In January 2017, the 8th mission of the Dutch team of Operation Hernia took  place. This year a team of eight surgeons and eight residents went to the Ghanaian towns of Keta, Wenchi and Bole. The teams had as goal to treat as many patients as possible.  A second equally important goal was to teach local physicians to perform inguinal hernia surgery with a mesh (Lichtenstein procedure under local anaesthesia), so they would be able to continue performing these operations after the mission had finished, and they eventually can teach others.

On Saturday the 7th January the members of operation hernia arrived in Accra.  The next day 8 surgeons and residents went by car to Takoradi and the other 8 took a domestic flight north to Kumasi.  There they split up and a team of four went by car to Wenchi while the other four drove to Bole in the northwest region of Ghana.

Since elective surgery and in particular hernia surgery is rare in this country, many patients travelled from near and far to be treated by the Dutch team of Operation Hernia.  An untreated inguinal hernia causes, besides effect on daily activities and cessation of professional activities, a substantial health risk.  In case of incarceration, mortality rates up to 80% are not exceptional.  So the goal of our visit is clear: treat as many patients as possible!  And, equally important, teach local physicians and nurses to perform hernia operation and provide care afterwards.

Takoradi team

After a drive of approximately 5 hours we arrived at Takoradi. During the trip we already got to know Ghana a bit and this made us more and more enthusiastic to start our mission. Since Takoradi has a fantastic coastline, we first visited the beach and ended the day with a dive and some drinks over there.  We speculated what the week would bring us.

The next morning, after the delicious Ghanaian breakfast, with Dutch peanut butter, we were split in three groups since we were working in three totally different hospitals.

GPHA is a private hospital.  Dr Bernard Boateng is the leading doctor in this beautiful hospital with even a CT-scan.  The theatre staff were friendly and very capable. Rapidly, an inguinal hernia was followed by a giant hydrocele alternated by an emergency Caesarean section. Days flew by, in total 27 operations were performed in this hospital.  The medical staff were well trained and a pleasure to work with.

The largest hospital, Takoradi hospital has its own hernia wing. The head of theatre there is Marian.  A great personality, she and her team made our mission even more special. Time flew, while working hard in the wing there was a lot of fun! In the Hernia Wing, a total of 29 surgical procedures were successfully performed.  The majority were adult male patients with inguinal hernias treated with a Lichtenstein procedure under local anaesthesia. The severity varied from H1 to H4 (large scrotal hernias), all treated with a mesh brought from the Netherlands. The Takoradi group operated on 9 children under the age of 9.  A herniotomy was performed with general anaesthesia.  In both the Hernia Wing and GPHA, young doctors were joining us to be taught about the Lichtenstein procedure. It was great to see their enthusiasm and we were convinced of their surgical skills.

Dixcove, a small hospital in the more rural area outside of Takoradi, was a great place to visit.  In this hospital, with an anesthetist known for his fast spinal anaesthesia technique, working was extraordinary. The theatre was used optimally, a Lichtenstein procedure was performed while a Caesarean section had to start.  No problem, in Dixcove they perform this at the same time in the same room!  A great experience!  We were very happy to work with the medical staff and hopefully the same applies for them. Working in this hospital was sometimes even a real party, especially when the scrub nurse started to dance to our music in between the surgeries.  The fact that we worked hard besides the fun is shown in the total of 20 surgeries performed. In total 76 patients were treated by the Takoradi group.

 

Bole team

Together with the Wenchi group we took an inland flight north to Kumasi. From there our groups split and the four of us were picked up by Baba, the Bole hospital ambulance driver. All the equipment we brought was loaded in the back of his pick-up truck and off we went. Our six hour drive was interrupted only for a short introduction to the Ghanaian cuisine: banku! (a mixture of fermented corn and cassava dough in hot water).  Along the way the setting changed into more rural scenery.  While listening to the car radio we heard a broadcast to invite patients with inguinal hernia to register for surgery at the Bole Hospital. This way, Dr. Josephat Nyuzaghl (Dr. Joe), one of the two local doctors of the Bole hospital and our contact person, had efficiently recruited patients for surgery!

After a long day of travelling we were welcomed by the hospital administrator and the medical director of the Bole hospital, and Dr. Joe kindly showed us around.  Many patients had responded to the radio broadcasts, so our days started early with the screening of patients that had queued up in front of the male ward.  After this we started surgery and worked together with the enthusiastic local operation team until all patients, that were put on the list that morning, were operated on.  The hospital has two functioning operating rooms and we therefore divided into two teams of a surgeon and a resident mixing the pairings. The vast majority of patients were operated on under local anesthetic, only some patients had a spinal anesthetic. We had the opportunity to use sterilized mosquito net meshes that worked very well.

Vitus, the pragmatic nurse anesthetist, organized the operation list and made sure everyone of the team knew exactly what to do.  Not a minute of our time there was lost. The whole team worked extremely hard, sometimes until late in the evening!  We had little chance to work together with Dr. Jatuat, the young local surgeon, who was kept busy with other patients since he and Dr. Joe are the only physicians in this region.  In total over the week we carried out 83 procedures in 74 men, women and children.  All patients stayed in the ward the night postoperatively and were discharged the next morning.

As a special treat after we finished Dr. Joe had kindly organized a send-off party with drinks and food (guinea fowl). We had the chance to thank the Bole Hospital staff for making us feel so welcome. We were presented with custom made smock, worn on special occasions. We would all like to reiterate our thanks to Dr Joe, Vitus and the staff at Bole Hospital. Finally we would also like to thank the Ghana Government for facilitating our mission. We will be visiting again.

Wenchi team

At Kumasi airport we were welcomed by Dr. Bibi Bosomtwe who took us on a 2.5 hour drive north through the beautiful Ghanaian landscape to the town of Wenchi.  Wenchi is the capital of Wenchi Municipal of the Brong-Ahafo Region in South Ghana with a population of around 40,000 people. On arrival we were greeted by Bernard Clement Botwe, the charismatic CEO of the Wenchi Methodist Hospital.  Afterwards we were brought to our accommodation for the upcoming week, a nice guesthouse just outside Wenchi. Here we were joined by Sarah, a Ghanaian scrub nurse with experience in assisting during the Operation Hernia Missions. She was asked specifically for this mission to come and assist, and to teach the scrub nurses of Wenchi Methodist Hospital.

On Monday morning we were picked up by the hospital bus and were taken to the Methodist Hospital.  It is a lovely typical Ghanaian hospital with approximately 300 beds. We met the anaesthesia medical officers, scrub nurses and the local physician we were going to train, Bismark Kubi.  After discussing our plans for the week we got acquainted with the two small but adequate operating theatres, which were going to be our work environment. The enthusiasm of the complete operating room (OR) personnel and everyone at the Wenchi hospital from the first second of our visit was impressive.

Every day started with screening of the potential patients. Numerous patients from the whole region surrounding the hospital had responded to the call for treatment. After screening, eligible patients were seated outside the operation theatres until surgery. Most patients were treated under local anaesthesia; they walked into the OR, underwent inguinal hernia correction with a mesh, and afterwards walked out of the OR by themselves. For exceptional cases, such as irreducible and bilateral hernias, spinal anaesthesia was available. Children with inguinal hernias were treated under general anaesthesia with Ketamine.

During our stay at Wenchi Methodist hospital, 45 patients with a total of 52 hernias were operated. Doctor Bismark Kubi, who was already well acquainted with hernia surgery but did not have any experience with the use of a mesh, was trained in performing the Lichtenstein procedure.  He proved to be a very skilled, kind and enthusiastic doctor who learned quickly. At end of the week, he was able to safely perform the procedure by himself. As we were able to donate a significant number of surgical meshes, adequate care of inguinal hernias at the Wenchi Methodist hospital can be continued.

We ended the week with a party on the final evening, which we organized to thank the staff of for their kind hospitality. Together with the OR personnel we looked back at a successful and enjoyable week. Kind words were spoken both from the Ghanaian and the Dutch side, and mutual hopes for future collaborations were expressed.

Acknowledgements

The Dutch Operation Hernia team gratefully acknowledges the MRC foundation for providing the necessary funds in order to be able to treat so many patients with such a large team.

Also the hospital staff of the anaesthesia, pharmacy and surgery departments of the Hospitals OLVG, St Antonius and Tergooi are gratefully acknowledged for providing materials and medication.

The surgeons performed the surgery on a voluntary basis in their own time.

Team Ghana 2017

Maarten Simons, Frank Ijpma, Eddy Hendriks, Nanette van Geloven, Bert van Ramshorst, Djamila Boerma, Wouter te Riele, Daphne Roos, Ernst Steller, Jasper Atema, Tjibbe Gardenbroek, Jip Tolenaar, Charlotte Loozen, Anne Loes van den Boom, Marjolein Leeuwenburgh, Joost Hoekstra

The Dutch Operation Hernia Foundation

Maarten Simons, Frank Garssen, Djamila Boerma, Nanette van Geloven and Eddy Hendriks

Missions

November 2015 “Operation Hernia” Mission to Bole, Ghana

Visiting Team

John Budd – Team Leader – Vascular and general surgeon

Anna Budd – Theatre nurse

Graham Howell – Urologist and previously a general surgeon

Rosemarie Howell – Theatre nurse

Travel Itinerary

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

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

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

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

Accommodation

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

Surgical Achievements

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

Adult Inguinal hernias 61 Inguinal Herniotomies (children) 15

Femoral hernia 1 Umbilical hernia 1

Hydroceles 18 Epigastric hernia 2

Lumps and bumps 8 Minor ano-rectal surgey 1

Four Emergency procedures were also performed:

Laparotomy and splenectomy for trauma

Appendicectomy for gangrenous appendix

Laparotomy and repair of perforated distal ileum for blunt injury

Caesarean section and tubule ligation

Training

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

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

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

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

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

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

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

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

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

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

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

Graham Howell 29/11/2015

Missions
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.

The Team, Bole

MARCH 2012
The team had initially been set up to travel to the Republic of Cameroon but because of delays in obtaining official letters of invitation needed to obtain visas a late change in destination was enforced. Cameroon will now be visited later on in this year I understand.

The Team, Bole

The Team, Bole

The English (John, Roger and Anna) and German (Guido, Thomas, Lilianna and Cordula) contingents having tentatively approached each other at gate 37 terminal 5 at Heathrow made their introductions and boarded BA81 bound for Accra. The initial omens were not good when take off was delayed by over an hour whilst the ground crew replaced a loose panel in the engine housing and then the in flight entertainment system failed. Things got worse when due to a mix up with communications we were left stranded at the airport for nearly two hours as nobody was waiting to meet us. Fortunately everyone remained very positive and in good humour and we were well looked after by a very attentive security guard and his mate (who were handsomely rewarded!). After a few phone calls by Chris Oppong we were eventually warmly greeted by Adams and Cosmos and transported to the Unique Palace hotel for the night. During the transfer a wrong turn resulted in an unplanned excursion through one of the seedier districts of Accra that has probably remained undiscovered by most tourists to Ghana. At one point we thought that we might never see our German friends again as they disappeared down a side street and we lost phone contact. We did however all manage to meet up at the hotel around 1.30am for a well-earned slumber in air-conditioned rooms.

Rising a little later than initially planned we breakfasted and set off for Bole at around 8.00am. The journey through the capital was relatively pleasant but on reaching the outskirts the main road seemed to vanish and became a mixture of dirt track and large potholes for about 30 miles! These 90 minutes of “entertainment” would have aptly graced any amusement park as a ride called “The Boneshaker”. At the end of this stretch the road turned into a virtually unblemished “motorway” for the next 7 hours giving us a relatively smooth birds-eye view of a typical Sunday in Ghana. The only obstacles on the road were the numerous broken down lorries and the free roaming sheep and cattle that took some avoiding. We arrived at our accommodation at the Cocoa Research Institute of Ghana in good time to meet Dr Joe our medical host and discussed the plan for the week over a very welcome cold Star beer. Compared to the other accommodation in Bole the Guest House was like a 5 star hotel but it was still somewhat basic by European standards. We were however extremely well looked after and the food was very tasty.

Monday started with a brief introduction to the hospital staff and we then unloaded the large amount of equipment and disposables that we had all managed to obtain from various sources in the UK and Germany. It would be very helpful if some shelves could be put up in the “storeroom” to make it easier to find things once they had been stored. We then visited the wards to check “some” patients and after an hour had seen nearly 40 patients (enough for 2 days operating!) with a mixture of hernias and hydrocoeles. Dr Joe had very efficiently recruited all the patients for the week via radio, television, local newspapers and leaflets and we all commend him for his sterling work. The hospital has 2 functioning operating rooms and we therefore divided in to two teams of 2 surgeons mixing the pairings on some days. One of the first patients was a 4-year-old boy who had his hernia operation carried out under ketamine that worked extremely well. During the course of the mission a number of children of similar age were operated on in a similar fashion and there were also a handful of patients who required spinal anaesthetics rather than local anaesthetic. All of these anaesthetics were carried out by Raymond a very proficient Cuban anaesthetist on secondment to Bole for 3 years. He had been accompanied to Bole by his wife (a physician) who was unfortunately struck down for the third time in a year with malaria. She was really quite unwell and this certainly reinforced the fact that we needed to take our anti-malarial medication religiously. The first day saw a total of 18 patients operated on between the two theatre teams and we finished about 7.00pm. What struck us all was the very muscular physique of all the patients especially the males and during the week we did not see one patient who would be classed as even a little overweight. We were also impressed by the sheer size of the hernias and hydrocoeles the likes of which we rarely see in the UK or Germany.

Village, Bole

Village, Bole

Operating, Bole

Operating, Bole

Tuesday started with breakfast at 7.00am which was the first meal so far that didn’t contain cold baked beans! It was then off to the hospital to start what turned out to be a rather gynaecological day. Lilianna (Thomas’s partner) a consultant gyaenocologist was presented with a 24-year-old woman with a grade 3 prolapse caused by a previous very prolonged labour. Her husband would not have intercourse with her and the only treatment normally available to her would entail a hysterectomy. Because of her age this would cause her husband to divorce her, as she would not be able to bear any more children. Lilianna successfully carried out a sacrohysteropexy to the patient’s great delight. Our lists were then interrupted by two emergency Caesarean sections performed by Tamara, a very excitable Cuban gynaecologist, assisted by Lilianna. Again we finished at about 7.00pm.

Wednesday saw nothing out of the ordinary apart from the fact that we became a little more adventurous with our evening meal choosing beef as opposed to the chicken that we had had for every lunch and evening meal up until then.

On Thursday as well as continuing the sterling work in the operating theatre we had the opportunity to visit some of the patients we had operated on in their villages. We did this in two groups to enable work to proceed as normal in the 2 operating theatres. The visits proved to be fascinating not only to see how quickly the patients got back to normal activities but also to experience first hand what life in a Ghanaian village community entailed. We had the chance to talk to the village people and also had the opportunity to visit the local school in Kiape to chat to the teachers and pupils (the latter ranging from age 4 to 14). We also visited Bole senior school where a significant number of pupils are boarders. Cordula the only non-medical member of the team took the opportunity during the rest of the week to explore the town and converse with the local people bringing back many fascinating tales.

Our final day of operating proceeded in a similar fashion to the rest of the week and at about 4pm we actually ran out of patients. We even managed to fit in a number of patients in the afternoon with various lumps and bumps. In total over the week we carried 94 procedures on men, women and children the vast majority under local anaesthetic. We had the opportunity to use sterilised mosquito net meshes that worked extremely well. Unfortunately we were not able to teach any of the Ghanaian doctors since Dr Joe is the only physician in the region and he was kept busy with all the other patients. We operated on 2 local Chiefs during the week and as an indication of their importance we noticed that they were always placed at the front of the queue when they arrived. We also had the opportunity to visit the town’s bustling market on Friday where we were made to feel very welcome with absolutely no hassling. We all commented on how lovely and friendly all the Ghanaians we met were and how they all seemed to be wearing continuous broad smiles and spouting “wicked” laughs (especially Adams!).

As a special treat after we finished on Friday Matron had kindly organised a send off party with drinks, food and even a bit of dancing. It gave the Bole hospital staff chance to thank all of us but more importantly it gave me the chance to thank all of them for making us feel so welcome. The four male surgeons were presented with Chief’s shirts and the females with material celebrating the 50th anniversary of the Ghana Nursing Association to make garments of their choice.

We left early on Saturday morning not looking forward to our 11-hour road journey back to Accra but with extremely fond memories of all of the people we came in to contact with in Bole. Anna would not recommend the goat fufu however!

We would all like to reiterate our thanks to Dr Joe and the staff at Bole hospital. Finally we would also like to thank the Ghana Government for facilitating our mission. We will be visiting again.

John Budd
Team leader

This is the second visit to Bole Hospital in Northern Ghana. The first visit was in November 2010. The team comprised Mr Chris Oppong and My Aby Valliatu.

The Medical Director, Dr Joe Nyuz and his theatre and ward teams should be congratulated for a well organised project. Adequate numbers of staff were mobilised. They were all well motivated.

A whole ward was dedicated to the project. This allowed a smooth and efficient transfer of patients to and from theatre and contributed immensely to success of this campaign. Once again we had good accommodation and were well looked after. We paid a courtesy call on the Bole Chief. He later presented us with a goat and yams.

Outcome: Aby and I performed 97 procedures in 79 patients. This is a rough average of 20 procedures a day!! We worked over only 4.5 days.

The highlight was the repair of huge bilateral femoral hernias. Each of the hernias were associated with a huge varix of the femoral (NOT SAPHENOUS) popliteal junction. The varices were plicated to reduce their size without occluding the lumen of the femoral vein. I had a similar case at Carpenter in 2010 and was assisted by Mr Hanafy. I wonder whether there is an association!

Training: One local surgeon, Dr Abraham Tsetsegah was trained in hernia mesh repair and given some mesh to use in his hospital. We hope to train more surgeons when we visit in November.

Future Development: The Medical Director of BOLE Hospital would like more than 2 Operation Hernia visits a year for both service and training. I will organise some more teams to visit in 2012.

Acknowledgements: We are again grateful to our sponsors – Unisurge; Leonhard Lang; Ansell; MEMS, Derriford Hospital – for their tremendous support.