Report of Operation Hernia’s Mission to Ho Volta Regional Hospital
November 2013

The Stats!

Location

Volta Regional Hospital in Ho, located in the Volta Region to the west of Ghana
Approximately 3 hours drive from the capital city, Accra

Personnel

From the UK: 3 consultant surgeons, 2 surgical registrars, one scrub nurse
Charge nurse Sister Josephine, who managed everything!
More than 10 theatre staff who rotated between recovery and theatre
Experienced anaesthetic nurses who could give spinals faster than we could scrub!

Patients

98 patients were recruited, 97 patients operated

Facilities

Initially three theatres, with the fourth emergency theatre being made available to us on the final 2 days.

Fixed operating lights and mobile lights
Sutures, gloves, instruments and mesh were brought by the team
2 diathermy machines present from previous trips, we brought a third
Unfortunately no air conditioning was available due to maintenance

Hospitality

We received 5-star treatment from hospital administration and theatre staff
Food and water between cases
Constant care and attention to our every need!

The Story

We congregate at the Baptist Guest house prior to departing to Ho. We meet Mr Oppong who has already arrived early, full of energy and knows everyone’s name. We all feel instantly special. We meet Bernard our hospital representative, who has already been coordinating things behind the scenes. A quick breakfast is followed by us loading up into our respective vehicles and the journey to Ho begins. It a beautiful 2.5hr trip, but one full of contrasts. The beautiful lush landscapes give way all too frequently to little townships, were the even from our vehicle we can see the poverty that so many live in. Grand buildings are side by side with mud huts, small mansions next to tin shacks. Our driver is enthusiastic, and often has to be reminded that we are not thrill seekers. The road is in relatively good condition with the usual perils of overloaded motorcycles, formula one-esque taxi drivers and the ubiquitous tro-tro (public minibus).

Our prayers are answered and we arrive safely at our accommodation. Our residence can only be described as beautiful. To say more would be to tempt you to join the mission for all the wrong reasons!

After a brief lunch we visited the Volta Regional Hospital. We meet the director of surgery, his administrator, head of finance and a senior surgical resident. We are welcomed into a conference room as if we were visiting dignitaries! After introductions and a heartfelt welcome it is time to see the rest of the hospital and staff. It’s a relatively new building, we are told as we walk around. All the buildings are bungalow style sprawling as far as eye can see. Fortunately the walks between the buildings are shaded. The first thing commented on however by our senior visiting surgeon was the ample parking available. I think this alone made his day!

On to the ward to see the patients preoperatively. They have been selected over a period of months, and are eagerly awaiting our arrival. As we enter the ward they have been patiently waiting for us and applaud spontaneously. After a warm welcome by the ward sister, complete with crushing hugs, we begin to see the patients. All the patients are admitted the night before surgery. We reviewed 21 patients, there was only one DNA. What impressed all of us was how organised the nursing and medical teams had been. From blood results to simple clinical notes, everything was in place, and we were able to review and assess all the patients in just over an hour. An impossible feat in the UK! We returned back to our accommodation in the evening, arms full of food that had also been gifted to us.

The week is made up of grueling 15 hours shift days where we operate, ward round, clinics and data collect tirelessly, whilst supported by the brilliant hospital staff, who do overtime to allow us to finish the cases. Our fatigue is quickly forgotten when we see the gratitude of the patients when their operation is completed. Most have travelled many miles to arrive, and wait patiently for their turn with no complaints.

We were pleased to finish all operations successfully on Friday with no complications. We were rewarded with our first social night out where we went for dinner and drinks, dressed in traditional wear that had been gifted to us by the Hospital staff. We left the following day, all of us promising to return the following year!

Special Thanks

To all the theatre staff at Volta Regional Hospital, Bernard, and Mr Chris Oppong.

Miriam Adedibe

Naami McAddy

Missions
November 2013

Itinerary

We met up in Accra and were driven in the Bole Hospital vehicle to Bole on 3 November – about 10 hours journey. We were housed at the Cocoa and Shea Research Institute Guest House for the duration of our stay. We were served breakfast and dinner every day. Lunch was usually provided in theatre. We returned to Accra on 9 November and to our respective homes thereafter.

Activity

Work started with team briefing usually about 07.45 and finished with team debriefing at about 18.30-19.00 hours most days. Prior to our arrival, patients were invited through radio broadcasts to register for surgery. We understand that a total of 205 patients turned up during the week. Of these, 101 patients underwent a total of 126 procedures during the five-day working week. The vast majority of the procedures were performed under local anaesthesia, with a few under spinal and five children and one adult lady under GA. The procedures performed were:

HERNIAS 85

HYDROCOELES 39

EPIDIDYMAL CYST 1

EXCISION OF TUMOUR 1

TOTAL 126

Miscellaneous

The local hospital doctor joined Mohan most days and obtained experience in performing some of the procedures.
The theatre team was well motivated, hard-working and very efficient.
The operating light in theatre one was very dim making visibility difficult.
There were two episodes of power outages on the first day with operations being completed with the use of torch lights.
There were no critical incidents.
One patient who underwent repair of bilateral inguinoscrotal hernias under spinal developed scrotal haematoma and was still an inpatient at the end of the mission.
The hospital donated traditional attires to visiting surgeons as sign of appreciation.

Recommendations

Arrange activity to coincide with times when demand for farming is less, for example, November and February. The heavy turnout during this trip might have been due to the diminished demand for farming at this time.
Mission activity should be extended to a period of two weeks to ensure maximum coverage at peak periods. The two week period might be covered by two separate teams if necessary.
Bole District Hospital would appreciate the donation of any medical equipment including a functioning theatre light.
Local doctors in the Northern Region of Ghana could be invited to participate and learn how to repair hernias during missions.

Missions
November 2013
Mission to Takoradi

The team arrived in Accra on the evening of Saturday 2nd November 2013. As a registrar in General Surgery this was my first trip with Operation Hernia, but I was travelling with experienced Operation Hernia member Melanie Precious and fellow first-timer Nicola Perrin, both Operating Department Practitioners, along with a large supply of surgical and anaesthetic equipment. The rest of our group comprised of Chris Macklin (Consultant Surgeon), Jurij Gorjanc (Consultant Surgeon from Austria and President of the Slovenian Hernia Society), Khaled Ismail (Consultant Anaesthetist), Beverley Parker (Registrar in Anaesthesia), Rafay Siddiqui (Registrar in General Surgery), and our team leader Shina Fawole (Consultant Surgeon), on his seventh Operation Hernia mission to Takoradi.

After a late-night dinner and an initiation to the unconventional practices of Ghanaian taxi drivers (including rolling backwards down the hill to start the engine, and opening the passenger side door to get the radio to work!), we spent our first night in the comforts of the Baptist Guest House. After a minor drama with an early-morning altercation between Melanie and a cockroach (“don’t you dare come any closer to me…!!) we set off on the three and a half hour minibus journey to Takoradi. We received a very warm welcome from our host Lillian and her helpers at the villa in Takoradi, and they even arranged a solar eclipse to mark our arrival! After unpacking our medical supplies we spent a relaxing and enjoyable afternoon at the Busua Beach Resort. In the evening we were visited by Dr Bernard Boateng, Chief Medical Officer of the Ghana Ports and Harbour Authority (GPHA) Hospital, and the plan for the week was set out.

On Monday morning the hard work really began. Each day a team of between two and four of us travelled to Dixcove Hospital, GPHA Hospital and the Takoradi Hernia Centre. The patients had been assessed and selected by Dr Boateng beforehand, and after a brief ward round to review all of the patients for the day, and decide on the most appropriate anaesthesia, the list started. We were warmly welcomed at all three hospitals, and worked alongside the local theatre teams and nurse anaesthetists, who were particularly skilled at spinal anaesthesia. Between the teams we operated on 105 hernias and 7 hydroceles in 107 patients, including 19 paediatric patients and 6 patients with recurrent hernias. Fifty-seven patients were operated on under spinal anaesthesia, 24 had a local anaesthetic and 26 had a general anaesthetic.

The days were long and intensive, but it was undoubtedly worth all the hard work to be able to achieve so much in just 5 days of operating. The impact that we were having on the patients was clearly apparent; I particularly remember one elderly gentleman who had travelled for nearly twelve hours to have his hernia repaired. The children were amazingly brave and compliant, not a word of objection or a tear from even the youngest ones. On one of the days at Dixcove Hospital, a local surgeon attended our list, and we were able to show him how we use the hernia meshes to reduce the recurrence rate for inguinal hernias. As a team we were fortunate enough to have both a Consultant Anaesthetist and a very skilled Anaesthetic Registrar with us, and as well as enabling us to operate on more children by means of general anaesthesia, it was also clear that the local nurse anaesthetists benefited from the training and advice they provided. Likewise, our experienced Operating Department Practitioners, Melanie and Nicola, were able to work alongside, and pass on their expertise to, the local theatre staff.

But it was not just the patients and the local theatre staff who benefited from our mission. All of the Operation Hernia team members gained invaluable experiences from the trip, which provided us with insights into our own practices in the UK and an appreciation of our own privileged situations, as well as improving our ability to adapt to challenging situations and make the best possible use of the minimal resources available. We are all especially proud of Melanie, for mastering the art of the scrotal bandage, after what was, it has to be admitted, a rocky start! As a group we are very thankful to Shina for his guidance, support and unwavering encouragement, unperturbed by any obstacle, apart from those baby lizards! Despite problems with an intermittent water supply, Lillian and her team ensured that we were comfortable, well fed and well looked after for the whole week, and we all appreciate her efforts.

From a personal perspective I feel very privileged to have been given the opportunity to be a part of such a fantastic, life-changing organisation. I am grateful to the other members of the team who were all wonderful colleagues and companions, and who provided much friendship, support and laughter. As a trainee surgeon I am particularly grateful to Chris, Shina and Jurij, whose patience and skill in training enabled me to operate on more challenging hernias than I have ever encountered before. I hope that I will continue to be involved in future missions with Operation Hernia.

Hannah Welbourn, ST8 General Surgery

Mission to Nalerigu Baptist Medical Centre
October 2013

Ghana was a very beautiful country. The people were very welcoming, we really felt like at home. The capital Accra is a big nice city. Almost all of the people speak English.

The surgical team comprised two consultant surgeons (Prof Guido Schuermann, Germany and Mr Chris Oppong –Lead, UK), two registrars (Ahmed Elmeghrawi, Germany and Miriam Adedibe, UK) and a nurse Kristina Horvath from Switzerland. Prof Guido was accompanied by his wife. Dr Zainab Alhassan, a surgical trainee from Komfo Anokye Teaching Hospital, in Kumasi Ghana, was sponsored under a new Operation Hernia Ghana Fellowship scheme to join the team for training.

Travel:

Most of us travelled on Portugal Airlines PTA and stopped over in Lisbon before connecting to Accra, Capital of Ghana. Mr. Chris Oppong and Miriam had arrived few days earlier.

We were met at the airport by Mr. Oppong and stayed overnight at the Baptist Guest House. The next morning we flew to Tamale in Northern Ghana and from there went by hospital 4-wheel drive to Nalerigu a journey of a couple of hours. Most roads were mostly tarred but one had a bumpy segment that was not tarred.

Hospitality:

We were warmly welcomed by the Manager of the Guest House in Accra. The accommodation was basic but comfortable. All our needs were met.

In Nalerigu Baptist Medical Centre we were housed on the hospital grounds in comfortable houses set in a picturesque setting of trees. The houses were well furnished. It was a pleasant surprise. The food was delicious, available at three times daily, breakfast (serve yourself), lunch & dinner.
Theatre staff:

There were at least 4 trained nurses and 2 auxiliaries. We had 2-3 anesthetists each day. They offered a good service. All the staff were competent. The anesthetists were skilled in spinal anaesthesia and were committed to quality patient care. The staff were very cooperative and helpful. The intensity of work we asked for was demanding, but they tried to cope. Most of our days ended after 4 pm. Perhaps the scene was set for such cooperation by an engaging speech made by Mr Chris Oppong and Prof Guido when we met the all theatre staff at the beginning of the mission.

Facilities:

2 theatres, one minor surgery room, one changing room, the sister’s office, a stock room, a sterilization room with one autoclave. One of the theatres was very large and was split into two theatres when required, e.g. when they had a Caesarean section. Each theatre had the following facilities:

Theatre table: old but functioning.
Anaesthesia machine: we didn’t use it, because of lack of oxygen cylinder.
Monitor: which was modern.
Ceiling theatre lamp: in only one theatre.
Standing lamps which had poor focus.
Air conditioner worked in both theatres.
Diathermy machine: in both theatres.
Surgical instruments & supplies: were adequately provided.

All theatre gowns, surgical drapes and gloves were provided by the hospital.

Outcome:

We operated on 44 patients and performed 46 procedures. This is a credit to the theatre staff for being willing to work hard to ensure that no patients were cancelled because of theatre time. All hernias were graded using Kingsnorth Grading and all operations were entered into Operation Hernia Database.

All hernia repairs were performed with affordable mesh, and all patients received perioperative antibiotic-prophylaxis (one single shot at induction), then regularly for 5-7 days. Most of the operations were done under spinal anaesthesia (apart from two inguinal hernias in which the repair was done under local anaesthesia).

Training:

For the first time Operation Hernia sponsored a local surgical trainee on a new scheme called the Operation Hernia Ghana Fellowship. The purpose of the scheme is to fund Ghanaian doctors to join Operation Hernia missions to gain more experience in Mesh Repair. The scheme was pump primed by a generous donation from Prof Guido Schuermann and was very successful. Operation Hernia is grateful to Prof Schuermann.

Social:

We could find time to visit Tamale’s famous traditional market, we all bought worthy beautiful gifts, souvenirs, etc.

On the last day in capital Accra some visited the national museum, where we were informed about the dark history of slavery in Africa.

We spent some time on the Atlantic Ocean beach, where we experienced riding horses. We also tried out some of the delicious dishes e.g. chili Fufu in one of the Ghanaian restaurants

Achievements:

44 operations performed in 5 working days.
Mesh-repair of hernias (more effective treatment) under antibiotics cover.
Training one local surgeon in mesh-repair.

Thanks

We would like to thank Dr Lisa Morhman the American surgeon, who delayed her departure to the US in order to supervise the mission. Our thanks also go to Mr Edward Addai, the hospital administrator for his hospitality.

The great success was mainly possible because of the incredible teamwork. Every team member participated fully in all the activities. There was an early start in the morning for post-operative ward rounds, followed by assessing the new cases and then operating all day long and into the evening.

We will be back………….

For operation hernia Nalerigu 2013

Dr.Ahmed Elmeghrawi.

Supplies in Magdi's garage

This time preparation started a long time beforehand almost more than a year ago. The team scheduled to go at the beginning was completely different from the team who actually traveled. This is due to twelve of those who originally expressed interest, apologizing at different times due to personal reasons and two withdrew due to separate skiing accidents one two months beforehand and one a week before the trip. We managed to recruit five surgeons, one anaesthetist, one anaesthetic practitioner, six theatre nurses, one ward nurse, two highly skilled helpers, and one medical secretary.

Supplies in Magdi's garage

Supplies in Magdi’s garage

This year’s trip faced more difficulties than previous years. British Airways withdrew the charity support and we had to book the normal way, and pay for all extra luggage. Fund raising was difficult and many struggled to meet their own cost let alone the other expenses. It was extremely difficult to get everybody together to help packing our medical equipments and know what else we needed to buy before we go. We had to diversify our sources of buying medicines to find the cheapest possible antibiotics, pain killers, local anaesthetics, meshes… etc.

The team efforts that made this mission a success, were amazing. We managed to fill up 55 boxes and bags each 23 kgs as required by BA. We had to wait till Christmas time and bought the tickets during a sale to obtain the cheapest possible fares. We have repaired our equipments with the help of our hospital engineers free of charge, Eschmann, donated two more sterilizers and one diathermy machine. We bought all necessary plates, gowns, light sources, computer printer’s cartilage, papers and all the medicines required to treat 300 patients. We have successfully arranged transport for 15 boxes with Intercare to meet the team flying from London Heathrow in time for check in. Our biggest achievement was collecting all these boxes from Accra Airport and passing through customs. After searching a sample of boxes, they let us all go, British and Canadians with more than 200 pieces of luggage. We deposited the bags next to the truck and came back in the arrivals to collect more loaded trolleys, until all luggage were accounted for and loaded onto the truck.

Logistics

Logistics

Operation Hernia team with local support

Operation Hernia team with local support

One observation was the smooth gelling between those who came before with more experience in these missions, and the new recruits who were a little apprehensive. They did not feel outsiders, they were helped and joined in the efforts from day one and felt how important and valued their service is. The work this year was less tense, more organized, easy, calm and effective. We have achieved almost the same result as the mission last year but we were less exhausted. Practice makes perfect, add to that good preparation and commitment.

The other observation was the friendship that is getting stronger between all workers, either, Ghanaians, Canadians or British and (Antje from Germany). The interdependence is growing every year. We know each other by name and we are cared for by a designated physician who is approached by anybody who falls sick from both expatriate teams. One of our nurses had an accidental needle stick. She was tested and the patient consented and tested for HIV. She was started on prophylactic antiretroviral immediately and was cared for by this designated doctor and nurses. She never felt alone and this support brought her back to work after 48 hours.

All adult patients were tested for HIV, and cared for as other patients but with more measures of protection. We tested each child for malaria when listed for an operation and started them on treatment if positive. We did not know how long we should keep the children on anti-malarial before we can safely operate on them. Our paediatrician, Dr Ellison consulted local community nurse Ernestina and both agreed that three days of treatment would be enough. Dr Ellison was consulted as well on a three years old child with a hernia who our anaesthetist Dr Tony was not happy to put to sleep because of chest wheezes. She decided the child requires a year’s treatment to improve his asthma before he could be safely operated upon under general anaesthesia.

24hrs postop strangulated inguinal hernia repair

24hrs postop strangulated inguinal hernia repair

We have managed to provide not only the direct care which we are capable of delivering but created the same hospital atmosphere of internal interdisciplinary referrals and consultation that improved our safety net and supplied more confidence and satisfaction in our capabilities.

This atmosphere allowed us to tackle one of the biggest challenge we have ever faced in our missions to date. A 35 year old man arrived with a strangulated hernia, three days before our departure date. He had his hernia in that position for a little more than 24 hours. We asked him why he did not go to a nearby hospital? He said “I do not want to die, the doctors are on strike and if they were not, I was told that nobody within 100 miles has the experience to operate on such a condition.”

He was sweaty with rapid pulse, in pain and distressed. We made the decision we will operate on him, and started resuscitation with what was left of the IV fluids, antibiotics pain killers etc we catheterized him. Dr Tony the anaesthetist decided to give him spinal anaesthesia with sedation rather then to put him to sleep as we were not sure about his oral intake before the operation. When we opened the sac the black bowel emitted offensive gangrenous odour. We had to extend the incision laterally and superiorly and there were more gangrenous bowel in the abdomen caught between the two loops in the hernial sac. We proceeded to do resection of 60 cm of small bowel and caecum and primary sutured anastomosis. The problems were the postoperative care, the IV fluids, IV antibiotics, observations, dealing with any complications. The other problem of recurrence of the hernia -as we did not put a mesh or attempt any repair- was of secondary importance. What was amazing was that the nurses came out with intestinal clamps already sterilized that I did not know we had them. When I asked as to where they got them from, they said it was me who brought them.

I knew I had to care for the patient overnight as we had less nurses than surgeons. We could not afford loosing a nurse the next day as that would put one theatre out of action. Many nurses from the British and Canadian teams offered to help. I have only accepted the help of Chris Mann who helped me with the operation. He observed the patient till midnight and I took over after that.

The Canadian team kindly supplied all the fluids, antibiotics and analgesia required. We the surgeons were not prepared for such cases (a lesson well learned). The patient had a monitor recording and hourly observations for two days. We recorded his intake and output. He received seven and half liters of fluid in the first 24 hours. He had three liters of urine output and the rest was sweat. His tachycardia gradually settled, temperature back to normal, the urinary catheter and the drain were removed on the second postoperative day. Early morning on the third day he opened his bowel three times and he was allowed soup which he appreciated. The day we were traveling back we typed all the operative information and post operative care, and gave him a copy and the local nurse a copy to deliver to the care centre with instruction on the remaining two days needed for antibiotics administration and dressing changes. We left him with lots of gifts, and some money to support his family till he can get back to work as a farmer.

The whole team from all nationalities has supported us in delivering the best care to this patient. A force from up above helped us to succeed, and protected him from complications.

This story tells us we not only have the skills to cure ailments but we can also save lives. These skills carry responsibilities and we should be prepared for that. Together with these medical skills, preparation, communication, team work, respect and love, supporting each other in work and difficult decisions, re important attributes. These are talents we learn and implement in our missions and daily lives, because they work.

This man’s wife told us “without you I would have been burying my husband now, thank you for not making our children orphans and me a widow”.

Magdi Hanafy

Consultant Surgeon

Mid Cheshire Hospitals NHS foundation Trust

Volunteer for Operation Hernia.

On behalf of Team Carpenter 2013 (Ghana-Canada-UK-Germany)

Home and away team

Takoradi March 2013 Report of the Belgian – Italo – Dutch team. Visit from March 9 – March 17 2013.

Home and away team

Home and away team

In March 2013 a team of four Belgian surgeons (Myriam Bruggeman, Paul Van Acker, Marc Huyghe and Casper Sommeling) accompanied by an Italian surgeon (Cecilia Ceribelli), two registrars (Stijn Heyman from Belgium and Annelien Morks from the Netherlands) and a Belgian nurse (Pina Orlando) again visited Takoradi in Ghana. Our main financial sponsor still is the Belgian Section of Abdominal Wall Surgery. We brought meshes (kindly donated by Medri, Covidien Belgium, Bard Italy and Assut Europe), gloves (Cardinal Health/Medline), disposable drapes (Mölnlycke Belgium and Medline) and suture material (Johnson & Johnson). Resterilized polypropylene meshes and so called “Indian meshes” made part of our luggage. Local anesthetics, syringes and needles were donated by Bbraun an BD; only the lidocaine with adrenaline and heavy Marcain was bought by us in Belgium.

This way for Hernia Operation

This way for Hernia Operation

Recovery

Recovery

After arriving at Accra, late Saturday night, for the first time we stayed at the Ghana Baptist Mission. The following Sunday we made the trip to Takoradi, meanwhile visiting Kosa Beach.

Again “the girls” (Kate, Linda and Benedicte) took good care of us, although they had more difficulties than the years before due to the frequent power cuts. They even proposed us to switch to a hotel, but their “candle light suppers” were much appreciated by us. This year we were lucky to meet Brian Dixon again, who was on “holiday” in Takoradi; however this means trouble shooting for him as a second nature, or as he states it “there are no problems, only challenges”. He contributed again to our mission in several ways, mainly on a logistic level, but also on solving local problems. He even might have solved the problem of running water in Dixcove hospital.

Paul & Brian

Paul & Brian

During the week we organised three teams that rotated in the three different hospitals (Hernia Wing, GPHA and Dixcove). We performed 86 operations in 86 patients, of which nine were children. Again most of the adult patients presented with groin hernias. The total number of operations seems low for the total number of team members but we were plagued by power cuts and interfering caesarean sections. This year in the adult patients two-thirds (51/77) were operated under local anaesthesia, but loco-regional anaesthesia (26/77) was used as a standard in all three locations in the more demanding scrotal hernias, contributing to a better comfort of the patients. The children of course were operated under general anesthesia.

The motivation of the local hospital teams is good and the level of care of the nurse-anesthetics in the three hospitals is high. The equipment in the hospitals is of a reasonable level, but the Dixcove Hospital is in need of sharp scissors and new operation gowns. Although with three teams we still made long days, but once again it was rewarding.

After a long week hard work we had dinner at the the “Gilou” restaurant Friday night together with Bernard Boateng Duah and his wife. On Saturday we made a trip to Green Turtle Lodge, the nicest place to be at the Atlantic Coast, were again we spent a wonderful day. At Sunday morning our group split up. Marc started on a trip of ten days through Ghana. Paul and Myriam stayed another week in Takoradi for holiday; however they were motivated to operate on the patients that were left over from the first week in the GPHA-hospital, so the first two days of their holiday they operated eleven patients (included in the total of 86).

Pina stayed another two weeks in Takoradi to work in the hospital as part of her training to be a specialized nurse. Cecilia, Stijn, Annelien and Casper made the trip back to Accra with a stop at El Mina Castle. Conclusion: again a rewarding mission; if the future team will enclose again as much members as this year we might go to other places in Ghana. We once again want to thank Bernard Boateng for the organization at the local level: selecting the patients on forehand and helping us out during the week.

Special thanks to Brian Dixon, just because being there.

Casper Sommeling, on behalf of the Belgian – Italo – Dutch Mission

Frank McDermott’s Second Mission November 2012

Team Ghana

Team Ghana

OH Mission to Volta Regional Hospital, Ho. (3rd – 10th November, 2012)

This was my second mission with Operation Hernia having returned from an amazing experience in Mongolia in 2011. I flew with a registrar colleague and friend, Mr Surajit Sinha, and we arrived into Accra to be greeted by Godwin, a hospital administrator from Volta Regional Hospital. Godwin was very welcoming and demonstrated throughout the week what a useful asset he is to the Hospital. Unfortunately one of my bags had not made the journey with me on the airplane which made for a challenging 48 hours in a hot and humid country!

Sunday

We spent the first night in the Baptist Guest House in Accra before travelling to the Volta Regional Hospital. On Sunday morning I met the rest of the team. Mr Chris Oppong I already knew as I had just completed a surgical rotation with him as a Colorectal Registrar in Derriford Hospital, Plymouth. He co-founded the charity with Professor Kingsnorth and as a Ghanaian was the perfect guide for my first adventure in this fascinating country. Joining us on the mission was an American team headed up by Dr Pedro Cordero, an Attending Surgeon based in New York. Pedro runs his own charity that has provided surgical care to Haiti and Philippines and we shared many interesting stories about providing surgical care in the developing world. The rest of his team comprised Aida St John and Carol Turner (American Theatre nurses), Peter Dixon (surgical trainee) and Alyssia McEwan (medical student). We all jumped on the hospital bus and began the 3 hour drive to the Volta Regional Hospital in Ho. You learn so much from driving through a new place. It gave the team the opportunity to gel and also see the captivating scenery fly by. We passed many small towns and witnessed the hustle and bustle of Ghanaian life with many street vendors selling some staple produce such as cassava, plantain and Tilapia freshwater fish interspersed with electronic stores selling sim cards for your mobile phone! Crossing the toll bridge over the Volta River gave stunning views of the region. I was not sure what to expect having never been to Ghana before but the hills were lush albeit the victims of deforestation over many years.

Eun balancing

Eun balancing

We arrived in Ho in the afternoon; it is the fifth most populous town in Ghana with a population of around 100,000. We drove to the hospital for a formal introductory ceremony with management from the hospital, the lead surgeon Geoff and a representative from the Ghanaian Royal Family, Mamma Tratto. This was all filmed by Ghanaian TV! The introductions all done we went to the ward to meet our patients and assess them prior to starting the real work the next day. Professor Kingsnorth has developed a scoring system for hernias grading them between H1 and H4. H1 being a small hernia that reduced on lying supine and H4 a recurrent or irreducible inguinoscrotal hernia. This scoring system is very useful for planning the list from a point of view of resources, type of anaesthesia proposed and for on-going data collection and audit. We assessed all the patients, checked blood pressure, Haemoglobin and sickle cell status and then planned the lists for the next day.

Monday – Friday

We were allocated three theatres in the surgical block for the 5 day mission. The theatre staff were very welcoming and we quickly developed a good rapport. We all stuck our first names on a label which broke down any barriers and emphasised that we wanted to work as a team to maximise the work we could do in this short time. We set a goal of operating on 100 hernias. We donated a diathermy machine to the hospital as well as 6 suitcases full of equipment that Pedro had brought. I operated with Sinha in Theatre 3 alternating cases. Our theatre team included ‘Old Sam’ an anaesthetic practitioner who was an expert at spinal anaesthesia, Eunice and Felica our theatre nurses and Gloria a circulator. The conditions were sweltering and even the Ghanaian staff said it was hot. On that first day I had to change my scrub top 7 times! As well as the heat we had some serious hernias to contend with. A lot of the hernias had been neglected for many years and were very large and stuck to cord structures. This made a big difference to the small hernias I’m used to operating on in the UK. We worked from 7:30 am when we were picked up from our hotel until the last case was done which was usually anywhere from 8-10pm. All patients had an operation note completed by the operating team and were sent home with a 5 day course of oral antibiotics and analgesia. We kept a prospective database of all the patients that we operated on. One of the main aims of OH is frugal innovation. Surgery is expensive but potentially lifesaving as Mr Oppong found out when two of the patients that were due to come in electively turned up with strangulated hernias. OH uses sterilised mosquito net as alternative to the expensive alternatives although we still rely on industry support for their kind donations. As mosquito net is very cheap it allows the local surgeons to perform an economical tension free mesh repair with consequent low recurrence rates.

Patient safety is the most important factor when we operate and something that has been in the spotlight over the last few years. We used a simple ‘timeout’ on the theatre whiteboard with patient details, operation proposed and who the team was for each day. This is something that the local staff found useful and was beneficial to us as Surgeons in a different environment. Aida and Carol also spent the week acting as scrub nurses but also sharing the benefit of their experience from working in the USA with the local theatre team. Some small changes could lead to a great improvement in patient safety. This was brought into focus when we met the local Governor whose brother had died following hernia surgery when a surgical glove had been left inside the abdomen.

Adapted ‘time out’

Over the 5 days we made many friends in theatre. We worked 13 hour days from Monday – Friday but were well looked after with beautiful local dishes. Sister Josephine, the theatre matron, deserves special mention. There was a stern side to her and she ran a tight ship but as the days went on we all developed a fondness and respect for her management and people skills. We managed to perform 99 procedures including 80 inguinal hernias, 50% of which were inguinoscrotal. 21 cases were performed under local anaesthetic, 2 under general anaesthetic and the rest were spinal. On the last day we shared a bottle of champagne with all of the theatre staff. There was an amazing feeling of accomplishment but also an immersive sensation of friendship and team work. I looked around at the American team, my friends from the UK and the Ghanian staff and found it utterly bizarre that I had only met a lot of them 6 days before. This is what OH does, it brings likeminded hard working and resourceful individuals together who want to make a difference and I hope this is what we’ve done.

The Team

3-11 March 2012
In March 2012 a team of four Belgian surgeons (Myriam Bruggeman, Paul Van Acker, Marc Huyghe and Casper Sommeling) accompanied by an Italian surgeon(Cecilia Ceribelli) and a Belgian nurse (Pina Orlando) again visited Takoradi in Ghana.

The Team

The Team

We brought meshes (kindly donated by Medri, Covidien Belgium, Bard Italy and Assut Europe), gloves (Cardinal Health/Medline), disposable drapes (Mölnlycke Belgium and Medline) and suture material (Johnson & Johnson). Resterilized polypropylene meshes and so called “Indian meshes” made part of our overweight luggage. Local anesthetics were donated by Bbraun, only the lidocaine with adrenaline had to be bought by us in Belgium.

This year special thanks to the Ghana Ministry of Health presented by Dr. Kwesi Asabir, Deputy Director Human Resource, who welcomed us Sunday morning in Accra.

After arriving at Accra, late Saturday night, for the first time we stayed at a hotel in Accra. The following Sunday we made the trip to Takoradi, meanwhile visiting Elmina Castle and Kosa Beach.

At arrival Sunday night in “the Villa” a nice meal was ready for us. Again “the girls” (Kate, Linda and Benedicte) took good care of us. The food they prepared was fine and far better than the Western food served in the local restaurants.

During the week we organised three teams of two, that rotated in the three different hospitals (Hernia Wing, GPHA and Dixcove). We performed 88 operations on 81 patients, of which eight were children. Most of the adult patients, presented with groin hernias (in six bilateral). In almost all these cases a Lichtensteinrepair was performed. For the first time we did use sterilised mosquitomesh (or Indian meshes, as it sounds less charged) we brought with us, in about half of the Lichtensteinrepairs. The handling is surprisingly good and suturing works fine. Half of the patients were operated under local anaesthesia, but loco-regional anaesthesia was used as a standard in all three locations in the more demanding scrotal hernias, contributing to a better comfort of the patients. There were four patients operated on recurrent hernia, of which one with an acute strangulated hernia on Sunday-morning just before we were to leave for Accra. The children of course were operated under general anesthesia, as well as one patient with a large upper abdominal incisional hernia.

Again this year there were some challenging scrotal hernias, and also the age of the patients we operated on is still increasing. The oldest patient was 94 years of age and in good condition!

The advantage this year was that we could split up in three teams of two, so that we could assist each other and could share the frustrations in operation another challenging hernia. Even if you think to have seen it all, another situation presents itself.

Operating Takoradi

Operating Takoradi

The motivation of the local hospital teams is excellent and the level of care of the nurse-anesthetics in the three hospitals is high. The equipment in the hospitals (also in Dixcove) is of a reasonable level. There was probably a shortage of heavy marcaine in one of the hospitals, and maybe also of gowns. The operation table in Dixcove is waiting a repair, so that it can be lifted to normal height.

Although with three teams we still made long days, but once again it was rewarding.

After a long week hard work we had dinner at the Planters Lodge Friday night together with Bernard Boateng Duah and his wife.

On Saturday we made a trip to Green Turtle Lodge, the nicest place to be at the Atlantic Coast, were we spent a wonderful day. At Sunday morning we said goodbye to the girls; on arriving at the GPHA-hospital to say goodbye to Bernard he had a little surprise for us. While the rest of the team took a trip to discovery the Takoradi-harbour, Bernard and Casper did perform an emergency operation for a recurrent and now strangulated groin hernia. Luckily for the patient and also for us the strangulated intestine was still vital, so we could preform a Lichtensteinrepair.

After that we drove to Accra, and after a last meal in the Airport View Restaurant we arrived at Kotoka Airport to travel back home again.

Conclusion: again a rewarding mission; due to the fact, that we were with five surgeons and one nurse, we could in teams of two operate in the three hospitals. We know the work we do is a drop on a hot plate, but it is very worthwhile on an individual level. As Belgian-Italo team we will engage us to go back next year to Takoradi.

We once again want to thank Bernard Boateng for the organization at the local level: selecting the patients on forehand; helping us out during the week and operating the people afterwards, that were on the list at GPHA but could not be operated by us.

Casper Sommeling, on behalf of the Belgian – Italo Mission

The Dutch Team

14-24th JANUARY 2012

The Dutch Team

The Dutch Team

This Operation Hernia mission was a collaboration between the Diakonessenhuis Utrecht and the Groene Hart ziekenhuis Gouda. A team of 4 surgeons and 2 surgical residents arrived in Accra, Ghana on the 14th of January.

On the 15th we made our way to Takoradi, where we were warmly welcomed by the ladies in the Government Guesthouse. On Monday morning we could finally start with our Operation Hernia!

The upcoming week we would perform our operations in three different hospitals: The Hernia Wing and The Harbor in Takoradi and finally the local hospital in Dixcove, a small village which is a 45minute drive from Takoradi. Each morning breakfast was prepared for us and we were picked up by a driver to bring us to the different hospitals.

In Takoradi we usually performed five to six operations: patients were preselected by a Ghanaian surgeon. On the morning of the operation we saw the patients and judged if we would perform the operation. Most patients had an inguinal hernia and unless the patient was not fit or the hernia was irreducible we would operate them. There were children as well as adults and we also treated some prisoners. Surgery was mostly performed under local or spinal anesthesia.

Some patients had a bilateral hernia, an (para-) umbilical hernia or a hernia cicatricalis (= a scar hernia caused by a previous operation).

In Dixcove there were not as many patients as we had hoped for: usually two or three a day. We usually had time to visit the village with the fortress by the sea or go to the market in Takoradi if we were scheduled for an operation day in Dixcove.

Tarora Hospital

Tarora Hospital

In all hospitals the OR personnel was good and spoke English very well, unfortunately the patients usually did not speak English and communication could be difficult.

A Ghanaian surgeon performed one surgery with our team on a patient with a large irreducible hernia. It was very useful to see how he performed the operation. Since they usually do not use a mesh he asked our team to finish the operation by placing the mesh. The meshes we did not use were left behind for the local surgeons to use. In total we treated approximately 65 patients.

After the last day of operations in Takoradi, we drove to the north during the nighttime. The road was uneven and because it was pitch black around us it was a spectacular ride. We arrived at Turtle Beach and could hardly see where we had arrived. But most important, we heard the wild sea and saw thousands of stars! The next two days were for relaxing, running and visiting the nearby village.

On Monday morning we were picked up by the driver and drove back to Accra. Along the way we stopped at the Cape Coast fortress, built by the English and also used by the Dutch to ship out slaves. After a last Ghanaian meal we were driven to the airport and said goodbye to Ghana: It was a wonderful experience!

The Leighton & Derriford team

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

Magdi Hanafy, reporting.

The Leighton & Derriford team

The Leighton & Derriford team

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

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

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

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

One of many operations performed each day

One of many operations performed each day

 

Patient care

Patient care

Tuesday 03 November 2009

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

Wednesday 04 November 2009

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

Thursday 05 November 2009

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

Friday 06 November 2009

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

Saturday 07 November 2009

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

Sunday 08 November 2009. Our Day off.

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

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

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

Part of the Leighton & Derriford team

Part of the Leighton & Derriford team

Tuesday 10 November 2009

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

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

Wednesday 11th November 2009

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

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

Thursday 12th November 2009

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

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

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

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

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

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