre was of basic design. Two theatres had an operating table, the third an operating trolley. The windows were sealed with polythene sheets and each room had a very much needed air conditioning unit. By the end of Monday each theatre had a table full of the necessary equipment and the shelves of the storeroom were full to bursting.

We quickly got into our routine of a busy hernia factory. The patients came from all over Northern Ghana and a few from neighboring Burkino Faso. They stayed at the local school until called for surgery. Each morning we were greeted by the wonderful site of the day’s admissions sitting under the shade of a large tree in the central courtyard of our “Surgical Block”. A typical day was 11 or 12 procedures. Most of the hernias were inguinal, many large and some enormous. Other cases included many hydroceles, epigastric hernias, umbilical and para -umbilical hernias, and lipomas. 90% of cases were done under local, the very large or children being done under General or local and sedation. As each day went by, I found myself adjusting my scale of size as my confidence to do large hernia under local anaesthetic increased.

The work was hard; the days were hot and long. With a small team it was a real challenge to run three theatres all of the time. There were 4 scrub nurses and so for many days there was no relief. After the first day there were only 2 diathermy machines. There was a limited supply of essential equipment and this had to be managed. Despite all of this there was the requirement for good practice. All patients had antibiotics and analgesia and a name band prior to surgery. A brief WHO check was performed to ensure ‘right patient – right operation – right side’. All children were screened for malaria prior to surgery and surgery delayed for a few days if positive until treated. Patients were screened for HIV at a pre-assessment to ensure that the whole team was aware of the patient’s status prior to the procedure. Between cases instruments needed to be washed and sterilized in a mobile sterilizing unit in each theatre. We were supported in our work by a team of local men, employed by the NEA, who acted as interpreters, theatre porters, Chaperones, admissions clerks and discharge coordinators! They were a very efficient team.

The Ghanaian people are wonderful. They were very kind, appeared very happy and so grateful for the work we were doing. The best time to see this was during the visit to the villages with the Canadian Ghana Health team. Each day of the first week the GHT headed to different local villages, organized by David Mensah and his team. One of the surgeons accompanied the offering a surgical opinion when required and listing new patients for next year’s trip. I had the opportunity to accompany them to the village of Yaara. The organisation of the team was impressive. I arrived to a sea of colour and noise. Yellow and white awning provided shade for waiting patients. Different areas had been allocated to Health Screening, Paediatrics, Dentists, General Practice, Dentists, Ophthalmology, Diagnostics and Pharmacy. This was the first opportunity that many of these people had of ever seeing a doctor. It was a big event for the village. Each day in the village started with a welcome from the Chief and the village elders and the Canadians often came home with gifts of goats and Yams, given in thanks.

I came away with lasting memories and new friendships and would thoroughly recommend this trip to anyone who is considering going. I enjoyed the surgical challenges and the environmental challenges. This takes you away from the comfort of your normal theatre, your favorite scrub nurse, your particular light and your must have suture! The days are long and tiring but very rewarding. I really enjoyed the opportunity to work alongside the Canadian team, led by Dr Jennifer Wilson. I will always remember the gratitude expressed by some of the patients and the inspirational leadership of Dr David Mensah.

Rob Hicks

Consultant Surgeon

Northampton General Hospital

Members of the German Team: Dr. Karl Moser (surgeon), Prof. Dr. Markus Heiss (surgeon), Dr. Andreas Kremer (anesthetist), Marion Koell (photographer)
Organizing Team in La Concordia: Kathia Tinixaray, Sandra Ocampo and Theresa Butron (Madrid)
Scientific Support: Samuel Shillcut.

Andreas Kremer the Anesthesist

Andreas Kremer the Anesthesist

When we arrived after our 16-hours journey from Düsseldorf to Quito, we were heartily welcomed by Sandra and her brother. They brought us in very comfortable cars within 4 hours to La Concordia, where we stayed in the nice Hotel Atos. On the same day we saw around 50 patients in the nearby area de salud 23 which was run by Kathia. This preoperative consultation was very well organized by Kathia and Samuel, who did also an excellent paperwork.

Situation at the Quninde District Hospital
The next day Sandra and Kathia took us to Quininde to the local district hospital, which was 40 minutes drive away. We were welcomed by the leading surgeon and led to the operating area. There we were left alone and really nobody took any notice of us. The whole crew including the surgeon in charge was lying on the patient´s stretchers and was not really willing to help us. A little bit puzzled about this situation we tried to start with the first operation. As we did not bring along drapes and gowns (we were informed by Theresa, that this would be provided) we asked a nurse. She said that we are not allowed to change the gowns between the operations – only the gloves. When we told her that we won´t accept this, she suddenly managed to get enough gowns for us. When we asked for a scrub nurse this was refused and between the operations the floor was not cleaned or the waste taken out. After 6 operations totally working on our own, while the local staff enjoyed a lazy day, we stopped working and complained to Kathia. She took care of this by bringing a nurse from the area de salud 23 to the hospital on the next day. During the week the support from the hospital staff got better and on the last 2 days it can be named good. They crew helped us with the patient transport, cleaned the operating theater and brought us the instruments. This was probably due to the pressure of Kathia and some thankful patients, who complained very forcefully to the manager of the hospital, about how we were treated.

Security
Unfortunately on 2 days parts of our equipment were stolen, although we left it in a locked room in the operating area. I was missing 3 of my 10 hernia sets, 2 presents for Kathia and Sandra and Andreas Kremer 5 bottles of local anesthesia and 3 precious clamps. Even the locks were cut. This was reported by Sandra to the local police, which is still investigating. According to Sandra the hospital is now willing to pay for the stolen hernia sets.

Patient details
64% of patients were male, with patient ages ranging from 10-72 and a median age of 41. Average family size was 4 people – 28% of patients were fathers.
The average years lived with hernia was 8.4 (6 median, 0-36 range). 67% of patients were in pain before surgery and 6% had vomiting. 88% of patients with inguinal hernias received mesh.

Operation details
In total we operated 43 Hernias: 24 inguinal hernias, 2 femoral hernias, 6 incisional hernia, 10 umbilical hernias and 1 epigastric hernia. Three patients (8%) had bilateral hernias, and 5 patients (14%) had two hernias that were not bilateral.
Inguinal hernias were reducible in all but one patient, who had a large inguinoscrotal hernia. 80% of all hernias repaired were primary.
Of 25 inguinal hernias, 24% were H1, 48% were H2, 24% were H3, and 4% were H4. Of the 6 H3 and H4 hernias, the inguino-scrotal component was Of 54 inguinal hernias evaluated, 28% were direct, consistent with an expected 25%-30%.
One lady with a huge incisional hernia was operated with a modified Ramirez procedure

Anesthesia
72% of patients received spinal anesthetic, 22% received local anesthetic, and 6% received general anesthetic. Due to a leak in the anesthetic machine it was one time very dangerous for one of our patients receiving general anesthesia. But Dr. Kremer was able to lead the patient through this difficult time.

Postop Course
Three patients were hospitalized, one for six nights (the lady with the huge incisional hernia). Antibiotic prophylaxis was not used in keeping with European Hernia Society (EHS) recommendations.
In the so-called ICU no nurse took really care of our difficult case. Therefore Dr. Kremer had to keep an eye on this case the whole day. As he was very busy, we had to cancel some of our patients on this day. As we did not want to risk the live of our patients we did not operate 3 additional patients with huge incisional hernias as planned.
Up to now all patients do fine and according to our knowledge no infections occurred.

Summary
Despite the trouble we experienced we had a marvelous time, because our patient were so grateful and Sandra was such a wonderful host. However in accordance with Kathia we advice not to send more teams to this hospital. We think that it is a very good idea to perform the next mission in the Centro de Salud La Concordia, where Kathia is in charge. We will definitely do another mission to La Concordia after this is arranged. We also want to thank Samuel for his excellent record keeping and wish him the best for his wedding next month with the his ecuadorian fiance.

Markus Heiss, me and a local surgeon

Markus Heiss, me and a local surgeon

This was the second visit of the charity to one of the most remote countries in the world. The team was Andrew Kingsnorth, John Schumacher Shaw (so-called by our hosts as he was the fastest scalpel in history), Alan Cameron, and Frank MacDermott. We had the unique privilege of having Tsetsegdemberel Bat-Ulzii Davidson (Tsetske) as our translator unique because although Mongolian, she is undergoing surgical training in the UK. As on the previous mission, we had the smooth, efficient and capable organizational skill of Mrs Enkhtuvishin of the Swanson Charitable Foundation.

Andrew Kingsnorth wrote about the first Mongolian visit in last year s report so I am doing this account as a novice to both Operation Hernia and to Mongolia. Before going further I must say that this mission was one of the most enthralling, worthwhile and fun things I have ever done. I was hugely impressed by the dedication of the Mongolian doctors and nurses; here in the UK we seem to have interminable delays in theatres, but in Mongolia the organization was superb (which did also mean we were kept busy in theatres all day!). And the anaesthetists skill with spinals was amazing. The Mongolian people were friendly and charming, and the scenery was stunning.

We arrived at Chinggis Khan airport -everything in Mongolia is named after their marauding hero and were loaded into 4x4s to travel down to Mandalgobi, our base for the first week. First surprise was the absence of any road for nine-tenths of the 260km journey; just tracks through the steppe. Seemingly relying on celestial navigation we arrived long after dark!

Mandalgobi is a one-horse settlement of 11,000 people on the edge of the Gobi. The hospital had been through some bad times after the fall of communism, but seemed to be improving rapidly under the able direction of Dr Dolzodmaa, who was herself a surgeon. We spent a very happy week operating on a mixture of adults and children. The equipment was fine and the theatre environment very satisfactory (although I was amazed to find that one of the couches had been manufactured in my home town of Ipswich). We had the usual somewhat stilted dinner with the deputy provincial governor, but Andrew s explanation of the purpose of the visit was well-received.

At the end of the week the whole team decamped (literally; the nurses came with us and brought the food and drink) for a bit of sightseeing so we were taken hundreds of miles into the Gobi to look at spectacular rock formations. We had two nights in ger camps out in the vast stillness of the desert before getting to the chaos of urban Ulaanbator.

The capital is a sprawling mass of pollution and congestion with some of the worst traffic in the world, but fortunately the 2nd hospital was within walking distance of the hotel. (John Shaw went to the paediatric hospital during this week). So we were on duty early for a post-operative ward round, followed by seeing the new cases, and then operating all day. There were attentive medical students, and lectures after the lists. We had again a mixture of incisional and inguinal cases. The operating lists were tightly-organized, with Andrew in one theatre and me in the other. So we were able to do cases ourselves or assist the Mongolians surgeons as appropriate (Andrew had met and taught many of them in 2010 and they were keen to show off newfound skills). We had a couple of evening social events, but there was actually no time for sightseeing in UB I don t think we missed much because the steppes had been wonderful and were a hard act to follow.

The success of this mission was due to the enthusiasm of our two professors, AK in the UK, and Tsagaan Narmandakh in Mongolia. There was a great feeling of teamwork at all levels and in the two weeks I felt we had achieved a great deal. In simple terms the team did 124 cases (58 children) cases, but more importantly we supervised the local surgeons who can hopefully build on this teaching. Mongolia is the ideal place for this kind of mission because the infrastructure exists to carry on the work after the visiting surgeons have left. Before I signed up Andrew told me this would be the most worthwhile holiday ever; he was wrong about the holiday bit, but it was certainly worthwhile in every other sense.

German American Team 2011

A German/American mission visited three regional hospitals in the area of Takoradi and Dixcove in southwestern Ghana from 14th to 25th July. The first team from Berlin consisted of Dr. Petra W?lkering (anestetist), Zhanna Bourtseva (OP-assistant and scrub-nurse), Manuale Menke (anestetist-nurse) and Dr. Ralph Lorenz (surgeon), who was leading the whole team.

German American Team 2011

German American Team 2011

The second team consisted of MD Timothy Napier (surgeon) from Mauston/Wisconsin, Dr. Karl Spitzer (surgeon) from Munich/Germany and Mario Frey (OP-assistant and OP-attendant) from Hamburg/Germany.

The suspected problems with the excess baggage (ca. 250 kg) on the check in desk where fortunately absent as well as the expected problems with the customs in Ghana. In Takoradi we were kindly accomodated in the Villa, the guesthouse of the Health-Department, where Kate, Lilly and Barbara expected us and supplied us lovingly with all we needed the whole mission through. A big heartfelt thanks to all!

The first two days were taken for acclimatisation and team-building and lead us to the sightseeing-points of the area. On Saturday already we visited on the way to a dreamlike beach of the Gold-Coast also the hospital in Dixcove, a small city westward of Takoradi. In that moment we were not aware that our humanitarian mission was also scheduled for this hospital. During our survey we were struck by the fact that no doctor was around ? he was attending an advanced training course in Accra for two weeks, we later heard.

During our survey in the hospital one patient touched us especially: a six year old boy was accommodated on the same day after a gas-explosion had caused third-degree burns in his face, both arms and both legs – the nurses did the wound treating meanwhile. This case would accompany us throughout the following week. We felt empathy and hoped passionately together with the nurses and attendants to save his life.

On Monday 18th July, we began with our work with two teams in Ports and Harbour Hospital (Takoradi) and in Takoradi Hospital. We performed surgery from 8 am to 8 pm treating as many patients we could. 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 three hospitals under the supervision of Dr. Bernhard Boateng-Duah for their perfect preparation and coordination!

Scrub Nurses, Dixcove

Scrub Nurses, Dixcove

Dr Ralph Lorenz

Dr Ralph Lorenz

The statistics added up to 77 operations on 67 patients within six days: All together 61 inguinal hernias were operated, including 32 inguinoscrotal hernias. 15 patients had a hernia with a 20 cm hernia sac (Kingsnorth classification H3/4-20 and 4 patients were treated with a large-size Hernia with a 30 cm hernia sac (Kingsnorth Classification H3/4-30). Futhermore 9 ventral hernias (6 primary -epigastric and umbilical and 3 incisional hernias) as well as 7 hydroceles were operated.

All of the three hospitals were attended by our teams within those six days. 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 additionally a hydrocele. Anesthetic methods included local as well as general anaesthesia, in certain cases spinal anaesthesia was the preferred method. Besides a postoperative hematoma in one case, all operations were successful without complications. The majority of the patients were outpatients. In addition, we assisted in one emergency-laparotomy and we supervise patients with chronic wounds, accident injuries and a thoracic drain. Mrs. Dr. W?lkerling however managed to give a lot of advices and tricks to the anesthetic nurses in charge. Our wish to instruct other local surgeons could unfortunately not be satisfied, since no Ghanaian surgeon could be present at that time.

The sustainability if our mission resulted mainly in giving away a lot of medicine materials the surgeons are now able to use. Without the generous support of numerous private and company donations as well as from the German Hernia Society this mission would have been unthinkable. We have gained a lot of positive insights through this humanitarian mission. Emotionally most touching was the deep thankfulness of the patients, and last but not least of the nurses and hospital workers.

The great success of that mission was mainly possible because of the distinguished capacity for teamwork of every participant. All team-members expressed their wish to participate on the next humanitarian mission. Furthermore, a lot of colleagues in Germany have a lot of interest for that project, and also uttered to participate themselves the next time. The small boy with the severe burns was at the same time attended by our team, especially through giving him urgently needed wound dressings and medicine. After initial fever, he was at the end of our mission ‘out of the woods’, free of fever and the large wounds were healing.

New hope for a new life! We are deeply thankful!

Ralph Lorenz f?r das Team Germany /U.S.

Operating, Malawi

Authors: Paul Thomas, Consultant General Surgeon, Epsom and St Helier Hospitals NHS Trust & Caris Grimes, ST4 in General Surgery, Epsom and St Helier Hospitals NHS Trust Introduction.

Operating, Malawi

Operating, Malawi

This visit to Malawi was a site inspection as part of Operation Hernia, a UK-registered charity which teaches and trains local surgeons in hernia surgery in low income countries. Previous visits have been made to West Africa but also Mongolia and Ecuador. This visit was made to establish a link in Malawi. Malawi has a population of approximately 13 million and its health service is provided by 4 central hospitals and 21 district hospitals, plus a number of smaller mission hospitals which are outside government funding. Our primary attachment was to Thyolo District Hospital, but we also had the opportunity to visit the Queen Elizabeth Central Hospital, and its linked orthopaedic hospital, the Beit-Cure Hospital in Blantyre. These are recognised as teaching units within the College of Medicine.

Thyolo District Hospital

Thyolo hospital serves a population of approximately 600,000 in an area of approximately 721 square km. Within this, there are 32 health centres and one mission hospital (Malamulo), approximately 10 km from the government district hospital. The majority of patients attend hospital under their own means but there is an ambulance service to transfer patients from the local health centres and to the central hospital in Blantyre in cases of emergency. The hospital is run by the District Health Officer (DHO, Dr Andrew Likaka), District Medical Officer (DMO, Dr Michael Murowa), 20 Clinical Officers and nursing staff. There are no other Malawian doctors other than the District Health Officer and District Medical Officer. Whilst we were there, there were three doctors on intern programmes, and one qualified doctor as part of VSO from the Netherlands. The HIV services in the hospital are currently supported by Medecins Sans Frontiers (MSF), who assist with day to day running of the hospital, transport, equipment and supplies. They are due to withdraw in approximately 18 months time, which we foresee will cause considerable pressure on current service provision. The hospital has a pharmacy which is stocked with a basic number of drugs, an x-ray department, run by two radiographers who can do plain x-rays and abdominal ultrasound using a curved array transducer, and a casualty department. The hospital has 350 beds but caters for 4-500 patients, although this can exceed 700 patients, by placing extra mattresses on the floors. It has three operating theatres, only two of which are used, and these are staffed by two anaesthetic clinical officers and 4-5 clinical officers with basic surgical skills. Two of these are more involved in gynaecology and one in orthopaedics. The hospital deals with a large volume of emergency medical and surgical problems. It has a particularly active obstetric department with about 4000 births per year. We saw a lot of complicated obstetric problems and there were two maternal deaths during our time there. There are visits from specialists from Blantyre. We were told that there is an Obstetrician/Gynaecologist who visits in 2 weeks out of four to run clinics and to train Clinical Officers in the common Obs and Gynae conditions. There are also occasional visits from other specialists.

Clinical Case Mix

During our two weeks, we saw a large number of patients presenting with various medical and surgical problems. We saw cases of malaria, tuberculosis, HIV (prevalence 12% in this population), cholera, rabies, meningitis, transverse myelitis, pyomyositis, acute and chronic urinary retention due to prostatic hypertrophy (large volume of cases). On the maternity side, there are approximately 16000 live births within the district per year, some 4000 are born in the hospital. There are sometimes 10 deliveries a night, and 4-5 caesarean sections per night. The overall district caesarean rate is approximately 4%, and the hospital caesarean rate approximately 10%. There were cases of post-partum haemorrhage and uterine rupture. On average there are about 20 maternal deaths per year, of which about half are direct obstetric deaths (PPH, eclampsia, ruptured uterus etc.). The others are mostly HIV related.

Operating, Malawi

Operating, Malawi

Our Experience Timetable

There is a structured timetable in the hospital. The day starts at 7.30 am with a clinical meeting, to which all clinical officers, overseas doctors, DMO, DHO, pharmacy and nursing staff are supposed to attend. Reports are given from the previous days admissions by all departments (surgery, paediatrics, maternity, , internal medicine). After the reports are presented, more detailed case reports are given and difficult cases discussed. Advice is given by the DHO, DMO and visiting doctors as required. There are also separate case presentations given as part of the on-going academic programme. At the end of the meeting, the DMO usually gave a report on the current supplies, what was available in pharmacy and the petrol and transport situation which was difficult during our time there. After the morning meeting, surgical ward rounds take place on Mondays, Wednesday and Fridays, and would take approximately 1-2 hours when we would see 15-20 patients. Patients were examined and management plans instigated. If they needed to be transferred to tertiary care, the relevant specialist was telephoned at Blantyre, and transport was arranged. They have a good system here where patients keep their own medical records in a health ‘passport’ and communication is maintained through this, including prescriptions.

On Tuesday and Thursdays, there is usually an all-day elective operating list, although emergency cases are done at any time and interrupt the elective lists. There is a surgical clinic on Wednesday afternoon, in which about 20-30 patients are seen. Our Experience We were attending the hospital as part of Operation Hernia, and therefore the focus of our activity was on hernia surgery. It had previously been arranged that the elective lists would be filled with patients who had complex inguino-scrotal hernias. We found this extremely interesting as we do not see this type of hernia very often in the UK. Technically, they proved to be quite demanding, especially as we did them all under local anaesthetic. We also inserted chest drains for pyothorax and haemothorax following trauma, saw cases of pyomyositis, severe third degree burns and advanced skin malignancy. We saw many cases of prostatic outflow obstruction, which are usually dealt with at Thyolo by the Clinical Officer within surgery who is able to perform transvesical prostatectomies. His logbook shows that he is doing more than 100 per year. One theatre is almost in constant use with caesarean sections, hysterectomies, and D&C’s.

Other activity

We had the opportunity to visit the local mission hospital at Malamulo. This is a privately funded institution and charges patients a small fee for the service. Unfortunately this is beyond the vast majority of the local population, and despite having slightly better facilities than Thyolo District Hospital, is relatively quiet – there were more medical staff than patients on the day we visited. The senior medical staff are on secondment from organisations in the United States. They do provide good training for the local nurses and clinical officers who then transfer to the government hospitals. They can also provide obstetric and paediatric care under a Service Agreement with the Ministry of Health of Malawi who then refund the costs. We visited Professor Eric Borgstein, Professor of Surgery and Professor Nyengo Mkandawire, Head of Orthopaedic Surgery, at Queen Elizabeth Central Hospital. This hospital was built 50 years ago to serve a population which has now increased fourfold. Our initial impression was that the fabric of the hospital was not as good as Thyolo, but that staffing levels and support facilities are much better with MRI scanning, CT scanning (currently out of service) and access to specialists such as oncology and neurology. The casualty department there sees approximately 700,000 adult patients a year, and 350,000 children. We attended the launch conference of the COST Africa project for two days whilst we were there. COST Africa is a large multicentre randomised controlled trial, funded by the European Union, to look at training Clinical Officers to provide surgical cover in district hospitals in Malawi and Zambia. There were attendees from both countries, as well as the Royal College of Surgeons of Ireland (RCSI). The Principal Investigator is Professor Ruairi Brugha, from the RCSI. This conference gave us great insight in the problems of providing surgical cover in low income countries. We also gained insight into the differences of provision of surgery in tertiary and secondary hospitals within Malawi and Zambia.

Towards the end of our stay, we convened a meeting between Professor Borgstein, Professor Mkandawire and the Dean of the College of Medicine in Blantyre, with a view to developing clinical and educational links between surgical trainees within the UK and the College of Medicine, Blantyre. We feel that the experience gained overseas would be very beneficial to trainees within the UK in a number of specialities, particularly general surgery, obstetrics, urology, paediatric surgery and orthopaedics. It is our plan to move this forwards as we received favourable interest at the Malawi end. We also feel that there is potential for exchanges in other staff, such as nursing and physiotherapy. We have drawn up a Letter of Agreement between Thyolo District Hospital and Operation Hernia to provide annual visits over the next three years initially to build on the skills of Clinical Officers in hernia surgery. This could potentially be expanded to involve other district hospitals in due course.

Dr José Antonio Pascual Montero, 12 Octubre Universitary Hospital, Madrid, Surgeon. Dr Jesús Salvador Torres Jiménez, Infanta Sofía Hospital, Madrid, Surgeon. Dr Jesús Ángel Garijo Ílvarez, Infanta Sofía Hospital, Madrid, Surgeon. Dr Miguel López Vizcayno, Sanitas La Moraleja Hospital, Madrid, Anaesthetist.

We left Madrid on April 23rd at the appointed time without any difficulty in booking the medical material. The flight was normal for some of us and rather exceptional for others who witnessed the landing from the cockpit, courtesy of the pilot. On arrival at the Mariscal Sucre Airport, Carlos Criado (airport commercial director) and Sandra Ocampo were waiting for us and speeded us through customs. The Health Centre staff took directly to La Concordia the parcels with surgical material.

We put up at Sandra Ocampo’s house to be taken later to know Quito’s historical centre, particularly La Ronda, where we saw one of the typical processions of the city, after which we went for dinner to Casa Dami?n, a restaurant owned by one of Dr Pascual’s friends from Segovia. After a night rest at Sandra Ocampo’s house in Quito, we started for La Concordia, where we were received by Dr Kathia Tinizaray and Haydee Caicedo, the three of them essential persons in the organization of the mission. We collected the surgical material to take it to the Alberto Buffoni Hospital in Quinindé where the mission was going to take place and where we were received by the staff very cordially and warmly. We arranged all the material we had with us and left everything ready to begin surgery the next day. Then we came back to the Health Centre where we checked 70 patients in order to programme surgery for the following days. We programmed 50 out of those 70 patients, and we finished work at 18:30 hours.

After some rest we had our supper, a typical barbecued grill from the place, prepared for us by our hosts at La Concordia, Sandra Ocampo and Dr Kathia Tinizaray. After supper we went to our lodgings in the Atos Hotel to gather strength for our mission the following day.

On Monday 25th we got up at 6 a.m. and after taking breakfast we started for Quinindé, at about 40 kms from La Concordia, and we arrived at 7:30 at the Alberto Buffoni Hospital where the staff and the 14 patients in readiness were expecting us. We started operating in the operation theatre they had arranged, but as we were three surgeons and one anaesthetist, we asked for the collaboration of surgeons and nurses of the hospital in order to be able to use the other operation theatre, with the understanding that if an urgency would occur, we would vacate it and would offer our collaboration if necessary.

On that first day we performed 15 interventions on 14 patients (2 eventrations, 6 inguinal hernias, 1 hydrocele, 1 scalp tumoration, 4 umbilical hernias, and 1 epigastrial hernia). One of the eventrations was very large and it required draining and hospitalisation for 48 hours. We want to stress that, besides the help from the hospital staff, two sisters, Carmen Alcibar and Rosa Alcibar, both helping nurses in the infirmary whom we had known in our previous Operation Hernia mission in CSDP in La Independencia, offered their selfless help which, in some moments, was of crucial importance. The work ended at 18:00 hours, and we made our way back to La Concordia in about 40 minutes thanks to the kindness of Sandra Ocampo who lent us her car for coming and going. After a short rest at the Atos Hotel we all had dinner together and got ready for the mission next day.

Tuesday 26: We again arrived at Quinindé Hospital at about 7:30 and started interventions at 8:00 with the collaboration of Dr Zhunala and Dr Preciado, so that we could use both the operation theatres, and we showed them our technique in hernioplastia with mesh, as the use of meshes is not common with them due to the scanty resources at their disposal. On that day we performed 11 interventions (2 eventrations, 2 inguinal hernias, 2 epigastric hernias, 1 criptoquidia, 3 umbilical hernias and 1 abdominal sebaceous cist). One of the eventrations was a huge one and it required drainage and 24 hours hospitalisation. We then left for La Concordia as the previous day in the car Dr Tinazaray had lent us in the morning.

Wednesday 27: Same time of leaving the hotel and arriving at the hospital, beginning our day at 8:00 with the help of the auxiliary staff of the operation theatres, with 12 interventions (2 eventrations, 5 inguinal hernias, 2 epigastric hernias, and 3 umbilical hernias). After finishing work at 16:00 hours we were invited for a meal by the two auxiliary sisters (Rosa and Carmen Alcibar) in their humble house in the outskirts of Quinind?, where we were introduced to their family and we duly appreciated her readiness, selflessness, and the great effort that going to work for the mission entailed. Back at La Concordia we, together with Dr Tinazaray and Haydee Caicedo, were invited for dinner by Sandra Ocampo. With them we planned future missions, and they indicated the possibility of extending such missions to villages in Esmeraldas and Santo Domingo de los Colorados.

Thursday 29: We begin operating at the usual time with 12 interventions (5 inguinal hernias, 4 umbilical hernias, 2 epigastric hernias, and 1 abdominal lipoma). We end at about 15:00 hours and, as a sign of gratitude, we share an aperitif with the operation theatre staff that had collaborated with us. We had a meeting with the director of the Alberto Buffoni Hospital, Dr Saavedra, in which we signed an agreement between Operation Hernia (Dr Pascual signing in the name of professor Kingsnorth), the Hospital and the La Concordia Health Region (Dr Tinazaray) for a three year period. Dr Javier Saavedra thanked us for the work done and urged us to carry out new missions in the Alberto Buffoni Hospital. We collected all the left-over material and we gifted part of it to the same Alberto Buffoni Hospital, and part to the La Concordia Health Centre.

We came back to La Concordia where we were received by the municipality mayor. In a simple act the statement of gratitude for our work was read out, and a copy of it was given to each one of us personally, and one to Operation Hernia. We then started for Santo Domingo de los Colorados, a city of about 200.000 inhabitants, where we were urged to open conversations for the possibility of future missions there. We want to emphasise that out of the 50 interventions carried out, 10 were on children between 2 and 10 years, and 2 on elders over 80. After a night in La Concordia, on Friday 30th we went back to Quito to come back to Madrid on May 1st.

Chris Oppong
Aby Valliatu

This is the second visit to Bole Hospital in Northern Ghana. The first visit was in November 2010. The team comprised Mr Chris Oppong and My Aby Valliatu.

The Medical Director, Dr Joe Nyuz and his theatre and ward teams should be congratulated for a well organised project. Adequate numbers of staff were mobilised. They were all well motivated.

A whole ward was dedicated to the project. This allowed a smooth and efficient transfer of patients to and from theatre and contributed immensely to success of this campaign. Once again we had good accommodation and were well looked after. We paid a courtesy call on the Bole Chief. He later presented us with a goat and yams.

Outcome: Aby and I performed 97 procedures in 79 patients. This is a rough average of 20 procedures a day!! We worked over only 4.5 days.

The highlight was the repair of huge bilateral femoral hernias. Each of the hernias were associated with a huge varix of the femoral (NOT SAPHENOUS) popliteal junction. The varices were plicated to reduce their size without occluding the lumen of the femoral vein. I had a similar case at Carpenter in 2010 and was assisted by Mr Hanafy. I wonder whether there is an association!

Training: One local surgeon, Dr Abraham Tsetsegah was trained in hernia mesh repair and given some mesh to use in his hospital. We hope to train more surgeons when we visit in November.

Future Development: The Medical Director of BOLE Hospital would like more than 2 Operation Hernia visits a year for both service and training. I will organise some more teams to visit in 2012.

Acknowledgements: We are again grateful to our sponsors – Unisurge; Leonhard Lang; Ansell; MEMS, Derriford Hospital – for their tremendous support.

Team Leaders: Andrew Kingsnorth & Etienne Steiner.

Where is Moldova? Why Moldova? During our preparations each time that I began to introduce the topic of our proposed mission, these two questions dominated the discussion. Imagine a small land-locked country, aligned to the East by a sliver of land which is claimed by its breakaway neighbour Transdniestra (which itself is infiltrated by Russian ‘advisors’), to the West by its sister country Romania, and to the North, East and South by its big brother Ukraine – then you will have some idea as to why Moldova has an identity problem. Stalin isolated the country further by redrawing boundaries to the South, cutting Moldova off from the Black Sea and even the Danube river except for 480 metres of access at the Giurgiulesti terminal which is suitable for only small vessels.

At a Hernia Congress in Paris in the summer of 2010, I was delivering a lecture about Operation Hernia missions to serve the underprivileged in Africa and the use of ‘mosquito net mesh’ for hernia repair. After the talk Dr Steiner stood up boldly and asked me if I realised that levels of poverty seen in African also existed in Europe (at the time I was the President of the European Hernia Society [EHS]). He then invited Operation Hernia and the EHS to organise a mission to Soroca (the birth-place of his parents) in the north of Moldova under his guidance. I agreed – and thus Moldova became the first European country to be taught to use Affordable Indian Hernia Mesh, at virtually no cost for the mesh material. Lichtenstein hernia repair or incisional hernia repair with mesh would otherwise not have been possible in a country with a populationof 3.5m, which has the lowest income per capita in Europe ($1800), and where in 2005 20% of people lived in absolute poverty (less than $2.15/day). In terms of human development Moldova is rated as ‘medium’, being ranked as 111th out of 177 nations.

Our team consisted of myself and Dr Etienne Steiner, his wife Brigid an ultrasonographer, his anaesthetist Dr Bernard Pelissier, Russian language expert and master hernia surgeon Professor Giorgi Giorgobiani from Georgia, President of the Georgian Hernia Society, Professor Tamaz Gvenitadze, and President of the Ukrainian Hernia Society Professor Yaroslav Feleshtynsky. Preparations had been somewhat erratic, with some uncertainty about our reception at Customs in Chisinau airport loaded with medical supplies on Saturday 9th April . We need not have worried, the bags were stranded at Vienna airport (and delivered the next day).

After formal greetings with our hosts we headed north for 150km along practically deserted, liberally pot-holed roads to Soroca. Winter was lingering, the temperature was just hovering above freezing, making our journey feel even more of an adventure. The terrain was flat with some gentle hills stretching into the distance and the road was never far from the Dniestra river to the east. The soil was yet to burst into life at the beginning of Spring and thus large swathes were exposed and appeared dark and rich, in places covered with extensive vineyards and orchards. The rural communities through which we passed had a Slavic air, populated with small, rustic, single storey cottages with pitched roofs and gables painted in a variety of shades of distinctive greens and blues. Little livestock was visible; although rough horse-drawn farmcarts were a relatively common sight. That evening we were treated to a fabulous welcome Dinner by the Medical Director of the Soroca District hospital ? and each night thereafter another Dinner was hosted in a different venue, so that we became quite familiar with excellent Moldovan wines, vodka, customs and speeches .

The next day, Sunday 10th April was a day for orientation, rest and relaxation. We wandered around the town square with its unreconstructed Soviet-style monuments (still with intact hammer-and-sickle) , sparsely stocked shops, and local folk shopping, waiting for busses or just socialising in the bitterly cold wind, sleet and hail. Thick padded felt caps for the men and head-scarves and shawls were the order of the day ? and were our first purchase. We were taken to the Rudi monastery, founded in 1770 and situated in an isolated sylvan setting. It is undergoing reconstruction after lying dormant for many years after destruction during the communist era. The visit was like stepping back into a medieval time of self-sufficiency, living off the soil and religious duty. The winter is survived by eating fruit and vegetables pickled in jars stored underground – just like our great-grandmothers had been accustomed to survive. After a vegan lunch with the abbot we returned to Soroca via a woodcutters lodge where wild boars were raised for hunting and variety of other animals were stocked such as goats, beavers and bees in the summer hives.

The working week lasted from Monday to Thursday and culminated in a meeting with the Deputy Minister of Health in Chisinau on the Friday. We were thanked warmly for our efforts and informed that the Operation Hernia mission was the first humanitarian mission to Moldova. Further visits were encouraged. Our pilot visit had accomplished operations on over 20 patients. A few were simple inguinal hernias which enabled us to teach the local surgeons the Lichtenstein method. The majority were large, incisional hernias which had probably not been offered surgery by the local surgeons because of the known high failure rate with sutured repair. Four of the patients were doctors working in the hospital. Mosquito net mesh was used in all cases. The working conditions were basic. Equipment would not have looked out of place in a medical museum. Instruments were clumsy, blunt and worn. Rags sufficed as drapes.

A tour around the hospital revealed motivated and well-trained staff working with extremely limited resources to the best of their ability. Oxygen was delivered from cylinders, hot water was limited, the only CT scanner was to be found in Chisinau. I was invited to operate on a case of necrotising pancreatitis, and subsequently gave a lecture on management of acute pancreatitis.

It had been a privilege to work with our colleagues in their difficult circumstances. We have a duty to help those in our own backyard. We will go back to Moldova. Join me!

Andrew Kingsnorth

The Moldovan surgeons that made our trip possible were: Angela Rusnac (Medical Director of the Soroca District Hospital), Valeriu Petrovici (Vice-Medical Director of the Soroca District Hospital), Veaceslav Costin (Head of Department of Surgery), Vasile Voloceai (Surgeon), Alexandru Samsonov (Surgeon), Serghei Manchevici (Urologist), Veaceslav Neamtu (Head of Department of Anaesthesia).