The team prepare to set off from Accra on the journey to Takoradi

Operation Hernia Report: November 2015 Mission to Takoradi, Ghana.

On the 21st November our team of six began our journey to Ghana. We comprised two consultant surgeons, Shina Fawole and Chris Macklin, a consultant anaesthetist, Josie Brown, a paediatric theatre sister, Lisa Macklin and two surgical registrars, Steve Pengelly and myself. We arrived in Accra on Saturday evening and spent the night at the Baptist Guest House before setting off for Takoradi on the Sunday. We managed to sneak in a trip to the beach on the Sunday and prepare for what turned out to be a very busy week of operating.

The team prepare to set off from Accra on the journey to Takoradi

The team prepare to set off from Accra on the journey to Takoradi

We spent the next five days operating at two hospitals in Takoradi; the Hernia Centre and the Ghana Ports and Harbour Authority (GPHA) Hospital, both of which have hosted Operation Hernia teams many times in the past. The patients had been selected prior to our arrival, coordinated by Dr Boateng, Chief Medical Officer of GPHA Hospital, which meant that there was no hanging around on the Monday and we were able to dive straight into work.

Over the 5 days, across the two hospitals, we operated on a total of 83 patients, including 8 children. In total, as a team we fixed 72 inguinal hernias, 7 other hernias (umbilical, epigastric and incisional) and 4 hydroceles. Needless to say, fitting in these numbers meant long and intensive days, and the local theatre staff and nurse anaesthetists worked incredibly hard to ensure we were able to get through all the patients. There was never any question of not sending for the next patient.

The Operation Hernia team plus the local staff at the Hernia Centre in Takoradi

The Operation Hernia team plus the local staff at the Hernia Centre in Takoradi

As previous volunteers have already attested to, the hernias seen were much larger than those commonly seen in the UK, meaning that the operations themselves were more challenging (and fun), particularly given the variability of the instruments as well as the occasional black out. The main difference was seeing the impact that our service had on the patients. With large hernias, many patients were unable to work and thus, a hernia repair can mean a return to work and the opportunity to provide for their families.

Operation hernia was an amazing and invaluable experience. Aside from the operative experience, it provides an opportunity to see and experience a different culture and provide new insights into our own practise. I am grateful to the other members of the Operation Hernia team and the local staff for making the experience so enjoyable and worthwhile. Special thanks has to go to Shina and Chris for their patience in training which enabled me to operate on large and challenging hernia, and to Lillian and her team who fed us remarkably well (considering the lack of electricity at times) during the trip.

Emma Upchurch, General Surgery Registrar

Missions

REPORT FROM HO MISSION NOVEMBER 14-21, 2015

This was the third Operation Hernia mission to Ho Hospital. The first mission was in 2012.

The team comprised the following members:

Coordinator: Miriam Adedibe Surgical Registrar;

Consultant Surgeons: David deFriend, Prof Guido Schuermann, Prof Odd Mjaland,

Surgical Registrars: Naami MCaddy and Sebastian Galler

Travel to Ho

Following arrival in Accra the team stayed overnight at the Baptist Guest House in Accra on November 14. All team members met with Chris Oppong for a briefing. The team travelled to Ho hospital the following day. They were met by Dr Geoff Nyamuameh, senior surgeon who took the team on tour of the hospital.

Accommodation and food

We enjoyed very good accommodation. We were hosted at Chances Hotel. This was specially arranged by Dr Ben Gbeve, a retired Plymouth Orthopaedic Surgeon whose nephew owns the hotel.

Theatre Sessions

We occupied three theatres for 4.5 days. One consultant and one junior were assigned to each – this allowed for maximum teaching. The 4th theatre was left for Ho Hospital to fulfil their emergency commitments.

It could not have been used as an extra theatre because it was impractical for us to do so due to:

1) A paucity of simple cases

2) Equipment/sterilised packs – Sister Lucy was struggling to equip the three theatres already running

3) Low staffing – again, Sister Lucy and the nursing staff pulled together and worked beyond their usual hours to complete this mission.

Outcomes

The total number of procedures performed was 80 and there were no early complications.

Post-operative patient reviews on the ward were performed by one of the visiting team when time allowed, otherwise the home team managed the patients.

Home Visit

As a first by the Operation Hernia team, 3 patients were visited over Friday afternoon and Saturday morning at their homes. The patients were happy to see the team and it was a wonderful opportunity for Operation Hernia to see the patients in their home environments.

This excellent idea had been suggested by Prof Guido Schuermann.

Debrief

1. Safety issues highlighted by team members included: sharps handling (scalpels should be handed over in a dish), swab count (not rigorously performed for each operation)

2. Worn-out needle holders

3. Diathermy: worn out accessories

This first section of the report was coordinated by Miriam Adedibe. Individual Team Members have provided their own additional comments and these are detailed below:

1. Prof Guido Schuermann

The Ho mission was a great success. The team was just perfect and it was very helpful that Naami and Miriam were with us. The hospital was well equipped and we could run three operating theatres for the whole week. We did more than 80 cases – most of them with huge hernias – without any major complication perioperatively.

The staff were excellent, highly motivated and very well trained. The hotel was the best I have ever seen in Ghana, all making it a very enjoyable and successful mission.

I thank the whole team for taking Sebastian and myself, for the friendly atmosphere and for the collegial and friendly exchange of ideas. It was just a great week!!

2. Miriam Adedibe

I fully echo Guido’s sentiment. The mission was a success in every way.

We completed the list of hernia repairs, totalling 81 cases, and most of these were relatively complex H3 cases. Many thanks for supporting me as the administrator/team leader. It was an unexpected opportunity from which I learned much. The team worked well together and were very helpful with suggestions on how to increase our efficiency in theatre. A special thanks to David (whose seniority and expertise was invaluable in many situations) and Naami (my co-pilot).

3. David deFriend

I can only say what a privilege it was to be part of such a great team and to have the chance to work with wonderful local staff and patients. Thanks to Miriam and Naami for organising us so well and for the report. I can’t think of anything to add except to say that I very much intend to go on another mission and would be honoured to work with all or any of you again. It went by so quickly that it almost feels like I never went away now that I’m back to the day job!

Chris, thanks again for the opportunity and it was great to see you.

4. Odd Mjaland

I am filled with great memories of a fun an interesting mission and happy to have made such nice friendships at my mature!!!! age. I felt young and revitalized when getting back to the frozen lakes and minus 7 in Norway. The cases were challenging but as I see it, the quality of our work could not have been much better. Working close with Naami was inspiring, the trailblazing energy of Miriam gave the group an energy boost that lasted long beyond the flight back home. I shall be back!! Miriam’s report covers our mission well and I would echo the comments about the problems with worn-out needle holders and diathermy equipment, areas for potential improvement.

Missions

November 2015 “Operation Hernia” Mission to Bole, Ghana

Visiting Team

John Budd – Team Leader – Vascular and general surgeon

Anna Budd – Theatre nurse

Graham Howell – Urologist and previously a general surgeon

Rosemarie Howell – Theatre nurse

Travel Itinerary

Direct BA flight London Heathrow to Accra arriving 21.30 on 14th November

Overnight stay in Accra at the Baptist Mission Guest House. Meet, greet and brief with Chris Oppong and teams heading for other destinations.

Nissan 4×4 road transfer to Bole: depart Accra 06.00 and arrival at 16.00

Return to Accra by road on 21st November with wash up at the Guest House and return flight to London departing 22.00

Accommodation

The Cocoa Research Institute Guest House ½ mile from the hospital in Bole provided comfortable and clean accommodation with full board and air conditioning if required. Morning pick up was at 07.30 and return at 19.30.

Surgical Achievements

The team carried out 112 elective procedures in 97 patients as follows:

Adult Inguinal hernias 61 Inguinal Herniotomies (children) 15

Femoral hernia 1 Umbilical hernia 1

Hydroceles 18 Epigastric hernia 2

Lumps and bumps 8 Minor ano-rectal surgey 1

Four Emergency procedures were also performed:

Laparotomy and splenectomy for trauma

Appendicectomy for gangrenous appendix

Laparotomy and repair of perforated distal ileum for blunt injury

Caesarean section and tubule ligation

Training

Basic surgical training and some surgical skills were imparted to Dr Asiz and Dr Gerald, two newly qualified general doctors.

Nurse training included theatre skills for the nurses and concept of swab count for laparotomies.

This was a return trip to Ghana for John and Anna and a first visit for Graham and Rosemarie – deferred by the West African Ebola epidemic the previous year. The plan had been to visit Keta on the coast but there was a greater surgical need in Bole despite another teams endeavours the previous week, and we headed up country in the Bole Hospital Nissan pick-up truck on metalled roads. The 50 miles of potholes and craters on first leaving Accra had fortunately been resurfaced since John and Anna’s previous visit 3 years ago. The 10 hour journey was remarkable by its near misses and our passing 19 overturned lorries en route.

We had very comfortable and clean accommodation in the Cocoa research institute guest house and the food was a very pleasing combination of local and European fare.

We were warmly welcomed by the hospital director and the theatre and ward staff. Our surgical day began on the ward each day soon after 7.30 with a pre-operative examination of the day’s patients with surgical marking and a review ward round for those who stayed overnight on day 2 onwards. We used both operating theatres available. Each is now equipped with effective air condition units which made the operating environment quite comfortable. We were most impressed by the ability and humbled by the enthusiasm of all the theatre team.

There were two very capable and experienced nurse anaesthetists – Vitus and Michael. The strategy was to use spinal anaesthesia for the adult patients with very large, irreducible hernia or large bilateral problems whilst the children were given IV Ketamine. There was a modern anaesthetic machine in the main theatre and pulse oximetry and Valley Lab/Eschman diathermy units in both theatres. The laparotomies were done under GA and the Caesarean section under spinal anaesthetic.

John had brought a substantial supply of disposables including mesh, syringes, needles, local anaesthetic, sutures and diathermy pads/pencils. The BMI Bath Clinic had kindly supplied the bulk. It would have been difficult to have managed without the imported supplies and the hospitals own resources were preserved as a result.

We were assisted for some of the operations by Dr’s Asiz and Gerald who were recently qualified doctors with an interest in surgery and there was some time to help them with surgical skills . Dr Joe, the Hospital’s resident doctor, was very supportive and we were fascinated to hear of his WHO secondments to Liberia as part of the Ebola effort and to Ethiopia with the Polio eradication programme.

Some of the hernia repairs were challenging and very worthy of our visit. The diathermy finger switch devices tended to degrade with recycling and we encountered a diathermy pad burn for reasons which weren’t immediately obvious. We had no returns to theatre but disappointingly our splenectomy patient failed to regain renal function post-operatively and died of multi-organ failure within 36 hours. It was a busy week of operating made light by the enthusiasm and hard work of the Bole staff. There was a very positive ambience in theatre and laughter reminding us of the surgical careers of our youth.

Anna and Rosemarie visited the local market on Friday morning kindly escorted by Agatha, one of the theatre nurses, to help with the robust matter of negotiating prices!

We spent our evenings in the guest house discussing how best to resolve the world’s problems but failing somehow to reach a solution. Our final evening in Bole involved a great send off by the theatre team in a down town hostelry and our introduction to BBQ’d chicken gizzards. We were honoured to receive traditional headman’s robes. We renewed and made friendships and look forward keenly to a return visit.

Graham Howell 29/11/2015

Missions

TEAM REPORT FROM NALERIGU MISSION: NOVEMBER 7-14, 2015

This was a good mission to the Baptist Medical Centre at Nalerigu in Northern Ghana. This mission was significant for the fact that the second Guido-Cordula Fellow, Dr Mohammed Bukari was a member of the team.

Team Leader: Chris Oppong

Members: Nazzia Mirza (Consultant Surgeon), Sandra Stanton (Theatre Nurse), Dr Mohammed Bukari (Surgical Registrar at Komfo Anokye Teaching Hospital).

Travel November 7, 2015

The team stayed overnight at the Baptist Guest House in Accra. The hour’s flight to Tamale, Ghana’s northern city, on the following day was seamless. This was followed by a 2-3 hour journey to Nalerigu in a hospital 4Wheel Drive vehicle. The road was in parts very bumpy!!!

Accommodation and food

We were provided with very good accommodation. Food was provided by a local chef who would do extremely well on the UK “master chef” TV programme. The accommodation is set in a leafy area of the hospital compound which also houses hospital staff. The morning walk from our accommodation to the hospital was an enjoyable experience. Wi-Fi was available in the “business office” but there were some issues with the network

Theatre Sessions

We met with the whole of theatre team. This was to affirm each member of the theatre team and share our ethos for the week: team work to deliver quality treatment to as many patients as we can manage with compassion and efficiency. We were all encouraged to wear name bands to help with integration of the team and to break down barriers. The WHO check list was used in parts. The whole team worked as a family. The nurse anaesthetists were excellent. The theatre lead and all the staff were very cooperative.

Training

The Fellow, Dr Bukari, was trained in mesh repair and performed 15 procedures independently in addition to 5 procedure performed assisted by a Consultant as part of his training.

Outcome

Total number of procedures performed was 49 (Hernias 43, including 11 herniotomies in children (26% of hernia patients); Hydrocoeles 4; Lipoma 1; with one return to theatre. Many more patients would have attended for surgery with improved communication and organization.

Post-operative complications

We had only one early complication. A poorly nourished adult male became septic after repair of a large scrotal hernia. He was returned to theatre for evacuation of scrotal haematoma and made a good recovery.

Debrief

A most important final event was a closing debrief meeting of all theatre staff and medical staff, including the Medical Director. There was an open, honest feedback from both the hernia team and the theatre staff. The highlights of the feedback were the following points:

1. The hard work of all team members was acknowledged and commended.

2. There is a need to improve communication with all hospital staff during the planning stages of future missions. This will facilitate better recruitment of patients.

3. Theatre requirements could be more effectively communicated to hernia team.

4. Decontamination and sterilization of diathermy pencils and cables was reviewed. It was agreed the pencils and cables would be cleaned with antiseptic and sterilised in antiseptic solution until required for surgery.

5. The hernia team thanked all the theatre and medical staff for the support received.

6. A group photograph was taken to remember the mission.

Chris Oppong

Consultant Surgeon and Chairman, Operation Hernia

OPERATION HERNIA MISSION: 6TH – 13TH JUNE 2015. KETA, GHANA

So the journey started with three of us meeting at Heathrow Airport on the flight to Ghana; Andy Clarke (Consultant Colorectal Surgeon and team leader), Alex Clarke (A-level student), Dimitri Pournaras (Oesophagogastric Surgical Registrar). A few hours later we landed in Accra. A short taxi drive to our accommodation where we joined Arun Ariyarathenam (Final year Oesophagogastric Registrar) and the team was complete. It was already clear that it was going to be a great week and we were filled with anticipation and excitement as well as apprehension for the unknown for those of us who was doing this for the first time.

The next morning we set of for Keta, having met David, our driver. A man of a few words, but of incredible commitment to the hospital and personally to us. He made it very clear that it was his DUTY to ensure that we were safe and comfortable even if that meant that he would drive us back from the hospital at 22:00 after a long day. But more of this to come…

The route to Keta is scenic and is a great reflection of rural Africa. David’s African music made it even more atmospheric. Having arrived at our accommodation and settled, we went to the hospital for a tour of the facilities and the first introduction with the staff.

Keta Hospital is a local general hospital with three operating theatres. Surgical services are provided on an ad hoc basis with the medical staff being mainly general practitioners with some of them having a special interest in surgery. Caesarean section is the most common operation and other procedures are performed depending on the availability of the more experienced surgeon.

There had already been a campaign on the radio inviting patients with symptoms suggestive of hernia, highlighting the fact that treatment would be provided free of charge by Operation Hernia. The local doctors assessed most of the patients during the previous weeks.

The next morning, after an early breakfast, David drove us to the Hospital. We reviewed the first patients. The challenge was assessing without knowledge of the local language and often using a translator. Considering other types of medical or surgical intervention, hernia is more straightforward to assess in this type of setting where there is a language barrier. The hernias we saw were as expected reflective of rural Africa surgical practice. Very large inguinal and inguinoscrotal hernias in thin individuals, almost exclusively male doing intensive labour work was the most common pathology encountered. It soon became apparent that some of the patients will need to be postponed as they were unfit for surgery mainly due to malaria and uncontrolled hypertension. Knowing that another mission would take place in November and therefore these patients could be safely operated a few weeks later makes the decision-making easier and underlines the importance of establishing recurrent missions in the same region.

The anaesthesia used was either local anaesthetic or spinal anaesthesia provided by the experienced anaesthetic nurses. Their practice was very efficient with a quick turn around and we soon agreed to use spinal anaesthesia more liberally allowing us to take on some more challenging cases and also reducing operating time and maximising our capacity. There was definitely no lack of hernias in Keta!

The apprehension of operating in a different setting, miles away both geographically and culturally from the NHS, faded away at the first “knife to skin moment”. The operating table was low, the operating light was weak and unreliable due to unexpected black outs (we found the headlight used by cyclists very useful!), most of the instruments were worn out and occasionally inappropriate for the type of procedure we were performing with wide variation in the contents of different sets identically labelled. The scrub nurses were extremely keen to help and also learn from our practice. And their enthusiasm made up for any deficiencies.

As soon as we started operating we realised that the operating is pretty similar wherever you are doing it. We tried to use all three operating theatres “taking over” the entire capacity of the hospital and challenging the local team and ourselves. The patients kept coming… We were determined to deal with as many as possible if not all, but keeping safety as our primary concern. On Tuesday we could see that we would be overwhelmed. We performed 20 hernia repairs on that day finishing after 10pm. We had to defer some patients for the next day and we were reassured that the patients would be looked after. What was surprising for all of us was than not a single patient complained. They all stayed, most of them spending the night outside as they were travelling from far, and were very grateful to be operated the next day…

Nights were spent in the local hotel having been driven back by David. Reflection on the day’s activities and plan for the next took place over dinner. A special moment was Andy sharing stories about Shorland Hosking with whom he had a personal and professional relationship.

An effort to include training as an important part of the mission remained a priority. The local doctors found it challenging to attend the operating theatre due to their other clinical duties. However, when they were with us teaching of basic surgical skills, principles of surgery and the technique of tension-free mesh repair of inguinal hernia using were provided. We also used every opportunity to teach the two visiting medical students from Spain, scrub nurses, staff nurses and nursing students.

By the end of the second day the scrub teams were getting used to us, some of the training was paying back and the teams were working as a well-oiled machine. Most of the time… The focus on safety we are accustomed with in the NHS was not the norm in Keta, and this is completely understandable in a healthcare system which is overwhelmed and where the focus is to provide the best possible treatment in the largest number of patients accepting a risk for specific individuals.

What became apparent to us was the desire of members of staff to introduce safety measures, to improve quality, to learn. Doing operations without a WHO checklist felt initially surprising and eventually unsafe. We discussed with different members of the teams and it transpired that they had similar concerns, the most acute being the fact that swabs were not counted. Anecdotes of errors and near misses were shared. We identified the limiting factor was the lack of white boards. Making sure that everyone was in agreement including the management of the hospital we managed to buy three boards on the Friday, our last day. Within minutes they were on the walls with the aid of the estates team. By that time the team were very excited. We did the first procedures using the WHO checklist with needle, instrument and swab count on our last day.

We finished on Friday when all available patients had been operated on. Sixty-five hernia repairs were completed. We left the next day with great memories. We are grateful to the medical and nursing staff of Keta Hospital and Operation Hernia. Special thanks for the Shorland Hosking Fellowship.

Arun Ariyarathenam

Alex Clarke

Andy Clarke

Dimitri Pournaras (Shorland Hosking Fellowship)

OPERATION HERNIA MISSION: 6TH – 13TH JUNE 2015 – TAKORADI, GHANA

TEAM LEADER – ADESHINA FAWOLE (CONSULTANT SURGEON)

TEAM MEMBERS – RUPA SARKAR (CONSULTANT SURGEON), RAJIV DAVE (REGISTRAR), ZOE SUN (REGISTRAR), MELANIE PRECIOUS (ADVANCED ODP, TEAM LEADER), CLAIRE CASEY (ODP)

Report by Zoe Sun

This was my first time Africa and first time with the mission, led by mission veterans Mr Shina Fawole (Team Leader and Consultant Surgeon) and Melanie Precious (Advanced ODP and Surgery Team Leader), along with my fellow colleagues Miss Rupa Sarkar (Consultant Surgeon), Rajiv Dave (Registrar) and Claire Casey (ODP). The mission was in June, the rainy season, rather than its usual time in November. We carried with us medical supplies for the duration of the mission including medications, local anaesthetic, mesh, syringes, needles, sutures, gloves, gowns and hats. With all these, we met at the airport ready for our mission led by our team leaders.

We arrived in Accra, Ghana on the evening of 6th June and stayed overnight in Accra. The next day, the taxi driver took us on a 4 hour journey to Takoradi. We stayed in a house owned by the local government and used specifically for teams on the mission. Lillian and her team of helpers stayed with us and looked after us during the mission. They did all the hosting, cooking and general maintenance. We visited one of the hospital sites in Dixcove and greeted the local team of nurses and doctors. Next to Dixcove was a tranquil, unspoilt beach where we shared a few drinks and a group photo and Mr Fawole taught us the suture-sparing mesh repair technique for hernias! The same night, Dr Bernard Boateng, Medical Director of GPHA (Ghana Port and Health Authority) Hospital, greeted us at the house. He and his team had assessed the patients locally and planned their operations and their respective hospital sites for their operations. We decided on the order of week and how to split the team along with Dr Boateng.

Monday was the start of the testing week. We based ourselves in two hospitals in Takoradi, Takradi Hernia Centre and GPHA into teams of three. Introduced to the local friendly and very outspoken team of nurses and ODPs, we started on our operations. The caseload consisted of primary and recurrent inguinal hernias, hydroceles, umbilical hernias and children with groin hernias. On average, there would be 8-10 cases per day. Most hernias were operated on under a local anaesthetic; recurrent and larger hernias had spinal anaesthesia, which the local anaesthetic nurses specialised in.

The challenge initially was with the size of the hernias and their chronicity. The rule was not to open the hernia sac if possible, but only Miss Sarkar stuck by this rule, we later found. After the first day, we divided ourselves in teams of two for each of the three sites, with those at Dixcove travelling an extra 2 hours return journey on a daily basis. We were faced with additional challenges, with power cuts and during a longer power cut, we learnt to operate under a torch light. We were also faced with shortage of running water, for which we were provided with water from a tank for scrubbing. At Dixcove, the same theatre was shared between elective and acute cases. Whilst we were carrying out our operation on children, two emergency Caesarean sections came through back to back. The operating tables adjacent to each other, we would be placed in the in stifling conditions when our local colleagues performed the emergency Caesarean sections.

The children were extremely compliant as were the adult patients. The nurses were outgoing and outspoken. Lilian and her helpers were extremely responsive to our needs back at the house. The people in general were very friendly and helpful. One young man, a patient, thanked us profusely as he could now find a wife now that he no longer has a deformity (his hernia). On the last day, we ended the day, altogether at the Hernia Centre with Dr Boateng, and had a group photograph to mark our time there. Many of the staff, were desperate for our return on following missions and explained how much they enjoyed our times together. We were greeted later in the house by politicians who were grateful for our work and wanted to improve the host’s programme for later groups and to include organised sight-seeing. We thanked Lillian and her team for their hospitality before embarking on a return journey to Accra the following day.

I was extremely grateful for this experience, learning not just about operating, but about people and cultures. I learnt that some aspects were not a good mix for my team members…Mel and cockroaches, Mr Fawole and Raj sharing a room, Miss Sarkar and ‘vegetable free’ foods, Claire and any Ghanaian foods. However, the team was fantastic, the experience invaluable. I have learnt a lot about myself, others and the skills I will carry forward in my future training and life thanks to Operation Hernia and my team leaders.

Zoe Sun