The Opening

Operation Hernia Team Inaugurates Hernia Centre in Eruwa, Nigeria December 2012

The Opening

The Opening

We arrived at Eruwa on Saturday 1st December. There were seven members from Madrid hospitals (anaesthetists: Francisco Duran and Miguel Lopez Vizcayno, surgeons: JA Pascual Montero, Teresa Butrón, Patricia Maldonado (resident), internist: Iñigo Espert, nurse: Ana belen Abenoja) who were joined by an additional member from the UK the following day.

The site was the Awojobi Clinic, which started at grassroots level in the 1980’s and has been steadily growing ever since. The clinic was set up to serve the local rural population but the level of care has reached a standard that attracts patients from as far away as Lagos, a 3-4 hour journey by road.

Surgeons & Supporters

Surgeons & Supporters

At work

At work

Work started on the Sunday and continued during daylight hours for five days. The patients would arrive from 8am and the 8 team members formed two surgical teams. Surgery was performed in the purpose built ‘Hernia Centre’ which was opened during the visit. The operations were performed under spinal anaesthesia and operations were predominantly Lichtenstein repairs using locally sterilised mosquito mesh. Workload varied each day depending on the numbers of patients who presented.

There was strong training ethos to the mission. Dr Awojobi has a total of five registrars who initially watched and later performed Lichtenstein repairs under direct Consultant supervision. The hernia centre will remain open after the end of the mission with the registrars operating independently.

Registrars attending for instruction in Hernia surgery

Registrars attending for instruction in Hernia surgery

On a couple of the afternoons we had finished the operating before nightfall and had the opportunity to visit other departments in the clinic. The emphasis is on delivering the highest possible level of health care using available resources. The results are impressive, with most of the departments present that one would expect in a far larger hospital. We also had the opportunity to observe some of the differences in presentation and treatment between European and Nigerian patients. One evening team members assisted local staff with completion of a traumatic amputation in a teenage boy.

The people of Eruwa and were welcoming and friendly and we made a lot of new friends. Over the week we performed at total of 44 operations on 38 patients. They were predominantly inguinal hernia repairs, but we also repaired two femoral hernias, one epigastric hernia, explored one groin for lymphadenopathy and removed a large lipoma without immediate complication. We left Eruwa not only satisfied with the procedures which we had performed but also enthusiastic that the training element of the mission will add to the ‘hernia centre’ and lead to ongoing benefit to the local population once we have returned to our home countries.

Chris Grocock

Surgical Registrar

Maria & Stephen

Giants of Gambia return December 2012

Maria & Stephen

Maria & Stephen

Maria Boutabba (Registered ODP and Sister Maria to the team and hospital community) reports

Operation Hernia Mission, AFRPC hospital, Farafenni, Gambia – 8th December -14th December 2012.

This trip proved to be extremely profound for both professional and personal reasons. I had a fantastic time, was incredibly busy dividing myself between different roles, including surgical assistant… but was so in my element. It was and remains a great privilege to have worked with like minded professionals who value safe patient care and doing the right thing for the right patient at the right time in a clinical environment so different to what we are used to in our own familiar healthcare systems. We all bonded so well and enjoyed each others company, particularly in the relaxing evenings, listening to Brian’s very funny anecdotal stories and saucy jokes.

In surgical assistant role

The multinational (English, Welsh, Irish working in Scotland, Polish and Swiss) team comprised of Andrew Kingsnorth, Lead Surgeon, Brian Stephenson, 2nd in command surgeon, Alan Woodward, Surgeon, Stephen Brennan, Surgeon, Slawek Koziel, Registrar surgeon, Katharina Wentowski, Anaesthetist, Michael Wentowski, Medical engineer and myself. Andrew has fondly named us the ‘Giants of Gambia’ for achieving what we did under the conditions we worked in.

Michael's den (self-made EME department)

Michael’s den (self-made EME department)

Katharina taking her patient to recovery

Katharina taking her patient to recovery

We had an eventful arrival into Banjul, where one of Andrew’s small bags got whisked off in error to a resort hotel. After a delay and interesting police reporting process, it was returned intact, not something we would expect in the UK! We later made our way to Banjul port, where we waited in anticipation for the ferry that would take us across the impressive Gambia River to Farafenni.

Following what felt like hours and after polishing off some chicken and rice, our ferry eventually arrived. Amongst much local excitement, and eruption of frustrated tempers by queuing lorry drivers, we were herded on mass onto the ferry. We travelled the smooth, oil like river under the guidance of beautiful star constellations. We landed safely in Farafenni and made our way to what would be our very basic accommodation for the stay, Eddies Hotel, checking in somewhere around midnight on the 7th December 2012.

Throughout that initial experience we were looked after by the hospital communications officer, Saini. Saini would prove to be our valued friend easing our right of passage throughout our entire stay. Saini very efficiently organised our off duty entertainment time; we would sample an African music and dance evening, eat barbecued goat, visit the Senegal border, fishing village, women’s garden and eventually the Atlantic ocean waves on our last day.

The next day we met with the hospital administration. The hospital architecture is impressive but does not reflect what we were to come to accept as an under funded, under resourced, disorganised healthcare system. Following group prayer we discussed what we hoped to achieve during our stay. The administration was welcoming but hinted at the lack of resources at the hospital.

A lot of work was undertaken by the team to turn a ‘shell’ into an efficient, fully functioning mini day surgery unit. The ‘theatre’ developed into 3 operating spaces, with all surgical equipment, instruments and make shift operating tables scrubbed clean and organised to be fit for purpose. We set up a sterile storage area, scrub and gowning area and mini sterile services unit. We had one working diathermy machine that had travelled with Andrew. A startling Gambia fact is that in the whole of the country there are only 4 surgical diathermy machines!!

The transformation of the ‘shell’ would prove to become the pride and joy of the team and the few local staff who joined us to help. Of benefit to our clinical work, was our magical medical engineer, Michael, who fixed life saving equipment, we so often take for granted in the UK. Without this repaired equipment, which included suction and a couple of abandoned pulse oximeters, we would have found it difficult to achieve safe anaesthesia for the 16 children we later treated.

Katharina and I quickly realised we would not have a functional anaesthetic machine, despite several modern machines being available. Sadly these were all in need of spare parts to put them back in working order. However with Michaels help, we had proper basic monitoring, an ambu bag, suction and access to cylinder oxygen. We trawled abandoned equipment from previous missions to retrieve IV access and airway management devices. Katharina is a brilliant and committed anaesthetist, who showed so much maternal compassion for the children. Together, we carefully planned how we would safely pre medicate, anaesthetise the children and recover them post operatively – We went right back to clinical basics which we both found professionally satisfying.

We operated on 29 adults, the majority having local anaesthetic, with or without the support of Ketamine and Midazolam. A small number of adults had spinal anaesthesia. We operated over 4 days, with an efficient turnaround, with a ratio of approximately 1 child to 2 adults. All 3 operating spaces were kept fully utilised. An average operating day would typically reflect up to 9 patients operated on before lunch around 2pm and then 3 more complex cases in the afternoon and tidying up time ready for next day operating.

Brian, Michael, Andrew, Alan, Maria, Stephen & Katharina (picture by Slawek)

Brian, Michael, Andrew, Alan, Maria, Stephen & Katharina (picture by Slawek)

Child ready for postop care

We saw and operated on large paediatric inguinal and umbilical hernias. The adults had primarily very large inguino- scrotal hernias. We had a couple of complex umbilical hernia repairs which became mini laparotomies to repair them! We also operated on femoral hernias including, rather unusually, a mother and her two daughters. All the patients, where screened using the Kingsnorth classification, with Andrew, booking the patients to the operating list which was reviewed with me on a daily basis.

We had little chance to teach and train the local hospital community – there were no surgeons apart from one Obstetrician from Cuba. I did some basic theatre training with the few local nurses who were assigned to help us in theatre, and I hope to bring one particular nurse to the UK for an exchange visit. We had a Scottish medical student, on overseas placement join us for 2 days, and she found the exposure within our team rewarding. On a couple of days, 2 volunteers joined us from the schools for Gambia project – this assisted us tremendously as they helped bring patients to theatre, reassure them and they also helped wash and pack instruments.

We all acknowledged that Farafenni is very reliant on mission teams to assist with elective surgery. It is a sobering fact that once mission teams leave, there is no sustainable system in place to allow the local health community to carry on. We were humbled by how far patients will walk to access surgical care. The patient’s appreciation was immeasurable but the smile said it all.

On the last day we met the hospital administration again and exchanged niceties. Each member of the team was rewarded with a hand made shirt and letter of appreciation. We were reminded that we had been absorbed into the hearts and minds of both the hospital staff and local community.

I hope that the ‘Giants of Gambia’ team will make another visit to Farafenni in 2013 as per the wishes of the hospital administration.

Giants of Gambia OH team

Hospital Dr Gustavo Dominguez

Report of Spanish Team November 2012

Hospital Dr Gustavo Dominguez

Hospital Dr Gustavo Dominguez

MISSION IN SANTO DOMINGO DE LOS TSACHILAS-ECUADOR

24 Nov – 1 Dec 2012

Team: Dr. Enrique Navarrete, Dra Pilar Concejo, Dr Juan Moreno, Dr, Antonio Dominguez, Dra Cristina Gonçalves, Dra M. Luisa Reyes, Dra Marina Infantes, Dr Francesc Marsal, surgeons , and Dr Antonio Dominguez anaesthesist. General surgeons from Sevilla, Ponferrada, Tortosa, Tarragona, and anaesthetist from Sevilla.

Last 24th November 2012, the Spanish Team left from Barajas airport (Madrid, Spain) to our destination in Ecuador, Quito. The doctors came from different towns and hospitals from Spain, and some are members of the group who participated in the mission in Aliade (Nigeria) in Nov 2011.

After a long trip with one stop in Panamá airport to change aeroplane, we arrived on Saturday night at the Mariscal Sucre airport, located in the center of the City.

In the airport Sandra Ocampo, our local contact and Dr Kathia Tinizaray, Provincial Director of Health in Sto Domingo de los Tsachilas, was waiting for us and helped us through customs.

The group rested at night in Sandra Ocampo´s house in Quito. On Sunday morning we visited a Quito historical centre, guided by Francisco Sandoval, a surgeon trained in Sevilla (Spain) years ago and his grandfather, who was born in Quito. After a lunch we started off to La Concordia, with a mini-bus. After a 4-hour trip (150 km) we arrived at night at our destination and we went to our lodgings in the Atos Hotel.

The Team

The Team

2 tables at work

2 tables at work

On Monday after breakfast, we started to Santo Domingo de los Tsachilas (de los Colorados) 45 km from La Concordia, where the Provincial Hospital Dr Gustavo Dominguez is, and where Dr. Kathia Tinizaray prepared one operation theatre with two surgical tables for the Spanish group this week.

We arranged the surgical material and prepared to start the operations on Monday morning.

Two surgeons visited the patients before the surgical assistance with the collaboration of Dr Angel Solorzano, rural physician from La Concordia and the rest of the group carried out the surgery and the control in the recovering area.

After four days and a half the team performed 63 interventions on 56 patients including children.

Recovering a child

Recovering a child

One afternoon we visited an “hacienda” together with Dr Sarmiento, the head anaesthetist at the hospital. He explained us about the local fruit and flora of the area such as cacao.

Afterwards the team, accompanied by Sandra Ocampos and bodyguards visited the local Indian Reserve “Los Colorados”. The visit was very interesting and the place very beautiful. The Indians danced native dances and showed us their customs and culture.

On Friday we returned to Quito and we took advantage to visit Otavalo and surroundings. After a lunch on Saturday morning at the Quito Golf Club in El Condado, invited by the local surgeon Francisco Sandoval and his family, we went to the airport to catch our flight back home.

We all felt very satisfied with our mission, and we made a lot of good friends.

Dr Francesc Marsal

Outside the OR

Alyssia McEwan reports
November 2012

Outside the OR

Outside the OR

Medical Student Experience (Alyssia McEwan) – Operation Hernia – Ghana, Nov 2012

Africa. I really had no idea what I was getting myself into when I bought my plane ticket to Accra, Ghana. It had taken a year to solidify the plans to join the Operation Hernia team – a year filled with board exams, medical school rotations, and sleep deprivation. It was hard to believe that the day had finally come to board the flight.

My first impression of Accra – the heat was sweltering! After traveling 10 hours from New York City in the aftermath of Hurricane Sandy, the hot African sun beating down was particularly impressive. I had already begun to feel the camaraderie and team mentality that was brewing amongst the United States members of our Operation Hernia Team. Our portion of the team was composed of: Dr. Pedro Cordero, the surgeon from the US team who I had the privilege of working with during my third year surgery rotation and who was instrumental in my being involved in this mission; Aida St. John, a theatre nurse who I had worked with also during my surgery rotation; Carol Turner, a traveling theatre nurse who I met for the first time on this mission; Peter Dixon, a surgical resident from New Jersey; and myself, a fourth year medical student from NYC. From the very beginning of our journey – dealing with missing documents, our bus breaking down on the way to the airport and a variety of other minor meltdowns – it was clear that we were bonding, whether we liked it or not!

The first time that we were all together with the entire team was outside the house where we were staying in Accra. Meeting the Chair of the Board of Trustees of Operation Hernia and lead consultant of the UK team, Dr. Chris Oppong was wonderful – he greeted me with a huge hug and said “call me Chris!” which broke any barriers of formality that could have theoretically been in place. We met the two registrar surgeons from the UK that morning (after a brief hello the night before)– Dr. Surajit Sinha and Dr. Frank McDermott. Immediately it was clear that we would all get along and that this was going to be an extraordinary trip.

The trip from the capitol city of Accra to the much smaller town of Ho was eye opening. Little tiny villages speckled amongst lush green countryside. Small children running around in near-nothing, women dressed exquisitely in form fitting clothing of the most captivating colors, people carrying a variety of items in baskets on their heads, goats, and a lot of selling, trading and working. Structurally-sound thatch roofed houses and above all a sense of community which was obvious in each of these villages, even while driving past at 55 km/hr. The smiles on the faces of the people were unlike smiles that I have ever seen in the United States – these were smiles portraying honest happiness. I kept asking myself “what do these people look forward to?” “what do these people worry about?” – the answer, I imagine comes down to the basic needs of human beings – food, shelter, water, family – the things that actually matter in this world. How different than what so much of the world thinks of.

I found our welcome to Ho Hospital unexpected. An impressive number of regional officials and hospital administrators joined in to welcome our team. There was a lot of this during our stay, lots of introductions to important people and making connections. Though, in my mind, none of these people were as important as the people who we met later that day, our patients.

We entered the doors of the ward that evening to see the patients who we would be operating on the following day. I had seen a handful of hernias over the past year but I had never imagined hernias like this. Basketball-sized masses extending into the scrotums of these men – one after the next. Its difficult to imagine how they managed for the many years that most of these men were carrying these burdens. How they could work and provide for their families is a mystery to me. These men were unlike any pre-op patients that I had ever come across. There was no air of nervousness or being frightened or any requests or questions. They were stoic and ready – ready for surgery and ready for their new lives.

The following day was day 1 in the operating theatres. We met the theatre staff who we would grow to love by the end of the week. Pedro had the brilliant idea of labeling everyone with makeshift tape nametags so that we could get to know the people who we would spend the week working with. In my mind, this was probably one of the most influential decisions of the entire mission. Being able to call each other by name is something that I believe contributed to the bond that we all formed. Nothing is sweeter to our ears than the sound of our own name, and being in an environment of strangers where we can begin to know each other by calling each other by name was very powerful. We learned that the person in charge of the theatres (and quite possibly in charge of the world) was Sister. Though she seemed very “all-business” in the beginning, by the end of the week the soft humanistic side of her was clearly shining through.

The kindness, generosity and politeness of Ghanaians is really beautiful. I felt so welcomed into the community and the hospital. The saying that is repeated over and over by Ghanaians is “you are welcome” – when you walk into a room, when you meet someone. The thing about this, is that it is honest – they were really welcoming us. It wasn’t just something to say to be polite, they really meant it. As much as the members of our team gained from going on this mission, I can say that the people who we worked with gained also. On the last day, one of the scrub techs who we worked with, Senyo, said to me in the most heartfelt and honest way “It has been so wonderful having you all here. It has really brought a lot to us and we will really miss you. I don’t even know how to say how I feel about the way that you have interacted with us and made us all feel. We really wish that you will come back.” It sent goose bumps up my arms when he said this because it became clear at that moment that every single person involved in this mission benefited – the international team, the local nurses and staff, the local surgeons, the hospital administrators and officials, and of course the patients and their families.

Bonded

Bonded

As a medical student, I was able to first assist during the cases. I spent time assisting Pedro, Chris and Sinha. Assisting with approximately 30 inguinal hernia repairs over the course of 5 days offered a unique opportunity for me. For the first time, it gave me the chance to really truly understand what was happening in the operating theatre. During the third year of medical school, we are briefly exposed to a variety of specialties. The rotations in each of these specialties last 1-2 months and by the end of the year we are expected to have made a decision about which specialty we would like do commit to for the rest of our lives. During my surgery rotation, I realized that I loved surgery but the problem that I had was that I could not understand how I could ever be a great surgeon. During my medicine, pediatrics, emergency medicine, and psychiatry rotations it was simple to understand that after 3-4 years of specialized training one could obtain the skills necessary to do those jobs. As a student, I was doing more or less the same things that I would do as a physician – interviewing patients, suturing, making decisions about antibiotics, counseling patients about smoking cessation, etc. But in surgery, I was never really holding the scalpel, understanding why decisions were being made, seeing the big picture, knowing what to do next or even truly understanding what I was looking at. I was retracting tissue and trying to ensure that the surgeon had good visualization, I wasn’t acting as a surgeon by any means. By assisting with the SAME procedure 30 times in a row in 5 days on this mission, I began to understand what was happening and what to do next. For the first time, I believed that I could become a surgeon – I could recognize the difference between a nerve, an artery and the vas deferens. I understood the anatomy of the inguinal canal and what went into the actual repair of a hernia, and why. I could actually for the first time visualize myself being on the other side of the table and knowing what to do next. This was a HUGE realization for me.

In order to feel this way, it wouldn’t have been enough to have simply observed and assisted in the operations. I was fortunate to be in the company of surgeons who love to teach, Pedro and Chris. During one case, I asked Chris a question about the anatomy (a question which he had probably already answered 5 times) and he realized that I was still confused. He removed all of the retractors from the deep tissue and skin and held the skin closed. Then he started at the beginning and slowly retracted each layer explaining and quizzing me on what we were looking at and what had been done. It was important to him that I understood, and somehow this man has been gifted with a seemingly endless amount of patience. At the end of that day, I expressed to Pedro that I felt much more comfortable with the anatomy but wished that I had packed my anatomy books so that I could review before tomorrows cases and understand even more. Pedro has been a surgeon for probably close to 30 years and thus naturally has an extensive and impressive knowledge of anatomy. He instinctively grabbed a piece of paper and drew out in exquisite detail the anatomy of the entire inguinal region – explaining every structure to me and confirming that I understood. By the next day, I was even more comfortable and was able to soak in even more from the cases.

Whatever the rationale that these two gifted and seasoned surgeons had for taking the time and putting the effort into teaching me I cannot say for certain. But what I know is that their efforts resulted in me leaving Africa with the confidence and belief that I could become a surgeon. I have always been interested in international medicine and global health and knew that no matter what specialty I chose, I would incorporate international work into my career. I see, however, through the Operation Hernia that simple surgeries such as hernia repairs can have an enormous impact on communities worldwide. Surgeries to correct hernias, cataracts, and cleft palates are simple yet absolutely life (and community) changing. Without this experience, I would not have believed that I could become a surgeon or have been able to see the results of correcting surgical disease in the developing world. I hope to be involved with future Operation Hernia missions in the future. I am very impressed with the mission of this organization – they are interested in sustainable and innovative improvements. Using mosquito net in place of brand mesh is just one example of the forward-thinking ideas that are born through leaders of this organization. This trip has changed the course of my life and I am forever grateful for the opportunity to have been a member of the 2012 Operation Hernia team.

Alyssia McEwan, BA, MS

4th year medical student

Touro College of Osteopathic Medicine – New York, NY, USA

Members of the Team

David Messenger: First Shorland Hosking Fellow November 2012

The ASiT/Operation Hernia Shorland Hosking Travelling Fellowship to Takoradi, Ghana

David Messenger, ST6 in General Surgery, Severn Deanery

Background

In March 2012, I was fortunate enough to be awarded one of the first ASiT/Operation Hernia travelling fellowships. The funding for my fellowship was donated largely by Howard Eggleston, a former patient of Professor Andrew Kingsnorth’s, and was named in honour of Shorland Hosking, a consultant surgeon from Poole, who died tragically in an air accident shortly after returning from an Operation Hernia mission to Nigeria.

Operation Hernia is an independent, not-for-profit organisation, whose mission statement is ‘to provide high quality surgery at minimal costs to patients that otherwise would not receive it’. It was initiated in 2005 from Derriford Hospital, Plymouth, via the city’s cultural links with Takoradi, Ghana. Operation Hernia has since expanded and to date has repaired over 6000 hernias, at 18 locations in 11 different countries with teams originating from 22 countries.

I have had a long-standing interest in hernia surgery and have never failed to appreciate the impact that an effective hernia repair can have on the quality of life of the patient. It was this opportunity to undertake a humanitarian mission where my surgical skills would be of maximal benefit to a community where healthcare resources are limited that prompted me to apply for the fellowship.

I chose the mission to Ghana, as this was my first experience of humanitarian surgery and I wanted this to be in a well established setting. The prevalence of inguinal hernia in Ghana is as high as 7.7% of the population.1 However, less than 40% are actually repaired, resulting in many patients developing long-standing inguinoscrotal hernias that are associated with a high incidence of morbidity and mortality.2 Presentation is often delayed and approximately two-thirds of cases are repaired as emergencies.

Sekondi-Takoradi is located in the Western Region of Ghana with a population of almost 450,000 (Figure 1). Its principal industries are timber, ship-building and crude oil. The discovery of the latter has led to a dramatic expansion of the metropolitan area in recent years. Most of the adult workforce is engaged in physically demanding jobs where the effects of an untreated hernia can be debilitating. The stark reality is that if you are unable to work, then there is little means to support both yourself and your family. The value of the mission could not be clearer.

Preparation

The co-ordination of the mission was masterminded by Mr Chris Oppong, a consultant surgeon from Derriford and Director of Operations for Ghana. It soon became apparent that an anaesthetist was required and I duly offered the services of my wife (!), Dr Natasha Joshi, an ST7 anaesthetic trainee, who was supported by a travelling grant from the Association of Anaesthetists of Great Britain and Ireland. Our preparations included undergoing an extensive vaccination programme, obtaining visas from the Ghanaian High Commission in London, arranging flights and gathering together an array of gloves, gowns, sutures, laryngeal mask airways and portable pulse oximeters! We are grateful to the Spire Hospital, Bristol, and those colleagues who were kind enough to donate equipment for the mission. Operation Hernia has pioneered the use of polyester mosquito net meshes as a cost-effective means of hernia repair and these were pre-sterilised at the Derriford and Royal Gwent hospitals prior to our journey.

After arriving in the capital, Accra, the team assembled at a local guest house, before travelling on to Takoradi by road the next day. In addition to Natasha and me, our team consisted of two consultant surgeons from Dewsbury: Mr Shina Fawole, team leader and a veteran of three previous Operation Hernia missions, and his colleague Mr Harjeet Narula. They were accompanied by Melanie Precious, a Senior Operating Department Practitioner, also from Dewsbury, proving the old adage that a surgeon cannot operate without at least one member of their regular theatre team! In fact, Melanie’s scrub and anaesthetic experience were to prove invaluable throughout the course of the mission. The final members of the team included Mr Rafay Siddiqui, an ST4 general surgical trainee from the London Deanery, and Mr Roger Watkins, a recently retired consultant surgeon from Derriford, who joined us for the final two days of our mission after conducting a separate mission to the Cape Coast (Figure 2).

The Mission

On arrival in Takoradi, we were met by Dr Bernard Boateng-Duah, Chief Medical Officer of the Ghana Ports and Harbour Authority Hospital, who was in charge of the logistical arrangements of our stay. We had the exclusive use of a Ghana Ministry of Health Villa, which provided a welcome respite at the end of a long day’s operating (occasional disruption to the hot water and electricity supplies not withstanding!). The culinary skills of the catering team were superb who ensured that we had the opportunity to enjoy variety of Ghanaian dishes (Figure 3).

Bernard had already co-ordinated the not insignificant task of selecting patients for our mission. Recruitment had largely occurred through radio announcements, clinic visits and perhaps most pleasingly through word of mouth. A prime example of this was the patient who told me he had waited all year for his hernia to be repaired just so the British surgeons could perform his surgery! We operated at three sites during the week: Ghana Ports and Harbour Authority Hospital, Takoradi Hospital and Dixcove Hospital, located a one hour drive from Takoradi (Figures 4 a,b and c). At Takoradi Hospital a disused wing had been refurbished in 2006, with funding from the British High Commission, to create the Hernia Treatment Centre that incorporated an operating theatre and day-case ward.

On the morning of surgery, patients were pre-assessed and a decision made with regards suitability for repair under local, spinal or general anaesthesia. As a general rule, inguinal hernias that were manually reducible were repaired under local anaesthesia, with irreducible hernias or those with a substantial inguinoscrotal component being performed under spinal anaesthesia. General anaesthesia was reserved for incisional hernias and paediatric herniotomies. Over the course of the five-day mission, our team performed a total of 94 procedures in 87 patients (Table 1). Inguinal hernia repairs accounted for 71 cases (including 6 recurrent), of which 39 (55%) were performed under local anaesthesia. The majority of inguinal hernias were inguinoscrotal, or H3/H4 according to the Kingsnorth classification system (Table 2)3. Polyester mosquito net meshes were used for repair in 37 inguinal hernias with the remainder being repaired using brand mesh left over from previous missions. The handling of the mosquito net meshes was broadly comparable to that of brand mesh, although we found that bigger bites with each suture were required to adequately secure the mesh. There were no post-operative complications and all adult hernia repairs were discharged on the day of surgery. Only one patient who had undergone repair of a large incisional hernia stayed overnight.

Initially, repair of the inguinal hernias proved to something of a technical challenge, owing to the anatomical differences between those encountered in Ghana compared to in the UK. Most inguinoscrotal hernias were due to a longstanding patent processus vaginalis that commonly required transection of the sac to facilitate reduction. Furthermore, these hernias were embedded within a well developed cremasteric muscle and tended to encircle the cord structures, which made dissection of the sac more troublesome. In many instances, partial excision of the cremaster was required in order to effect sound mesh repair around the deep ring.

Personal Experience

I can honestly say that the experience of operating solidly for 12 hours each day, in an environment subject to power cuts, poor lighting, a lack of running water and frequently defective equipment has been the most rewarding of my career to date! I was especially proud of Natasha, who as the sole anaesthetist dealt effectively with a number of challenging anaesthetic situations, mainly related to leaking circuits and a limited oxygen supply.

During the week I performed a total of 32 procedures: 21 inguinal hernia repairs (three recurrent), six paediatric inguinal herniotomies, two incisional hernia repairs, two hydrocoelectomies and one epigastric hernia repair. Eleven of these procedures were performed independently with the consultant operating in another theatre. Many patients had travelled long distances for their surgery and I was humbled by the gratitude that they showed our team. I was amazed at how well the patients tolerated their procedures and it was often quite difficult to get them to admit that they were in any pain. In the UK, I could never imagine performing a sizeable inguinal hernia under local anaesthetic in a 30 year old male without any form of sedation.

The local nursing staff at all three centres worked tirelessly and were extremely welcoming. There was no need to rely on iTunes for entertainment in theatre, as we were often serenaded with gospel singing throughout the cases! Anaesthetic cover was provided by nurse anaesthetists who for the most part were highly skilled and keen to learn from Natasha. I was particularly impressed by the nurses at the Hernia Centre who were actively engaged in improving their practice and had implemented the use of pre-assessment proformas, antibiotic protocols and a handwashing policy. They were ably led by Sister Marion who had previously undertaken a one month elective placement at Derriford hospital (Figure 5). The only reluctance we encountered from the nursing staff occurred at Dixcove when we embarked on our final case of the day at 7.00pm. We later learned that the staff preferred to leave in daylight hours to avoid the snakes that would appear at night on their walk home!

It was at Dixcove that we encountered patients with the largest hernias (Figure 6). The community at Dixcove is less affluent than Takoradi with one doctor serving the needs of over 20,000 patients. Consequently, these hernias were longstanding and in one instance emergency repair of a hernia that had become obstructed was required. The reality of everyday life in this community was illustrated by the case of a 6 year old boy with an inguinal hernia who only weighed 13kg. We decided not to proceed with surgery as he had a right basal pneumonia and instead admitted him for intravenous antibiotics. Despite also having recently recovered from malaria, his mother was still desperate for him to undergo surgery as his hernia was limiting the physical contribution he could make to domestic tasks.

Social Aspects

Ghana was the first African nation to gain independence from the British in 1957 and is proud of its status as a stable parliamentary democracy in a politically volatile region. It is a majority Christian country, with a sizeable Muslim minority, and is compromised of over 100 ethnic groups. It is the relative inter-religious and inter-ethnic tolerance that has seen Ghana avoid the civil wars that have afflicted neighbouring states. Whilst in Accra, we visited the Kwame Nkrumah Memorial Park where we able to learn more about the birth of Ghana as a modern nation and the concept of pan-Africanism (Figure 7). This also proved to be a popular setting for newlyweds to pose for their wedding photographs! It is perhaps the following quote from Nkrumah that best sums up Ghana’s drive to achieve middle-income country status by 2015,

‘We have the blessing of the wealth of our vast resources, the power of our talents and the potentialities of our people. Let us grasp now the opportunities before us and meet the challenge to our survival.’

Summary

This was a thoroughly worthwhile mission for all those involved. Despite having never met each other before, I thought that the team gelled together well. Shina was an inspiring team leader, navigating us through several tricky situations (often related to Ghanaian taxi journeys!). Harjeet and Roger provided sound advice and were both excellent trainers. The contribution from Natasha and Melanie was immense who managed to instigate a change in practice with regards to the administration of spinal anaesthesia – tilt the patient head down, rather than perform a second injection of local anaesthetic if the spinal does not act immediately. I found Rafay to be a supportive and well-rounded colleague who like me benefitted tremendously from this experience. It was not until I returned to work in the UK that I realised that this mission has matured me both as a surgeon and as a person. It has taught me to be adaptable, more understanding of the limitations within the NHS and perhaps most importantly has given me a much needed perspective on life. I would recommend, therefore, that any trainee looking to broaden their surgical horizons should become involved with a humanitarian mission.

Recommendations

I have listed below two simple but achievable aims that would improve the quality of care received by the patients in Takoradi.

Routine adoption of the WHO pre-operative checklist at all hospitals.
The purchase of portable pulse oximeters for patient monitoring both peri- and post-operatively. We donated our own to Dixcove hospital. This may be best achieved through Lifebox, a not-for-profit organisation, that aims to put a pulse oximeter in every operating theatre throughout the developing world (www.lifebox.org)

Acknowledgments

I am grateful to ASiT, Operation Hernia and Howard Eggleston for providing financial support. Thanks must also go to Mr Chris Oppong, Dr Bernard Boateng-Duah and Mr Eddie Prah for ensuring such a memorable and well organised mission.

References

DL Sander, Porter CS, Mitchell KC, Kingsnorth AN. Operation Hernia: humanitarian hernia repairs in Ghana. Hernia 2008;12:527-529
Clarke MG, Oppong C, Simmermacher R, Park K, Kurzer M, Vanotoo L, Kingsnorth AN. The use of sterilised mosquito net for inguinal hernia repair in Ghana. Hernia 2009;13:155-159
Kingsnorth AN. A clinical classification for patients with inguinal hernia. Hernia 2004;8:282-284

Tables and Figures

Table 1

Table 2

Welcome to the Team

Report from the local staff at St Vincent’s Hospital, Aliade November 2012

Welcome to the Team

Welcome to the Team

REPORT OF OPERATION HERNIA TEAM MISSIONED TO ALIADE;

28TH OCTOBER – 3RD NOVEMBER, 2012.

We would like to express our appreciation for the understanding, patients, generosity and good work you came and did for our people from 28th October – 3rd November, 2012. In fact your team came with their unique way which was nice. Dr. Andreas Osterwalder came with great sense of humor and creative magic power at the send-forth party.

Your team (Andreas, Giampiero Campanelli & Cristina, Shambhu Yadav, Paolo Sorelli) arrived at our hospital on a Sunday 28th October, 2012. As soon as the reception was over and the departure of the Okpoga team was complete, you rested for a few minutes and thereafter proceeded to the theatre for orientation.

Teaching

Teaching

A Tough Case

A Tough Case

We were meeting for the first time in life and our friendship started. It was as if both teams were working together for a long time.

The items brought for the hospital were handed over to the team leader Mr. Peter Azaagee and were fully introduced on how to use them without problems, following your demonstration were there was need.

Your generosity came out fully as the new and modern diathermy machine with all its components was coupled and tested in the presence of all members of the newly formed team.

The cordial working relationship gave you the highest scores among the previous teams that had ever visited us and that was the most reason why you were able to handle a123 patients in one week successfully.

A Little One

A Little One

In addition, your team is the very first that has recognized the hospital team following the gifts to our members. This serves as encouragement to us.

Finally, the people of this hospital will never forget your team for the good work, cordial working relationship and generosity we experienced from you within a short period of one week which we worked together. The community will ever remember the visit of 28th October – 3rd November, 2012, mostly the 123 patients you operated.

Thank you.

Sign: Mr Azaagee Peter and Theatre Team

Cc: Prof. Campanelli G.

:Shambhu Yadav

:Paolo Sorelli

:Christiana Spata

: Catholic Diocese of Makurdi

Campaign poster

2 weeks at Sergio E Bernales Hospital, Lima Sept 21 to Oct 7 2012

Campaign poster

Campaign poster

I’m Anna Pascual, a Medical Student. I took part in the Humanitarian Expedition led by the Spanish Dr Teresa Butrón and her surgeons’ team in the Cooperative Project in Lima (Peru) conducted from the 21st of September until the 7th of October. We have spent two weeks in the Sergio E Bernales Hospital of Lima full of great experiences and unforgettable moments that day by day have made us grow as people and as a team.

The team of Surgeons in Action’s Foundation that have worked in this expedition for 2 weeks in the Hospital Sergio E Bernales of Lima has been made up by three General Surgeons (Drs Teresa Butrón, Pepa Castillo and Carmen Martinez), two Plastic Surgeons (Drs Palmira Garcia and Ana Lopez), a Paediatric Surgeon (Dr. Alejandro Unda), two Anaesthesiologists (Drs Manuel Gabaldón and Paula Tardáguila), a Haematologist (Dr. Rosario Butrón), a Medicine student (Anna Pascual) and an Economist (Maria Barroso). The Doctors came from different hospitals in Madrid and Malaga, and in my case from Barcelona. So I didn’t know anybody and I thought that it would be difficult getting myself adapted to the different tasks and the way of working of each member of the team, but nothing was how I had expected, in fact, in two days I could feel as if I was one useful Doctor more in the team: I assisted the hernia operations, I did a part of the data base, I helped the anaesthesiologists when they required me… and I learnt everything about the operating theatre at the same time I felt more useful every day.

After 11 hours of flight (and 7 hours of difference between Spain and Peru) the team arrived on Saturday morning at Lima’s city. We were exhausted, but in order to carry out the mission, Dr Butrón, our team’s leader, motivated us to start working hard that same morning. We planned some operations for the next Monday and we did 5 hernia’s operations on patients that had been arranged for that same day. That was how the Expedition started.

In the operating theatre

In the operating theatre

One of our younger patients

One of our younger patients

During the next two weeks we worked so hard and enjoyed of our work at every moment. We finished each day satisfied with all the operations we had done and satisfied because of the happiness of our patients after being operated or when they went back home. Also some patients with huge hernias came to thank us for having solved their problem. So we could feel so satisfied and happy for the work we had done.

We were living in Coma’s town, near the Hospital. Every morning when we left to work and every night when we went back to the hostel we could see the poverty and the needs that they had in that area. Also the Hospital was under minimums, and one of the things that shocked us more were the bad conditions of the shared bedrooms (8 beds per room) in front of our operating theatres. Observing around us we knew that our help would always be useful there.

Our main objective was to operate on as many hernias as we could in order to solve the maximum number of cases (we couldn’t solve the sanity of the city but we could improve the life of the people we operated on) and avoid the recurrences. One of the problems we saw was that most of the hernias were recurrent (and when we opened the incisions there weren’t any muscles and tissues anatomy) because of the technique used there (Bassini or sometimes herniorrafy or other incorrect techniques), but our surgeons knew that with the technique we were using, the hernioplasty and others based on free tension techniques, like Lichstenstein’s technique, we could avoid the hernias’ recurrences. That’s why the aim of our surgeons was to teach the Surgery Residents at the Hospital the free tension techniques we used and spread them. In two weeks we couldn’t do much more things, but it was enough for us, we were so satisfied.

During the two weeks we spent there we operated a total of 98 hernias and 17 procedures of plastic surgery, and 13 patients of the total were children. So the biggest volume of patients have been for hernia’s surgery. Among all the hernias we’ve operated on, 52 were inguinal, 23 umbilical, 12 epigastic, 6 crural and 5 incitional hernias.

Marketplace at Ollantaytambo

In addition, I would like to say that not everything was just working. One of the first afternoons we attended to a congress of the General Surgeons Society of Peru, where two of our surgeons gave a Symposium about opened abdomen: Dr Butrón gave the paper about “Negative pressure therapy in abdominal wall wounds” and Dr Castillo “Components separation technique”, both chaired by the Professor Juan Jaime Herrera, President of the General Surgeons Society of Peru. Furthermore a part from surgery and more surgery, we had one Sunday to visit some beautiful corners and squares of Lima and one full weekend that we spent in Cuzco and the lovely Machu Picchu. And for our merit, to conclude our task in Lima, we received the gold medal from the Department of Health of the Peruvian government.

Hernia Tutorial

Return to Malawi September 2012

Hernia Tutorial

Hernia Tutorial

Report on Operation Hernia visit to Thyolo District Hospital, Malawi 8th -15th September 2012

This was my 2nd visit to Thyolo as part of Operation Hernia following a successful trip last year. On this occasion I went on my own but I had the assistance of Francis, one of the clinical officers who was on the course last year. Eight new clinical officers from Thyolo and adjacent District Hospitals attended the course. They already had basic surgical skills and were providing the obstetric service under the supervision of the Senior Clinical Officer Steady Vinkhumbo. I am grateful to Professor Kingsnorth for supplying me with enough mosquito mesh to repair the hernias and enough for many years in the future! I am also grateful to St Anthony’s Hospital in Cheam for assisting with sterilization I took enough mesh, suture material and other supplies to cover the course and subsequent repairs as from last years experience they have very little stock. I would also like to thank my Trust (Epsom and St Helier) for giving me professional leave and Ruthie Markus of AMECA, a charity working in Malawi, for assistance with accommodation.

The trip was coordinated well in advance with the assistance of the District and Local Medical Officer. Francis planned for 8 patients a day in advance but we could have done more this year as I had access to two theatres for much of the time usual NHS story of competing with obstetric emergencies. There was a clinical officer who provided a spinal anaesthetic in the majority of patients. This is an advantage after last years experience when we repaired most of the hernias under LA or regional blocks. African hernias are more difficult than we see in this country and the surgery is definitely easier for the larger inguino-scrotal and recurrent hernias some had had previous darn repairs or herniotomies at the Central hospital!

Each day I attended routine rounds starting at 0800 followed by a teaching session for all staff shame we cannot replicate this at home. Apart from the Medical Officer and a visiting MSF doctor there are no qualified doctors in Thyolo. I would then do a teaching session on hernia surgery that was reinforced on each day of the course. The principle of the course was ‘see one, do one and teach one’ along the lines of Training the Trainers course in UK. I was amazed how quickly the trainees picked up the mesh technique. Each candidate was able to do 2 supervised hernias by the end of the course and we performed some simple herniotomies in children.

It was an intense week and I would strongly recommend providing the course if the opportunity arises. I think it is important to structure it as a teaching course and go back to the same place to provide consistency and encourage sustainability. I was very impressed that Francis was so good at teaching his colleagues within the course environment. It is my intention to return to Thyolo next year.
I also had the opportunity to visit Queens in Blantyre and I hope to run a Thyroid course along similar lines next year. I would be happy to advise anyone who is considering reproducing the course at other sites. Once again many thanks to Andrew Kingsnorth for giving me the opportunity to work with Operation Hernia.

Paul Thomas

Hands on Teaching

Hands on Teaching

Magdi & Professor Narmandakh

3rd Annual Mission June 2012

Magdi & Professor Narmandakh

Magdi & Professor Narmandakh

As a Specialist Registrar in General Surgery, I was extremely fortunate to join the 2012 Operation Hernia mission to Mongolia through the great generosity of the Pitts-Tucker Fellowship. This Fellowship was kindly donated by the JPT charitable trust, which provides opportunities for young adults to travel in the exchange of cultures and to bring delivery of medical facilities in difficult to reach foreign areas, and awarded through Association of Surgeons in Training.

The Mongolian mission was led by Professor Juri Teras (Estonia), together with Magdi Hanafi (British), Fennie Wit (Dutch) and Kristjan Kalling (Estonian Anaesthetist). The Mission was also joined by Vahur Laiapea, a film-maker making a documentary on the Mission for Estonian television. Fortunately the filming predominantly focused on the Estonian speaking members of the trip!

We all met in Ulaan Baatur by Mrs Enkhtuvishin of the Swanson Charitable Foundation, who was again the tireless local co-ordinator for this third Mongolian mission, together with the Chief of the department of Surgery Professor Tsagaan Narmandakh. There was momentary anxiety as Magdy, together with all the meshes, sutures and local anaesthetic for the mission had missed the flight- he did finally make it a day later (minus the local anaesthetic, confiscated by customs). We immediately headed out to the Khustain National Park, a short distance but very long and bumpy drive from the Soviet-style sprawl of Ulaan Baatur into the vaste grassland steppes. Here, the Przewalski’s horse, once extinct in the wild and limited to 12 animals in captivity, was reintroduced via Dutch conservationists. They now number more than 300 in the wild, mostly in Khustain, and we were fortunate to be given a tour of the park by Piet Wit (Fennie’s father) who managed the reintroduction program for many years in Mongolia.

Przewalski's horses in Khustain

Przewalski’s horses in Khustain

The hosts and Operation Hernia Team in Hospital #2

The hosts and Operation Hernia Team in Hospital #2

We returned, inspired and enthused, to the capital for the first part of the mission, in the capital’s Teaching Hospital #2. This hospital has been host to two previous missions, and we were pleased to hear that they have regularly been performing tension-free inguinal hernia repairs in the intervening period, and had almost finished the stock of mesh left over from the last visit. They had arranged a pre-assessment clinic on Sunday afternoon, and we recruited a large number of patients for surgeries over the coming days. Most of these were very large incisional hernias, with many of the inguinal hernias having being performed by the surgeons prior to our arrival. We had access to two theatres with monitoring for general and regional anaesthesia, and a third more basic theatre for local anaesthetic repairs. Parallel cases allowed training to be provided to a wide range of staff, from medical students and residents to staff surgeons. The theatre equipment was very adequate, but all team members commented on the scrub nursing staff who were exceptional. Interestingly, there were some new laparoscopic stacks, and largely re-sterilised disposable laparoscopic instruments which are being used for laparoscopic cholecystectomies.

For the second half of the mission, we headed north, to the town of Erdenet, just a short distance from the border with Russia. This industrial town is centred on the fourth-largest copper mine in the world, and is the second largest city in Mongolia, with around 90,000 population. One specific local problem was that most local community healthcare workers would refer patients presenting with a hernia directly to Ulaan Baatur, an 8-hour journey each way, rather than to the local hospital. As in Ulaan Baatur, we were interviewed on local television which advertised our presence (increasing recruitment) and we hope ultimately serving to validate the surgical department in Erdenet. Unlike Teaching Hospital #2, the preoperative clinic was unscreened, and so we saw a number of interesting and varied non-hernia pathologies, such as penile hypospadias and undescended testes in adults. The hospital in Erdenet was well equipped, with a state-of-the-art high-definition laparoscopic stack in one theatre, whilst one of our patients became the first patient to undergo an abdominal scan in the newly installed CT scanner. The bulk of the surgical workload was inguinal hernia repair, predominantly paediatric. Again, we performed a large number of cases training both staff surgeons and residents. Perhaps the timing of the mission immediately prior to the Naadam festival, a three-day national holiday which sees almost every Mongolian taking to their horse and riding to their local village, limited adult recruitment, explaining the high percentage of children treated!

Wresters warming up at the Naadam Festival

Wresters warming up at the Naadam Festival

Alongside the surgery, we were very well entertained by our always generous hosts and included a concert featuring traditional Mongolian throat-singing. Dr Sanchin, a staff surgeon from Hospital #2, took us to visit his uncle’s ger camp where we sampled fermented mare’s milk beer and cheese, while elsewhere we gorged on an entire stewed goat. The highlight was a visit to the Naadam festival, where we watched Mongolian wrestling (the rules of which I am no clearer about now) and long-distance horse racing over a course of 40km with jockeys aged between 5-8yrs old.Overall it was an excellent mission to a rapidly developing country. The work that Operation Hernia has performed on previous trips was evident, and it is clear than in Teaching Hospital #2 use of tension-free meshes is becoming routine part of practice. Meanwhile I hope that we have provided some teaching and training to surgeons in Erdenet which can be built on during future missions. The success of the mission was due to the extensive planning and organization, both by Mrs Enkhtuvishin and the hosting surgeons, especially Professor Narmandakh- many thanks once again!

Adam Stearns

Indian village life

2-14 June 2012
First Mission to India

Indian village life

Indian village life

Team members: Andrew Kingsnorth, Hans Lechermann from Germany, and David Earle & Lee Farber from the USA.

Regular readers of Operation Hernia reports will recognise the name Dr Ravidranath Tongaonkar (Ravi), the Indian rural surgeon who over the last 16 years has popularised the use of inexpensive mosquito net mesh for the repair of hernias. Operation Hernia (OH) has adopted this frugal technology which offers poor patients the chance to receive a modern tension-free inguinal hernia repair at no increased cost above that normally charged for a far less effective (and painful) sutured repair. Over the last three years OH has applied this technique in over 3000 patients, and in the process has taught the operation to many local surgeons.

The opportunity to work with Ravi was therefore not to be missed. From the start Ravi worked with speed and efficiency to organise a mission for us, which included 8 days of operating (during which we treated over 134 cases), one day of teaching and a long weekend touring the Eloora and Ajanta caves which are India’s number one and two World Heritage sites (with the Taj Mahal in third position!)

To many of us India is an enigma. A once great empire with the earliest written language, non-confrontational religions, a rich cultural heritage and exotic foods – but now crushed by the weight of a massive population explosion which places 800 million of its people into a position of deprivation and subsistence living. India is ranked as 140th in the world in nominal GDP/capita. It has the largest concentration of people (42%) living below the World Bank’s international poverty line of $1.25/day; half of children are underweight and 46% under 3 suffer malnutrition.

Against this backdrop we worked with Ravi in the 50-bed private hospital that he has built up over the last 40 years, and with his colleague Dr Kulkarni who has had similar but more recent achievements, in Shahada, a town about 20 km away. “Private” is used in the sense that the affordable charges provide them and their families a modest standard of living, while a great number of poor patients, without the means to pay are treated free of charge. The hours are arduous: 6 days a week, 24 hours on-call, clinics with 80-100 patients, end-stage diseases in patients aged before their time. To work in such conditions, cheek-by-jowl with in-your-face poverty requires commitment – and this has been solved by making the hospitals a family affair – husband and wife, and more recently son and daughter-in-law have joined the team to provide paediatric, obstetric and anaesthesia skills.

Indigenous village

Indigenous village

Roadside home

Roadside home

We were met at Mumbai airport in the heat and humidity of the pre-monsoon season. It was Sunday, so the traffic was less hectic, with less weaving and dodging required by the ubiquitous tut-tuts, which often had impossible numbers of passengers hanging onto fragments of the bodywork, smiling broadly. Perhaps as a foretaste of rural practice we were taken to a plush, private city hospital with high quality facilities and after a typical, delicious spice-laden lunch , headed onto the expressway (recently repaved) to Dhule, the city nearest to the towns of Shahada and Dondaicha. From the coast we climbed onto the magnificently fertile Deccan plateau, occasionally interrupted by jagged, but low-lying mountain ranges. The soil, which is farmed intensively, is only productive if the monsoon rain falls in sufficient quantity each year – and then each family only derives produce from as much land as it rents (or sometimes owns). Irrigation was widespread for fields of rice, wheat, oilseed, jute, fruits, sugarcane and potatoes.

In Shahada we stayed in a low-cost (750 rupees) hotel, that provided a comfortable bed, air-conditioning (AC), an omelette for breakfast, and stupendous curries after the days work, the digestion of which was eased by the local beer (8% proof). At each hospital we received a wonderful traditional “lighting the lamp of knowledge” welcome with garlands, speeches and photo call for the local media. A typical day involved an 8 o’clock pick-up, patient assessment (using the Kingsnorth Clinical Classification for planning the operating list), followed by a 4-table assault on the 16-20 patients operated on each day. Conditions were basic, clean and efficient, with variable AC. Diathermy was intermittent. Nurses, medical students and the occasional surgeon provided assistance, which made up for the poor lighting. Intraoperative Indian music was a dream – even when accompanied by Dave’s singing! Of the 134 patients, 23 were children; many adult hernias were of more than 10 years standing, most patients were painfully thin. Incidental conversations with the patients through interpreters, revealed the average daily wage for a farmer, labourer or artisan (e.g. a tailor) to be about 100-200 rupees (£1 = 75 rupees).

Street in Dondaicha

Street in Dondaicha

Each evening after the surgery, we were introduced to an aspect of the local community. We visited a village populated by an indigenous community (the constitution of India recognises 212 scheduled tribal groups which together constitute about 7.5% of the population), which felt like stepping back in time a thousand years. We were taken around the local Community College which especially supports the free education of tribal peoples and also housed a Gandhi museum. We hugely enjoyed a Rotarian evening and later had a tour of several of the immense number of projects that the Dondaicha branch supports – including an Eye Hospital with modern-day standards, and a 400 hundred pupil Middle School.

This was an unforgettable trip. Hans, David and Lee worked tirelessly. We travelled long distances together and observed many aspects of India which we enjoyed with humour and good companionship. I think that I will have no trouble in recruiting next year’s team for India

Andrew Kingsnorth

June 2012