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.

  No %
Inguinal Hernias 7 25%
Umbilical Hernias 16 57%
Epigastric Hernias 4 14.2%
Hydrocoele 1 3.6%
No of CHILDREN 14 52%

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

Introduction

The main event was a Hernia Course organised for the Surgical Registrars at the teaching Hospitals at Kigali, Rwanda. This was at the invitation of the Head of Surgery at CHUK Teaching Hospital. In collaboration with Rwanda Legacy of Hope (RLOH) – a Rwandan Charity – an ENT team accompanied the Operation Hernia team.

 CONSOLIDATED PATIENT NUMBERS

 TRAINING OF SURGICAL RESIDENTS

The patients were operated on the two centres as shown below: 

Training Centre Patients Operated On
CHUK 39
Rwamagana 46
TOTAL 85

  SERVICE DELIVERY

  Hernia Surgery 

Hospital Patients Operated On Adults Children
Gahini 45 25 20
Kigeme 21 20 1
Kirinda 6 5 1
TOTAL 72 50 22
       
HERNIA TOTAL 144 100 44

  

 ENT Surgery 

Hospital Patients Operated On Adults Children
CHUK 12 0 0
       
   

  SUCCESSES

  1. Intense training of 14 Surgical Residents in hernia surgery. Most of the trainees were trained to the level of “Able to perform procedure with minimal help”. In the process, 85 patients were offered surgery for their hernias.
  2. Very good feedback from trainees regarding hernia lectures and training in the operating theatre.
  3. Effective collaboration between RLOH ENT surgeon and CHUK ENT surgeons. Plans for the 2018 mission to include training of registrars agreed were agreed.
  4. Equipping Rwandan Hospitals to the tune of over 100,000 Euros.
  5. Successful recruitment of 32 Volunteer Consultant Surgeons and Anaesthetists and Nurses from UK, Germany and Austria. They all funded their own travel and other related costs.

  ACKNOWLEDGEMENTS AND GRATITUDE

1The Government of Rwanda arranged Medical and Nursing Registration for the RLOH Medical Team.

2. The Government of Rwanda waived all Custom and Clearance costs for medical equipment imported by RLOH

3. The Government of Rwanda provided high quality accommodation for RLOH team during their stay in Kigali. The Hospitals provided the accommodation for teams that worked in the district hospitals.

4. The Government of Rwanda funded a Certificates Ceremony.

 

CHRIS OPPONG FRCS, CONSULTANT SURGEON

MEDICAL DIRECTOR RWANDA LEGACY OF HOPE AND CHAIRMAN OPERATION HERNIA

 

Report of Operation Hernia.nl’s Mission to Ghana, January 2016

Our recent missions to Keta and Sunyani in Ghana took place from 9 – 17 January 2016. They were heart-warming adventures focussing on both treatment and education.

It is a great honour to inform you that the Dutch team of “Operation Hernia” recently finished a successful seventh mission in Ghana. “Dutch Operation Hernia” started in 2009 with three dedicated surgeons and has expanded significantly over the course of the years. This year a team of 15 went to Ghana to use their surgical skills to treat children and adults with inguinal hernias.

The prevalence of inguinal hernias in Ghana is high (7.7% among male citizens) and nearly 25% of patients have to cease professional activities due to their symptoms. Despite these numbers elective hernia surgery is rare in this country. Elective surgical programmes are unusual in Ghana as many regular government hospitals are understaffed (with an average of only nine doctors per 100,000 citizens). Consequently, 80% of patients with a symptomatic inguinal hernia remain untreated. Besides a fundamental effect on daily activities these untreated hernias bear a substantial health risk with mortality rates of up to 80% in case of incarceration and strangulation.

Therefore, the key aims of ‘Operation Hernia’ are treating as many patients as possible and, at least as important, teaching local doctors to perform hernia surgery independently. After having treated 143 patients and having trained nine local doctors we look back on a very successful week in both respects. We are delighted to provide you with some of our impressions.

As soon as we arrived in Ghana, all 15 doctors were divided into two groups; on Sunday the 10th January one group took a short flight to Sunyani whereas the other group went by road to Keta.

Keta mission (8 physicians, supervised by Dr Boerma and Dr Garssen)

As soon as we got out of the car we smelled the African odour of little bonfires and heard warm African music played at the small road-side shops. The weather was beautiful with a warm sun and blue sky. We instantly enjoyed the great beach vibe in town. The beautiful hostel we stayed in, situated along Ghana’s southern coastline, was even more beautiful and relaxing.

The next morning, the hospital bus picked us up from up from our hostel to take us to the hospital. Keta Hospital is a lovely, small and clean provincial hospital with 300 beds and 5 medical officers. After a short walk through the hospital gardens on our way to theatre, we were welcomed by the friendly theatre staff. After a short introduction we started with the operations. A total of 70 hernias were operated by the Keta group. Inguinal hernias (severity grade H1 to H4) were treated with a Lichtenstein procedure, using meshes which were brought from the Netherlands. Although the main focus was inguinal hernias, other hernias such as umbilical and incisional hernias were also operated by the team. Local, spinal and ketamine anaesthesia were used.

The hospital staff and the Dutch Operation Hernia team worked well together. Local doctors were joining the operations to learn and practice Lichtenstein procedures. We were very pleased to hear that one of the medical officers even performed a Lichtenstein procedure on an incarcerated hernia on his own, one week after we left!

In the evening we spent time enjoying real Ghana life. We swam in the sea, listened to music, danced with local people and enjoyed the local food. We had a nice interaction with colleagues from the hospital who we invited for diner on the last night. The hospital administrator gave a beautiful speech and thanked us for all the effort. On Friday afternoon we finished the last surgical procedures and travelled back to Accra. But not before a thousand pictures were taken and all telephone numbers were exchanged.

Sunyani mission (7 physicians, supervised by Dr Simons)

After an impressive flight through inner Ghana we arrived in Sunyani, the capital town of the Brong-Ahafo Region with over 250,000 citizens. We were welcomed by Professor Tabiri, a well-respected surgeon born and bred in Sunyani and one of his residents, Dr Eric Owusu.

We took up residence in a nice lodge after which we were introduced to the team and, more importantly, to our patients in Sunyani Regional Hospital. We were impressed by the warm welcome and by the great facilities including well-maintained surgical theatres in this large teaching hospital.

The next morning, after an inspiring speech by the hospital’s medical director, we started with a fruitful team briefing in which the plans for the upcoming week were discussed.

As soon as everybody was aware of these plans surgery could start. Teams of Dutch surgeons, Ghanaian medical officers and Ghanaian scrub nurses made a great effort to treat all 75 patients who had responded to ‘the call for treatment’. Similar to the Keta mission, the most frequently performed procedure was mesh-based inguinal hernia repair using local anaesthetic. For exceptional cases of irreducible and recurrent hernias spinal anaesthesia was available. Children with inguinal hernias were treated under anaesthesia with Ketamine.

By using instructional videos, lectures, but of course most importantly hands-on-training, local medical officers became familiar with the common surgical procedures. Many of them will work independently in small medical posts throughout the country and we have high hopes that hernia surgery will be part of their ‘arsenal’.

Professor Tabiri proved to be an outstanding host next to an experienced surgeon. He showed us around in his hometown, enabling us to fully absorb the Ghanaian culture. What struck us was the inexhaustible optimism and hospitality that was present everywhere we went. During a memorable final evening local gifts from both Sunyani and Amsterdam were exchanged and inspiring words were spoken. Within one week a solid team had been formed and we all regretted that it already was time to say goodbye.

On Friday evening we were reunited with the Keta group in Accra. We stayed at the lodge close to the beach and shared all experiences of the past week. After some leisure time we had to go back to the airport to catch our flight to Amsterdam. Time had gone by so quickly!

We are very grateful for a fantastic experience and we would like to thank all the sponsors below who have made this journey possible. We are all looking forward to expand our mission with the “Dutch Operation Hernia” team next year!

Dutch Operation Hernia Teams: Maarten Simons, Djemila Boerma, Frank Garssen, Suzanne Gisbertz, Nanette van Geloven, Eddy Hendriks, Jonathan Vas Nunes, Anne Ottenhof, Bert van Ramshorst, Wouter Derksen, Frank IJpma, Theo Wiggers, Ellen Reuling, Charlotte Loozen, Maarten Anderegg

Sponsors & partners: Chris Oppong of Operation Hernia, MRC-Foundation Medline Atrium Medical, Departments of Anaesthesia & Pharmacy of: Academic Medical Center, Amsterdam, Amstelland Hospital, Amstelveen, Flevo Hospital, Almere, OLVG Hospital, Amsterdam, Sint Antonius Hospital, Nieuwegein, Ter Gooi Hospital, Hilversum, University Medical Center Groningen, Groningen

PREMIER OPERATION HERNIA MISSION TO KETA HOSPITAL, VOLTA REGION, GHANA
NOVEMBER 9-16, 2013
Mission to Keta Hospital

Operation Hernia activity in Ghana continues to expand. In 2012 a team led by Chris Oppong made a very successful visit to Ho Hospital in the Volta Region of Ghana for the first time. This year, another team made a premier visit to Keta Hospital, also in the Volta Region of Ghana. This brings to nine, the number of Operation Hernia centres in Ghana. The centres are: Bole Hospital, Nalerigu Hospital and Carpenter in Northern Ghana; Takoradi Hospital, GHPA Hospital and Dixcove Hospital in the Western Region; CapeCoast Hospital in the Central Region; Ho and Keta Hospitals in the Volta Region.

Planning: The success of the mission was due to the hard work put into local organisation by the Hospital Administrator, Mr Serene Akpenya, supported by the Medical Director. They deserve very high commendation. Patient recruitment was so efficient, they had over 200 patient registered for the mission. This was as a result of very effective publicity. Half of the patients were reserved for the next mission from Holland in January 2014. All the patients were screened by local doctors, and registered with known mobile telephone numbers. This allowed the hospital to change appointments without difficulty. This will hopefully facilitate follow-up which has been a major issue. Our accommodation was in a local hotel. Transportation was efficiently organised. We had a breakdown on our way from Accra but a replacement vehicle was soon arranged. At the end of our mission, the team were congratulated by the Regional Medical Director.

Team: The team was made up of three Consultant surgeons (Terry Irwin, Roger Watkins and Chris Oppong, the Leader) one Anaesthetist (Stephen Millen), two nurses (Jenny Irwin, Caroline Lee) and a medical representative (Jess Peace). The team stayed overnight at the Baptist Guest House in Accra and were picked up the following day for the trip to Keta. All the surgeons were experienced Operation Hernia Surgeons. The team spirit generated was tremendous.

Theatres: Patients were reviewed by surgeons and their hernias graded and theatre list prepared. All patients had a pre-operative oral antibiotic and an analgesic. We had at our disposal two regular theatres and one theatre that was a converted recovery ward. This latter theatre was used for local anaesthetic cases. All theatres were equipped with diathermy machines. One had to be repaired by local engineers. The theatre and ward staff were all excellent.

Outcome: A total of 101 procedures were performed of which 87 were inguinal hernia repairs, 1 incisional hernia and 2 paraumbilical hernia repairs. 11 hydrocoeles were repaired as well. 5 of the hernia patients were under 12 years old (respectively aged 2, 2, 3, 11 and 12 years). 44% of the hernias were scrotal (Kingsnorth H3, H4). Only 5 procedures were carried out under general anaesthetic. All the other operations were performed under either local anaesthetic or under spinal anaesthetic. GA was administered by the team anaesthetist. Spinal anaesthetic was provided by a competent local nurse anaesthetist and the team anaesthetist. Recovery after GA took considerable amount of anaesthetic time. Teams should equip themselves with portable pulse oximeter. This proved invaluable. Only one immediate complication was recorded: a scrotal haematoma that had to be evacuated in theatre.

To conclude, the premier Keta mission was hugely successful in every department. I will recommend the centre to future volunteers.

Chris Oppong

November 2013

Mission to Nalerigu Baptist Medical Centre
October 2013

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

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

Travel:

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

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

Hospitality:

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

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

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

Facilities:

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

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

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

Outcome:

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

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

Training:

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

Social:

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

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

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

Achievements:

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

Thanks

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

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

We will be back………….

For operation hernia Nalerigu 2013

Dr.Ahmed Elmeghrawi.

The cheque presentation

Wednesday 8th May 2013

Plymouth

Staff at the Nuffield private hospital in Plymouth raised over £4000 to support Operation Hernia. The money was raised through a staff charity ball, which saw donations reach £2,994, and the remainder was put in by staff and patients at the hospital.

Ria Cox (deputy finance manager, Nuffield Health Plymouth) presented a cheque for £4674 to Raj Dhumale, Brian Dixon and Chris Oppong, Board members of Operation Hernia.

The Team

Report from a German-British Mission in Rwanda, February 2013

The Team

The Team

Background

Rwanda – a country on the move: after the genocide with up to 1 million victims almost 2 decades ago Rwanda has evolved rapidly. As one of the countries with the lowest corruption index Rwanda announces an accelerated growth and has established a compulsory school attendance for children free of charge. The government with president Kagame undertakes great efforts in the future program 2020 in the field of birth control, generation of energy and environment. In recent years a revolutionary health system was established: every citizen of Rwanda pays a very low contribution for a health insurance and every citizen gets a primary health care. But there are still a lot of problems: for example there are only 221 physicians for 12 million inhabitants available in Rwanda (0.2 per 10 000 inhabitants comparing to Germany 36.0 per 10 000) and 4050 nurses (*World Health Statistics 2012).

Dr Ralph Lorenz & Dr Dr Elda Balikwisha

Dr Ralph Lorenz & Dr Dr Elda Balikwisha

Dr Maral Miller

Dr Maral Miller

The Mission

After the exploratory mission by Chris Oppong in February 2012 a plan to come back with a big operating team of 12 German and British Healthcare-Professionals could be realized: this bi-national team stayed from 08th to 18th February in two regional hospitals in Nyamata and Remera Rukoma.

The first team from Berlin consisted of two surgeons, Dr. Ralph Lorenz and Dr. Jens Heidel and the anesthetists Dr. Maral Miller as well as and two theatre nurses, Ines Kuhl and Peggy Grassmann.

The second international team consisted of the three surgeons MD Chris Oppong from Plymouth, Dr. Karl Spitzer from Munich and Dr. Christine Kosch from Berlin, the anesthetist Dr. Petra Wölkerling from Berlin, the theatre nurses Helena Azevedo und Sandra Gess from Plymouth and the anesthetic nurse Carolin Dauksch from Berlin.

The expected problems with the excess baggage (24 boxes with more than 500 kg) on the check in desk where fortunately absent as well as any kind of conflict with the customs in Rwanda. The only surprise in Kigali was that we had to remove all plastic film from the boxes, since Rwanda’s law has placed a ban on imports of any plastic bags and packing. So Kigali is a very clean city with no plastic waste at the roadside – what a difference that makes!

Pastor Osee from the Legacy of Hope aid organization had prepared everything perfectly: not only did he organize a really warm welcome at the airport in Kigali with temperatures of 25 degrees Celsius after a long flight from freezing Germany – he also arranged a beautiful accommodation in a nice guesthouse in Kigali.

A big heartfelt thanks to Pastor Osee with his team!

After the first two days for acclimation and team-building, we already visited on Saturday both hospitals for the last preparations. On the following day, the whole teams visited the King Faisal hospital, the biggest and model-hospital in Rwanda by invitation of the CEO Dr. Jean Bosco Butera. We were deeply impressed about the perfectly equipped facilities.

On Monday 11th February we began with our work with two teams in both hospitals, performing surgery from 8 am to 8 pm with as many patients as we could. Still, there were many patients on the waiting list.

At this point we would like to say a deep-felt thank you to the regional persons in charge as well as to nurses and attendants in the two hospitals under the supervision of Dr. Alfred Rutagengwa (medical director of the Nyamata Hospital) and Dr. Kalinda Viateur (medical director of the Remera Rukoma Hospital) for their perfect preparation and coordination!

Resume

The statistics added up to 95 operations on 78 patients within five days:

All together 72 inguinal hernias were operated, including 20 hernias in children and 17 inguinoscrotal hernias. In one case of an incarcerated hernia with chronic abscess formation there was a need for an emergent resection of the small bowel.

Furthermore 10 ventral hernias (epigastric, umbilical and incisional hernias) as well as 14 hydroceles were operated.

Nearly all patients apart of the younger patients were supplied with a mesh. Thanks to the generosity of companies’ donations in all cases original meshes could be used instead of mosquito-nets. All currently possible open operation-techniques like SHOULDICE, LICHTENSTEIN, Plug and Patch and TIPP were applied. The diagnostic findings however cannot be compared to European standards. Nearly all hernias were indirect, mostly with a small defect but with a large hernia sac. In certain cases there was additional a hydrocele.

As anesthetic methods we used mostly general anesthesia with laryngeal masks, in certain cases also local anesthesia and spinal anesthesia. The majority of Patients stayed for one or two nights in the hospital since their journey home would have been too long.

All operations were successful without complications and all patients were discharged from the hospitals during our stay.

The long-term sustainability of this mission resulted not only in giving away a lot of medical equipment the surgeons are now able to use, but also in educating the local Professionals. The surgeons were trained step-by-step in doing Hernia repair with meshes and the local anesthetists received supervision by our anesthetists Marla and Petra. Last and not least our nurses gave a lot of advice and techniques to the nurses in charge. It was an excellent team-work in these mixed teams from Rwanda-Germany and UK. After one week of training Dr. Elda Balikwisha – a young surgical resident at Nyamata hospital has perfectly performed a Lichtenstein Repair by himself – a big success!

Dr Jens Heidel & Dr Nzeyimana Jean Berchmans

Dr Jens Heidel & Dr Nzeyimana Jean Berchmans

After the return to Kigali we got two more personal contacts with people. A Meeting with the president of the Surgical Society of Rwanda Dr. Emile Rwamasirabo has developed a vision of a closer collaboration in case of education. So it might be possible to organize a hernia workshop for all surgeons during a next mission in Rwanda.

A very ceremonial and emotional finish of our humanitarian mission was a church service on Sunday in Kigali with Pastor Osee and a congregation that cheerfully welcomed the European visitors. And after this stressful working week the German team travelled through this beautiful country with its breathtaking landscapes.

Without the generous support of numerous private and company donations as well as the unselfish commitment of all team members this mission would not have been thinkable. The great success of that mission was mainly possible because of the distinguished capacity for teamwork of every participant.

We have gained a lot of positive insights through this humanitarian mission. Emotionally most touching was the deep thankfulness and appreciation of the patients, and last but not least of the nurses and hospital workers. During one week an outstanding personal and cooperative partnership had developed.

All team-members expressed their wish to participate on the next humanitarian mission.

We are deeply thankful and we look forward meeting again in Rwanda!

Ralph Lorenz für das Team Germany /U.K.

February 2013

Dr José Antonio Pascual Montero, 12 Octubre Universitary Hospital, Madrid, Surgeon. Dr Jesús Salvador Torres Jiménez, Infanta Sofía Hospital, Madrid, Surgeon. Dr Jesús Ángel Garijo Ílvarez, Infanta Sofía Hospital, Madrid, Surgeon. Dr Miguel López Vizcayno, Sanitas La Moraleja Hospital, Madrid, Anaesthetist.

We left Madrid on April 23rd at the appointed time without any difficulty in booking the medical material. The flight was normal for some of us and rather exceptional for others who witnessed the landing from the cockpit, courtesy of the pilot. On arrival at the Mariscal Sucre Airport, Carlos Criado (airport commercial director) and Sandra Ocampo were waiting for us and speeded us through customs. The Health Centre staff took directly to La Concordia the parcels with surgical material.

We put up at Sandra Ocampo’s house to be taken later to know Quito’s historical centre, particularly La Ronda, where we saw one of the typical processions of the city, after which we went for dinner to Casa Dami?n, a restaurant owned by one of Dr Pascual’s friends from Segovia. After a night rest at Sandra Ocampo’s house in Quito, we started for La Concordia, where we were received by Dr Kathia Tinizaray and Haydee Caicedo, the three of them essential persons in the organization of the mission. We collected the surgical material to take it to the Alberto Buffoni Hospital in Quinindé where the mission was going to take place and where we were received by the staff very cordially and warmly. We arranged all the material we had with us and left everything ready to begin surgery the next day. Then we came back to the Health Centre where we checked 70 patients in order to programme surgery for the following days. We programmed 50 out of those 70 patients, and we finished work at 18:30 hours.

After some rest we had our supper, a typical barbecued grill from the place, prepared for us by our hosts at La Concordia, Sandra Ocampo and Dr Kathia Tinizaray. After supper we went to our lodgings in the Atos Hotel to gather strength for our mission the following day.

On Monday 25th we got up at 6 a.m. and after taking breakfast we started for Quinindé, at about 40 kms from La Concordia, and we arrived at 7:30 at the Alberto Buffoni Hospital where the staff and the 14 patients in readiness were expecting us. We started operating in the operation theatre they had arranged, but as we were three surgeons and one anaesthetist, we asked for the collaboration of surgeons and nurses of the hospital in order to be able to use the other operation theatre, with the understanding that if an urgency would occur, we would vacate it and would offer our collaboration if necessary.

On that first day we performed 15 interventions on 14 patients (2 eventrations, 6 inguinal hernias, 1 hydrocele, 1 scalp tumoration, 4 umbilical hernias, and 1 epigastrial hernia). One of the eventrations was very large and it required draining and hospitalisation for 48 hours. We want to stress that, besides the help from the hospital staff, two sisters, Carmen Alcibar and Rosa Alcibar, both helping nurses in the infirmary whom we had known in our previous Operation Hernia mission in CSDP in La Independencia, offered their selfless help which, in some moments, was of crucial importance. The work ended at 18:00 hours, and we made our way back to La Concordia in about 40 minutes thanks to the kindness of Sandra Ocampo who lent us her car for coming and going. After a short rest at the Atos Hotel we all had dinner together and got ready for the mission next day.

Tuesday 26: We again arrived at Quinindé Hospital at about 7:30 and started interventions at 8:00 with the collaboration of Dr Zhunala and Dr Preciado, so that we could use both the operation theatres, and we showed them our technique in hernioplastia with mesh, as the use of meshes is not common with them due to the scanty resources at their disposal. On that day we performed 11 interventions (2 eventrations, 2 inguinal hernias, 2 epigastric hernias, 1 criptoquidia, 3 umbilical hernias and 1 abdominal sebaceous cist). One of the eventrations was a huge one and it required drainage and 24 hours hospitalisation. We then left for La Concordia as the previous day in the car Dr Tinazaray had lent us in the morning.

Wednesday 27: Same time of leaving the hotel and arriving at the hospital, beginning our day at 8:00 with the help of the auxiliary staff of the operation theatres, with 12 interventions (2 eventrations, 5 inguinal hernias, 2 epigastric hernias, and 3 umbilical hernias). After finishing work at 16:00 hours we were invited for a meal by the two auxiliary sisters (Rosa and Carmen Alcibar) in their humble house in the outskirts of Quinind?, where we were introduced to their family and we duly appreciated her readiness, selflessness, and the great effort that going to work for the mission entailed. Back at La Concordia we, together with Dr Tinazaray and Haydee Caicedo, were invited for dinner by Sandra Ocampo. With them we planned future missions, and they indicated the possibility of extending such missions to villages in Esmeraldas and Santo Domingo de los Colorados.

Thursday 29: We begin operating at the usual time with 12 interventions (5 inguinal hernias, 4 umbilical hernias, 2 epigastric hernias, and 1 abdominal lipoma). We end at about 15:00 hours and, as a sign of gratitude, we share an aperitif with the operation theatre staff that had collaborated with us. We had a meeting with the director of the Alberto Buffoni Hospital, Dr Saavedra, in which we signed an agreement between Operation Hernia (Dr Pascual signing in the name of professor Kingsnorth), the Hospital and the La Concordia Health Region (Dr Tinazaray) for a three year period. Dr Javier Saavedra thanked us for the work done and urged us to carry out new missions in the Alberto Buffoni Hospital. We collected all the left-over material and we gifted part of it to the same Alberto Buffoni Hospital, and part to the La Concordia Health Centre.

We came back to La Concordia where we were received by the municipality mayor. In a simple act the statement of gratitude for our work was read out, and a copy of it was given to each one of us personally, and one to Operation Hernia. We then started for Santo Domingo de los Colorados, a city of about 200.000 inhabitants, where we were urged to open conversations for the possibility of future missions there. We want to emphasise that out of the 50 interventions carried out, 10 were on children between 2 and 10 years, and 2 on elders over 80. After a night in La Concordia, on Friday 30th we went back to Quito to come back to Madrid on May 1st.

Chris Oppong
Aby Valliatu

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.

Plymouth team, Takoradi 15-22 NOVEMBER 2009

On the 15th of November at 4am a team of 9 arrived in Takoradi, Ghana. 101 procedures, 3 c-sections and one neonatal resuscitation later they returned. After a comfortable flight for some more than others we arrived at Accra airport to be greeted by Mr Oppong and a team ready to get us to Takoradi. After a bumpy few hours we reached the Villa and the smiling faces of the indispensible girls that would look after us for the next week.

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We brought with us surgical equipment and also clothing- football shirts, chalk, maps. Coffee and cereals are very expensive there and I d recommend bring your own if you can t do without. After some rest we were taken out to see some of the surrounding area and stopped by a village in which a young boy had been diagnosed with talipes last year. This time a girl in her early 20s was brought to our attention she was unable to walk due to a gibbus. We later got her to Dixcove hospital where they commenced her on TB treatment which is free.

We worked from 3 centres; in Takoradi the Hernia centre and Ghana Health Ports Authority Hospital (GPHA) and for the first time the more rural Dixcove. I had the pleasure of visiting all 3 places. We were also joined by 4 surgical senior registrars from the Teaching Hospital in Kumasi, Ghana s second Medical School. This training was arranged by Mr Oppong and Prof Michael Ohene Yeboah.

My first day was at the hernia centre I walked in to theatre (the only place with air-con) and within the first few hours I had encountered the biggest hernia I had ever seen (that is till the next day). Over at GPHA there is only one theatre and one man and I finally had the pleasure of meeting the infamous Dr Bernard Boateng-Duah who was responsible for the smooth running of our stay. His unassuming manner belies the fact that he is responsible for all the cases at GPHA. I would also like to thank him for finding all the hernias and the t-shirt! My day at Dixcove started with a bumpy 45 minute journey in a version of an ambulance and I was sat on a seat. There one doctor covers the hospital and a population of 20,000 and he had a smile to greet us. His skills like many doctors in Ghana ranged from medicine to appendicectomies and caesareans. One theatre meant that occasionally lists were interrupted for emergencies. At all the theatres equipment was basic but the staff expertise made up for it. The sets presented to us were variable in terms of quality and quantity and required an open mind. We often didn t arrive home till gone 7 and my hat goes off to Mr Oppong who did 3 days at Dixcove arriving home at near 10 each night with his team.

If you have never experienced living in a developing country it may not be what you expect. However, I found the villa comfortable and welcoming and it added to the experience. We had air conditioning and running water though I must admit we did have a few power cuts. But who can deny the pleasure of being spoilt every evening with a freshly cooked meal and greeted with true Ghanaian hospitality and warm enquiries as to your day. I have never seen such food and the presentation, thanks to Bridget, it was often spectacular. In addition there was Lillian, Kate and Bernadette who made our stay as stress free as they could. Not only did they help with money changing but also shopping! We finished early on Friday and had an hour by a pool before a celebration meal at a local Ghanaian restaurant.

Our special treat for the weekend was a visit to the stilt village and then on to Green Turtle lodge for a night staying in huts on the beach. On the way to Accra to catch our flight we visited El Mina Fort for a sobering tour of the slave trade. The journey was broken for lunch overlooking the sea at Biriwa resort. After freshening up and a meal we left Accra

Although the system is sometimes frustrating there are many battling to try and make a change. Catching a group of children share one sweet without a second thought and the smiles and laughter brought by simply having their picture taken was a lesson in humility. This was probably the hardest week of work I have done. The days were long and we operated non stop. Also we had to contend with a different environment and were constantly challenged in one way or another – be it a loss of electricity, unfamiliar equipment and the language barrier. But the staff friendly and I had to marvel at their innovation and way they worked to minimise waste. It was physically, mentally and emotionally hard at times but would I do it again- of course!!

I would like to thank all those who supported us in various ways from donations of their time, money, equipment or clothing that made this a special trip possible for us and the people we managed to meet along the way.

Eiling Wu
Surgical registrar