INTRODUCTION

This is the first Operation Hernia mission to Botswana. The Operation Hernia team worked at Kanye Seventh Day Adventist Mission Hospital (KSDAH), a district hospital at Kanye. The Botswana mission has been in the planning stages for over a year.  Much credit goes to the CEO, Dr Innocent Mugandi and the local Surgeon, Dr Andrew Ojuka but also to Dr Kabala the CMO, the Hospital Matron Keabitsa Ramatele and Mr Patson Kaumba the Finance Manager who worked in the background to facilitate the process.

Botswana is a beautiful developing country blessed with very welcoming people and adorned by famous nature reserves. Years ago, it was classed among the 10 poorest countries in the world. The diamond and cattle industry have, however, transformed the country and its people. The country is the size of France but has a meagre population of 2 million. The south has vast lands of arid savannah. The north has more tropical weather.

The capital, Gaborone was a very pleasant surprise. It is a modern city with several shopping malls which are all well patronised. There is easy access to ATMs all over the city and even at Kanye.  The streets are clean and the sky is blue with no haze.

KANYE TOWN

Kanye is the capital of the Southern District of Botswana. It is 83 km south of the capital Gaborone. It is served by only one district hospital which is the SDA mission hospital.  Although Botswana is an African country, this time of the year is their winter. We were surprised by the cold nights, when temperatures dropped to 4 degrees centigrade and in the morning.

KANYE SDA HOSPITAL

Kanye hospital is a 167 bed hospital efficiently run by the CEO and his administrative staff. It is relatively well equipped and staffed compared to district hospitals in other developing countries visited by Operation Hernia. The first impression the hospital makes on visitors is its cleanliness.

OPERATION HERNIA TEAM

The team comprised Mr Chris Oppong, Consultant Surgeon (Team leader), Mr Paul Fisher retired Consultant who works part time and Boikhutso Shianaya who is a male nurse at the Nuffield Hospital in Plymouth. He is a Batswanan. He trained and worked at Kanye Hospital before moving to the UK. He was the link between Operation Hernia and Kanye Hospital. He arrived in Botswana 2 days ahead of the rest of the team.

TRAVEL ARRANGEMENTS

All volunteers paid for their travel costs. There is a flight to Johannesburg and a connecting flight to Gaborone, arriving on Sunday June 25, 2017. We were welcomed warmly by a hospital party who also sorted out one luggage that did not arrive on our flight.

ACCOMMODATION

The team was housed in a hospital guest house which was on site. Food was provided by the hospital kitchen.  We were provided with very warm safari blankets to battle the surprisingly extremely cold nights and mornings.  Our jumpers came in handy too!

MEDICAL REGISTRATION

The registration process began well before we left the UK. The licensing authority in Botswana, the Botswana Health Professionals Council (BHPC), were not satisfied with our documentation and therefore we spent the best part of Monday, the first day of the mission, sorting this out. Our hosts were extremely helpful in the negotiations with the BHPC.  Later in the day we met all the operating theatre and ward staff as well as the hospital administration.  Chris Oppong stressed the need for team working and the importance of every member of the team.

PATIENT RECRUITMENT

The mission was promoted in clinics and schools in the KSDAH catchment area. As a result most of the patients were children with large umbilical hernias.  A list of 15 patients was compiled for each of the five days.  All the patients were previously screened by local doctors. The Operation Hernia team examined all the patients either the night before or on the day of surgery.  A few patients who had insignificant hernias were reassured and discharged.

WARD

The ward staff deserve a great deal of credit. They ensured that patients were prepared for theatre in a timely fashion. They were available to return recovered patients to the ward on time and the nurses made themselves readily available to assist the surgeons on ward rounds.

Nurse Boikhutso Shianaya was an effective liaison officer linking the wards and theatre.  He ensured that patients who had their operations under local anaesthetic were managed as day cases where possible.  Preparation of theatre lists appeared to be a novel concept. This seems to be the experience of the Operation Hernia team on our travels. We will suggest ways to facilitate generation of theatre lists.

HOSPITALITY

1. The loss of activity on Friday provided an opportunity to visit the Mokolodi Nature Reserve. This was generously organised for us by the hospital management and for which we were very grateful. The “rhino trekking” was a most exhilarating and very successful adventure as we were able to get so close to these ferociously massive but at the same time “friendly” beauties of the Mokolodi wild.
2. On Saturday we toured the Gaborone city centre. The highlight of the tour was the Three Dikgosi Monument, an imposing and a truly fitting monument to the three wise men who rescued the soul of Botswana.

OPERATING THEATRE

The first working day was Tuesday, June 27, 2017 started with a meeting with all theatre staff where the week’s routine, team working and the ethos of the mission was discussed to ensure efficient working.

We were impressed with the theatre organisation and the facilities in each theatre. The two main theatres were used for the mission. They are equipped with anaesthetic machines, monitors and piped gas. There was only one diathermy machine. Operation Hernia provided a diathermy machine and accessories, surgical instruments including five Travers self-retaining retractors, sutures and mesh. Local anaesthetic was freely available although we provided 1% lignocaine donated by the Nuffield Hospital in Plymouth, UK.  The nurses were well motivated and enthusiastic.  Mrs Beatrice Manda, is a competent and well taught manager who coordinated the two theatre lists efficiently and as a result patient turnover was impressive.

The two operating lists run smoothly because every single staff member – from the orderly who cleaned the floor between cases to the anaesthetists –  played their role effectively with little prompting. The team worked like a well-oiled Swiss grandfather clock. This is credit to the theatre manager and the staff who were willing to work for her.  No one wanted to let the team down. The third theatre is for minor cases. It can be used for local anaesthetic hernia repairs.

There is a dedicated two-bed recovery ward equipped with a monitor and a portable oximetry/BP Kit for GA cases for both adults and children. The one-to-one care the patients received was commendable. Each operation started with a stripped down version of the WHO check. It was not as exhaustive but demonstrated the ethos of safety in theatres.

At any one time, we had two anaesthetists who provided GA and spinal anaesthetics when required. The most senior of the anaesthetists, Tim, is very experienced especially in anaesthetising children.  He was very supportive of the other two anaesthetists. The hospital provided gowns and surgical drapes. At the end of each day’s session a debrief session was chaired by the theatre manager and attended by all in theatre.

THEATRE EQUIPMENT

Operation Hernia has donated essential theatre equipment and surgical instruments to KSDAH. The list has been published and is outlined above.

MESH FOR HERNIA REPAIRS

Mesh repair of groin hernias is the standard in the developed world. It produces the best long-term results in terms of recurrence. Most developing countries do not routinely use mesh for inguinal hernia partly because of lack of expertise, but mostly because of the affordability of mesh. Operation Hernia provided a low cost, affordable, polypropylene mesh.  The use of this mesh for hernia surgery was first documented by Dr Tongaonker, an Indian surgeon, and has been popularised by Operation Hernia. The affordable mesh has been used by Operation Hernia on missions to low and middle resource countries since 2006. It was sterilised and packaged in the UK for the training workshop.

The safety profile and outcome of repairs performed with affordable mesh is comparable with results from repairs performed with brand meshes.

OUTCOMES

There were, effectively, 2.5 days of operating.  On Thursday, we had only 4 patients. Although the 15 patients had been recorded for each day only 4 were available for surgery on Thursday and no patients turned up for a Friday operating list. This was due to the fact that a much loved and respected former president of Botswana died the week before mission and his burial was held at Kanye, his hometown on the Thursday to be followed by a long weekend holiday. The funeral was well attended. This and the subsequent bank holiday affected patient attendance.

28 procedures were performed in 27 patients. This was less than half of the planned 70 patients due to reasons outlined above. This was made up of 16 umbilical hernias, 4 epigastric hernias, 1 hydrocoele and only 7 inguinal hernias.  52% of the patients treated were children under 13 years of age.  This is the largest proportion of children in any hernia mission undertaken by Operation Hernia. It is heartening to note that there were no complications.

Table 1: Breakdown of cases.

DEBRIEF MEETING WITH MANAGEMENT

1. The hospital CEO, CMO, Deputy Matron and Finance Manager met with the team to review the mission. As a first mission, we all judged the week as a success in spite of the low patient numbers. There were legitimate contributing factors, which have been alluded to earlier. The success was not only due to the very efficient organisation of the mission, it was because all the operations were performed safely. It was unanimously agreed to organise the 2018 Operation Hernia mission at a time to be decided on later.
2. The management debrief was followed by a debrief with all hospital staff where the valuable contribution of all the various hospital staff was recognised. The Operation Hernia team were presented with gifts by the management team.

ACHIEVEMENTS

1. Overall assessment: A well organised and executed programme, proof that KSDAH can organise big international events successfully.
2. Patient throughput:  27 patients with various hernias were treated safely.
3. Operating theatres: Very well organised Theatre sessions
4. Donation: We have donated essential equipment and hernia surgical instruments to KSDAH
5. Ward management: Well-coordinated ward management of patients.
6. Team ethos: Recognition of and engagement with the culture of Team Work

ACKNOWLEDGEMENTS

Operation Hernia would like to acknowledge the support of the following:

1. CEO: Dr Inocent Mugandi
2. Dr Andrew Ojuka: KSDAH Surgeon
3. CMO: Dr Hilaire Kabala
4. Matron: Keabitsa Ramantele
5. Deputy Matron: Dolly Lekgowe
6. Theatre-in-charge: Beatrice Manda
7. Ward-in-charge: Mosibudi Rantadi
8. The KSDAH Drivers
9. Mr Tim Rambiki, Senior Anaesthetist, and the two junior anaesthetists
10. All staff at KSDA

Chris Oppong FRCS, Consultant Surgeon

Chairman, Board of Directors of  Operation Hernia