Hebron International Hospital

Phnom Penh, Cambodia May 2013

Hebron International Hospital, Phnom Penh, Cambodia, May 15-25 2013

Team members: Andrew Kingsnorth, Scott Leckman, Denis Blazquez, Petr Bystricky, Simon Clarke, Sheri Kardooni (trainee) & Paulina Mysliwy (anaesthetist)

Darkness descended on Cambodia in 1975 when the Vietnam war extended into Cambodia and the Khmer Rouge took over the country. Evacuation of the cities, genocide of three million of its fifteen million people and 10 years of rule by the Soviet-backed Peoples Republic of Kampuchea resulted in unbelievable suffering and horrors for the surviving population. Since the country was reunited under the monarchy in 1993, huge strides have been made to re-establish the culture and rebuild the economy of a country that originated in the vast 9th century Khmer empire that dominated the Indo-China peninsula. Angkor was the centre of power of this empire, where an unimaginable series of temples (Wats) were constructed and which, through satellite technology has been established as the world’s largest pre-industrial city, with an estimated population of one million.

Food market economy

Food market economy

Finger print consent

Finger print consent

Cambodia has just lifted itself into middle-income status with an average per capita income of $1040, although 20% of people still live below the poverty line on less than $1.25 per day. Health indicators are dismal; life expectancy is 60 for men, and 65 years for women and 23% of children die before the age of 5 years. It is the third most land-mined country in the world; 60,000 have been killed and thousands maimed, many being children playing in the fields or herding animals.

Tourism is the second largest source of hard currency and the main exports are timber, rice, fish, garments and rubber. The legacy of the war-torn countryside is one of the highest levels of deforestation in the world: primary forest cover was 70% in 1969, in 2007 it was down to 3%. There is free compulsory education for 9 years, literacy rates are over 70%. Few hospitals exist, and healthcare provision is largely left to a poorly trained private sector.

Our base in Phnom Penh was in the remarkable Hebron International Hospital (HIH) in a poor district near to the international airport. It is staffed by a Korean Medical Ministry team, which provides two levels of care – primary care for local residents and a base for short-term mission teams such as Operation Hernia. HIH opened in a small house in 2007, progressed to construction of a 70 bed hospital with 3 operating theatres and a staff accommodation block in 2010, with a vision to open a nursing school and a medical school in the next 20 years. This degree of commitment is quite extraordinary.

Sheri assisting Scott

Sheri assisting Scott

We were housed in a respectable but inexpensive hotel in Phnom Penh, and transported by minibus each morning to the HIH. The team had two paediatric surgeons (Simon & Denis). Andrew, Scott and Petr were able to handle the older children, so we had decided to run a “Children’s Hernia Hospital” for a week. Without gaseous anaesthesia Paulina improvised magnificently to enable the team to operate on over 70 children in the week of the mission, which was a remarkable achievement and brought many happy and tearful smiles to the parents of these children .

The team managed a trip to the Angkor Wat at Siem Reap and harrowing visits to the Tuol Sleng torture chambers in Phnom Penh, and the mass burial graves and Genocidal Centre at Choeung Ke.

Operation Hernia has plans to provide a long-term commitment to HIH.

Andrew Kingsnorth

Brazil team

Maranhao, Brazil March 2013

Brazil team

Brazil team

Brazil Report, 16-25 March 2013

Operation Hernia Team: Andrew Kingsnorth, Todd Heniford, Shambhu Yadav, James Brewer, Heidi Miller & Lorenzo Dimpel (anaesthetist). Brazilian coordinators: Flavio Malcher, Luis Soares.

Brazil is the engine of South America. A vast country with 200 million population, bordering all the other South American countries except Ecuador and Chile, and with extensive natural resources and protected habitats. Its topographical diversity includes not only the Amazon, the largest river in the world by volume, but also hills, mountains, plains, highlands and scrubland. Brazil has a highly advanced technological industry concentrated in Sao Paolo, manufactures & exports cars and aeroplanes, and is due to take delivery of a French nuclear submarine in 2015. A two million kilometre road system includes 184,000 of paved roads. Statistics for the various ethnic groups indicate that 48% are classified as white, 43% brown (multi-ethnic, or pardo), 8% black and 0.4% Ameri-Indian. These limited facts give a mere glimpse into the amazing cultural, scenic and human elements that make a trip to Brazil a thrilling experience.

Our destination was Maranhao State in the north east. It is the second poorest state in Brazil (after Amazonia) with 24% illiteracy and the highest levels of inequality. It features the spectacular sand-dunes of Lencois (Lencois Maranhenses National Park) and the Parnaiba river delta with stunning lagoons, deserted islands and beaches. The northeastern part of the state is heavily forested and is the eastern extension of the tropical moist forests of Amazonia.

Two tables

Two tables

Dunes of Lencois

Dunes of Lencois

From Rio de Janeiro we flew into the San Luis, the State capital of Maranhao, just 3 degrees south of the equator with a tropical monsoon climate, and a population of one million. The city is situated on an estuary of three rivers and has a vast deep water seaport, and the best preserved historical city centre of colonial Portuguese architecture of all Latin America. On account of its striking architecture it is known as “The Tiles City”.

In the last decade significant progress has been made to provide public services to deprived regions in Brazil. In Maranhao two recently built modern highways (BR-010, BR320) criss-cross the State, new schools have been constructed and over 30 new hospitals with approximately 50 beds are being built. Presently, the government is having difficulty in recruiting trained doctors to staff the hospitals in these remote areas. Our first destination was to one of these hospitals in the town of Coroata (population about 50,000), where we travelled overnight by road on a four and a half journey from San Luis to arrive in darkness, but ready for the first days work.

The home team was extremely well-organised. Cases had been prepared and worked up to include not only straightforward inguinal hernias, which we used to teach the local surgeons and residents, but also children and several incisional hernias. Our programme had been supported by the Minister of Health for the State and extra staff had been drafted in, including a locum anaesthetist from Rio who was able to handle several simultaneous spinal anaesthetics, and intravenous general anaesthetics, so that 21 cases were achieved on the first day.

The town’s hotel was situated just behind and over a petrol station. Early morning breakfast on the verandah of the hotel afforded exciting views of the town as it awoke amidst the noise of goats, motor cycles and mule-drawn carts going about their daily business. On the second day we worked until 9PM to complete another 19 cases and then set off for another night drive back to San Luis arriving at 3AM after a splendid midnight feast at a truck stop in Mirando do Norte

Luiz, James & Flavio

Luiz, James & Flavio

After this rather exhausting start to the mission, the next day consisted of a tour of the Old City, a traditional business lunch at a Senac restaurant, and in the evening a tour of the flood-lit city, the presidential palace and a visit to the Sarney museum of fine art, followed by a buffet dinner hosted by the State Minister of Health.

During the next two days Flavio had organised a Hernia Congress followed by a hands-on workshop in Hospital Tarquinio Lopes Filho to teach complex hernia surgery to consultant surgeons. Both days were very interactive. More than 100 surgeons attended. Each Operation Hernia member gave at least one lecture, and we demonstrated several complex techniques in the operating theatres. The dinner on the night after the congress took place in the beach restaurant of Cabana Del Sol where Lorenzo’s birthday was celebrated by a barber shop quartet (actually the waiters)!

The next day we headed for the second hospital in the town of Barrierinhas, a four hour drive to the east of San Luis. Here we had the luxury of staying in a beach hotel and took a trip up the Parnaiba river to see the dunes of Lencois. The operating consisted of two long days with four operating theatres active to complete another 50 cases. The support from the Brazilian team was amazing, with constant refreshments, and even time to celebrate another birthday- red pixie hats were donned in the operating theatre, balloons strewn around the coffee room before the a cake was cut and more songs sung!

This was a very well-structured and advanced mission which will be repeated in another region of Brazil in 2014

Andrew Kingsnorth

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

Team members

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

Northampton, Rob Hicks, Sue Johnson

Canada Lawrence Turner, Ira Bloom, Teresa Buckley

Inverness Morag Hogg

Germany- Antje Haupt

Southampton Sarah Hasted

Operation Hernia to Carpenter, Northern Ghana. November 2011

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

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

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

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

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

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

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

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

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

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

Rob Hicks

Consultant Surgeon

Northampton General Hospital

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

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

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

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

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

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

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

Team Leaders: Andrew Kingsnorth & Etienne Steiner.

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

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

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

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

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

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

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

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

Andrew Kingsnorth

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

Anglo-Irish and Swiss Team

Anglo-Irish and Swiss Team, Aliade, Nigeria 17-27 FEBRUARY 2010

Annyar You’re welcome. With a touch to the forehead and chest followed by a slight bow, each colourfully dressed greeter would then take our hand and shake it. Regardless of social or financial station, the heartfelt greeting was the same annyar.

Anglo-Irish and Swiss Team

Anglo-Irish and Swiss Team

Four European surgeons (Richard Stephens, Shorland Hosking, Peter Nussbaumer, Andrew Kingsnorth) and one anaesthetist (Richard Salam) bumped for six hours in a very full minibus from the airport to our hospital base for the next week. Presentation of flowers, singing and dancing greeted us as we stepped into the 41°C heat. Posters around the town (photo) had heralded our arrival Operation Hernia by Professor Kingsnorth and team . Boxes of instruments, diathermy machines, gloves and sutures were hoisted onto porter s heads and taken to the operating theatre for unpacking and sorting. No electricity for 24 hours a day is normal, necessitating a new generator being installed to provide continuous (African style) power for theatres.

And so we started. By dawn patients with hernias started arriving; young, old, fit, HIV negative, HIV positive, pregnant, curious. Following confirmation of a hernia(s) they made their way to the theatres where they waited their turn. Nobody seemed to mind waiting for as long as it took word on the street came back that this was a small price to pay for a well performed procedure as a day case. Like the children of Israel they kept coming and we kept operating two tables on the go from 8 til 5. Eighty patients and one hundred hernias later we reached full time and still they kept coming. Names were taken with the promise that the next hernia team arriving three months later would see to their hernia.

The Team - Operating

The Team – Operating

Training the local medical team

Training the local medical team

By day two an important discovery was to change our approach in a significant way. Initially, the hospital s medical officers came to theatre for training but it quickly became apparent that their surgical skills were considerably less than those of the theatre scrub nurses. Furthermore, these nurses interest and enthusiasm to learn the mesh repair (they were familiar with the Bassini technique) was impressive. And so they began to assist, progressing naturally into performing under supervision. As they were taught (see photo), their enthusiasm visibly increased, work rate and efficiency improved further and the whole team worked so well. What a difference empowerment makes. It needed to, for it was the Europeans who began to wilt by mid-afternoon. Despite three air conditioners, theatre temperatures reached 30°C during the afternoon session.

Armed with mesh generously donated by several companies the pile of mesh nonetheless shrank rapidly at the rate of 20 hernias per day. The solution was simple but brilliant. Mosquito net was cut to size and sterilised. Initial attempts at high temperatures were rapidly modified when the net melted in the autoclave. The right temperature was found and the problem of sterile mesh was solved easily and cheaply.

Boys swimming, Aliade, Nigeria

Boys swimming, Aliade, Nigeria

Stepping outside the theatres onto the wards revealed a much bigger problem. HIV. Sub-Saharan Africa has been devastated by this virus. In our area of Nigeria forty per cent of the population are affected. In our hospital eighty per cent of the work load is HIV related. Thanks to huge inputs by overseas charities, antiviral drugs are now available free of charge. The effort in education and community is impressive.

As we said our goodbyes at the Hospital, “annyar came at us from all directions. How strange, until we learnt that annyar not only means welcome; it means thank you.

Shorland Hosking

The official opening of the ACE Clinic by the local Oba

ACE clinic in Eruwa, Oyo State, Nigeria

The official opening of the ACE Clinic by the local Oba

The official opening of the ACE Clinic by the local Oba

Jaeck Adamek, Rob Hart and Andrew Kingsnorth, with registrars Jamasp Dastur and Sameer Kadam completed the fifth mission at the ACE clinic in Eruwa, Oyo State, Nigeria during 12-20 November. Seventy patients received mosquito net mesh repair under local anaesthetic.

Operation Hernia also contributed to the International Federation of Rural Surgeons meeting that was taking place simultaneously (picture below shows the official opening by the local Oba), and organised by Dr Awojobi, with the participation of the Association of Rural Surgical Practitioners Of Nigeria.

Local leaders at the opening ceremony.

Local leaders at the opening ceremony.

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).

In surgery, Eruwa, Nigeria

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

 Arriving in Nigeria with all our luggage

Arriving in Nigeria with all our luggage

MY DIARY: Saturday 8 August

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

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

Sunday 9 August

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

The Leighton Hospital team

The Leighton Hospital Team

In surgery, Eruwa, Nigeria

In surgery, Eruwa, Nigeria

Monday 10 August

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

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

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

Tuesday 11 August

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

Wednesday 12 August

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

Thursday 13 August

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

Friday 14 August

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

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

Theatre Superviser Kareem

Theatre Superviser Kareem