David Messenger: First Shorland Hosking Fellow November 2012
The ASiT/Operation Hernia Shorland Hosking Travelling Fellowship to Takoradi, Ghana
David Messenger, ST6 in General Surgery, Severn Deanery
In March 2012, I was fortunate enough to be awarded one of the first ASiT/Operation Hernia travelling fellowships. The funding for my fellowship was donated largely by Howard Eggleston, a former patient of Professor Andrew Kingsnorth’s, and was named in honour of Shorland Hosking, a consultant surgeon from Poole, who died tragically in an air accident shortly after returning from an Operation Hernia mission to Nigeria.
Operation Hernia is an independent, not-for-profit organisation, whose mission statement is ‘to provide high quality surgery at minimal costs to patients that otherwise would not receive it’. It was initiated in 2005 from Derriford Hospital, Plymouth, via the city’s cultural links with Takoradi, Ghana. Operation Hernia has since expanded and to date has repaired over 6000 hernias, at 18 locations in 11 different countries with teams originating from 22 countries.
I have had a long-standing interest in hernia surgery and have never failed to appreciate the impact that an effective hernia repair can have on the quality of life of the patient. It was this opportunity to undertake a humanitarian mission where my surgical skills would be of maximal benefit to a community where healthcare resources are limited that prompted me to apply for the fellowship.
I chose the mission to Ghana, as this was my first experience of humanitarian surgery and I wanted this to be in a well established setting. The prevalence of inguinal hernia in Ghana is as high as 7.7% of the population.1 However, less than 40% are actually repaired, resulting in many patients developing long-standing inguinoscrotal hernias that are associated with a high incidence of morbidity and mortality.2 Presentation is often delayed and approximately two-thirds of cases are repaired as emergencies.
Sekondi-Takoradi is located in the Western Region of Ghana with a population of almost 450,000 (Figure 1). Its principal industries are timber, ship-building and crude oil. The discovery of the latter has led to a dramatic expansion of the metropolitan area in recent years. Most of the adult workforce is engaged in physically demanding jobs where the effects of an untreated hernia can be debilitating. The stark reality is that if you are unable to work, then there is little means to support both yourself and your family. The value of the mission could not be clearer.
The co-ordination of the mission was masterminded by Mr Chris Oppong, a consultant surgeon from Derriford and Director of Operations for Ghana. It soon became apparent that an anaesthetist was required and I duly offered the services of my wife (!), Dr Natasha Joshi, an ST7 anaesthetic trainee, who was supported by a travelling grant from the Association of Anaesthetists of Great Britain and Ireland. Our preparations included undergoing an extensive vaccination programme, obtaining visas from the Ghanaian High Commission in London, arranging flights and gathering together an array of gloves, gowns, sutures, laryngeal mask airways and portable pulse oximeters! We are grateful to the Spire Hospital, Bristol, and those colleagues who were kind enough to donate equipment for the mission. Operation Hernia has pioneered the use of polyester mosquito net meshes as a cost-effective means of hernia repair and these were pre-sterilised at the Derriford and Royal Gwent hospitals prior to our journey.
After arriving in the capital, Accra, the team assembled at a local guest house, before travelling on to Takoradi by road the next day. In addition to Natasha and me, our team consisted of two consultant surgeons from Dewsbury: Mr Shina Fawole, team leader and a veteran of three previous Operation Hernia missions, and his colleague Mr Harjeet Narula. They were accompanied by Melanie Precious, a Senior Operating Department Practitioner, also from Dewsbury, proving the old adage that a surgeon cannot operate without at least one member of their regular theatre team! In fact, Melanie’s scrub and anaesthetic experience were to prove invaluable throughout the course of the mission. The final members of the team included Mr Rafay Siddiqui, an ST4 general surgical trainee from the London Deanery, and Mr Roger Watkins, a recently retired consultant surgeon from Derriford, who joined us for the final two days of our mission after conducting a separate mission to the Cape Coast (Figure 2).
On arrival in Takoradi, we were met by Dr Bernard Boateng-Duah, Chief Medical Officer of the Ghana Ports and Harbour Authority Hospital, who was in charge of the logistical arrangements of our stay. We had the exclusive use of a Ghana Ministry of Health Villa, which provided a welcome respite at the end of a long day’s operating (occasional disruption to the hot water and electricity supplies not withstanding!). The culinary skills of the catering team were superb who ensured that we had the opportunity to enjoy variety of Ghanaian dishes (Figure 3).
Bernard had already co-ordinated the not insignificant task of selecting patients for our mission. Recruitment had largely occurred through radio announcements, clinic visits and perhaps most pleasingly through word of mouth. A prime example of this was the patient who told me he had waited all year for his hernia to be repaired just so the British surgeons could perform his surgery! We operated at three sites during the week: Ghana Ports and Harbour Authority Hospital, Takoradi Hospital and Dixcove Hospital, located a one hour drive from Takoradi (Figures 4 a,b and c). At Takoradi Hospital a disused wing had been refurbished in 2006, with funding from the British High Commission, to create the Hernia Treatment Centre that incorporated an operating theatre and day-case ward.
On the morning of surgery, patients were pre-assessed and a decision made with regards suitability for repair under local, spinal or general anaesthesia. As a general rule, inguinal hernias that were manually reducible were repaired under local anaesthesia, with irreducible hernias or those with a substantial inguinoscrotal component being performed under spinal anaesthesia. General anaesthesia was reserved for incisional hernias and paediatric herniotomies. Over the course of the five-day mission, our team performed a total of 94 procedures in 87 patients (Table 1). Inguinal hernia repairs accounted for 71 cases (including 6 recurrent), of which 39 (55%) were performed under local anaesthesia. The majority of inguinal hernias were inguinoscrotal, or H3/H4 according to the Kingsnorth classification system (Table 2)3. Polyester mosquito net meshes were used for repair in 37 inguinal hernias with the remainder being repaired using brand mesh left over from previous missions. The handling of the mosquito net meshes was broadly comparable to that of brand mesh, although we found that bigger bites with each suture were required to adequately secure the mesh. There were no post-operative complications and all adult hernia repairs were discharged on the day of surgery. Only one patient who had undergone repair of a large incisional hernia stayed overnight.
Initially, repair of the inguinal hernias proved to something of a technical challenge, owing to the anatomical differences between those encountered in Ghana compared to in the UK. Most inguinoscrotal hernias were due to a longstanding patent processus vaginalis that commonly required transection of the sac to facilitate reduction. Furthermore, these hernias were embedded within a well developed cremasteric muscle and tended to encircle the cord structures, which made dissection of the sac more troublesome. In many instances, partial excision of the cremaster was required in order to effect sound mesh repair around the deep ring.
I can honestly say that the experience of operating solidly for 12 hours each day, in an environment subject to power cuts, poor lighting, a lack of running water and frequently defective equipment has been the most rewarding of my career to date! I was especially proud of Natasha, who as the sole anaesthetist dealt effectively with a number of challenging anaesthetic situations, mainly related to leaking circuits and a limited oxygen supply.
During the week I performed a total of 32 procedures: 21 inguinal hernia repairs (three recurrent), six paediatric inguinal herniotomies, two incisional hernia repairs, two hydrocoelectomies and one epigastric hernia repair. Eleven of these procedures were performed independently with the consultant operating in another theatre. Many patients had travelled long distances for their surgery and I was humbled by the gratitude that they showed our team. I was amazed at how well the patients tolerated their procedures and it was often quite difficult to get them to admit that they were in any pain. In the UK, I could never imagine performing a sizeable inguinal hernia under local anaesthetic in a 30 year old male without any form of sedation.
The local nursing staff at all three centres worked tirelessly and were extremely welcoming. There was no need to rely on iTunes for entertainment in theatre, as we were often serenaded with gospel singing throughout the cases! Anaesthetic cover was provided by nurse anaesthetists who for the most part were highly skilled and keen to learn from Natasha. I was particularly impressed by the nurses at the Hernia Centre who were actively engaged in improving their practice and had implemented the use of pre-assessment proformas, antibiotic protocols and a handwashing policy. They were ably led by Sister Marion who had previously undertaken a one month elective placement at Derriford hospital (Figure 5). The only reluctance we encountered from the nursing staff occurred at Dixcove when we embarked on our final case of the day at 7.00pm. We later learned that the staff preferred to leave in daylight hours to avoid the snakes that would appear at night on their walk home!
It was at Dixcove that we encountered patients with the largest hernias (Figure 6). The community at Dixcove is less affluent than Takoradi with one doctor serving the needs of over 20,000 patients. Consequently, these hernias were longstanding and in one instance emergency repair of a hernia that had become obstructed was required. The reality of everyday life in this community was illustrated by the case of a 6 year old boy with an inguinal hernia who only weighed 13kg. We decided not to proceed with surgery as he had a right basal pneumonia and instead admitted him for intravenous antibiotics. Despite also having recently recovered from malaria, his mother was still desperate for him to undergo surgery as his hernia was limiting the physical contribution he could make to domestic tasks.
Ghana was the first African nation to gain independence from the British in 1957 and is proud of its status as a stable parliamentary democracy in a politically volatile region. It is a majority Christian country, with a sizeable Muslim minority, and is compromised of over 100 ethnic groups. It is the relative inter-religious and inter-ethnic tolerance that has seen Ghana avoid the civil wars that have afflicted neighbouring states. Whilst in Accra, we visited the Kwame Nkrumah Memorial Park where we able to learn more about the birth of Ghana as a modern nation and the concept of pan-Africanism (Figure 7). This also proved to be a popular setting for newlyweds to pose for their wedding photographs! It is perhaps the following quote from Nkrumah that best sums up Ghana’s drive to achieve middle-income country status by 2015,
‘We have the blessing of the wealth of our vast resources, the power of our talents and the potentialities of our people. Let us grasp now the opportunities before us and meet the challenge to our survival.’
This was a thoroughly worthwhile mission for all those involved. Despite having never met each other before, I thought that the team gelled together well. Shina was an inspiring team leader, navigating us through several tricky situations (often related to Ghanaian taxi journeys!). Harjeet and Roger provided sound advice and were both excellent trainers. The contribution from Natasha and Melanie was immense who managed to instigate a change in practice with regards to the administration of spinal anaesthesia – tilt the patient head down, rather than perform a second injection of local anaesthetic if the spinal does not act immediately. I found Rafay to be a supportive and well-rounded colleague who like me benefitted tremendously from this experience. It was not until I returned to work in the UK that I realised that this mission has matured me both as a surgeon and as a person. It has taught me to be adaptable, more understanding of the limitations within the NHS and perhaps most importantly has given me a much needed perspective on life. I would recommend, therefore, that any trainee looking to broaden their surgical horizons should become involved with a humanitarian mission.
I have listed below two simple but achievable aims that would improve the quality of care received by the patients in Takoradi.
Routine adoption of the WHO pre-operative checklist at all hospitals.
The purchase of portable pulse oximeters for patient monitoring both peri- and post-operatively. We donated our own to Dixcove hospital. This may be best achieved through Lifebox, a not-for-profit organisation, that aims to put a pulse oximeter in every operating theatre throughout the developing world (www.lifebox.org)
I am grateful to ASiT, Operation Hernia and Howard Eggleston for providing financial support. Thanks must also go to Mr Chris Oppong, Dr Bernard Boateng-Duah and Mr Eddie Prah for ensuring such a memorable and well organised mission.
DL Sander, Porter CS, Mitchell KC, Kingsnorth AN. Operation Hernia: humanitarian hernia repairs in Ghana. Hernia 2008;12:527-529
Clarke MG, Oppong C, Simmermacher R, Park K, Kurzer M, Vanotoo L, Kingsnorth AN. The use of sterilised mosquito net for inguinal hernia repair in Ghana. Hernia 2009;13:155-159
Kingsnorth AN. A clinical classification for patients with inguinal hernia. Hernia 2004;8:282-284
Tables and Figures