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

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

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

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

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

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

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

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

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

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

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

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

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

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

Arun Ariyarathenam

Alex Clarke

Andy Clarke

Dimitri Pournaras (Shorland Hosking Fellowship)