At Work

Takoradi, Ghana January 2014

Operation Hernia – Polish Team to Takoradi/Dixcove (Ghana)

18-25.January 2014

Team members: Maciej mietañski, Kamil Bury, Magda Bury, Maciej Pawlak, Stefan mietañski, D. Richert

At Work

At Work

Since 2005 Operation Hernia sends doctors of good will to Takoradi in Ghana to help Dr Bernard Boateng Duah to treat people suffering from hernia and related diseases. On the 17th of January 2014 three doctors under leadership of Maciej mietañski fled cold Polish winter and have landed in benevolent and warm embraces of Accra to become a part of fantastic charity mission.

After a day of traveling with few sightseeing stops in Kakum National Park and Elmina Castle we have reached Takoradi. During the week of intense work the two teams, one in Takoradi and the second in Dixcove, we have managed to operate more than 50 cases. For the young doctors Kamil Bury and Maciej Pawlak it was an amazing and memorable experience. We were the second team to work in Dixocve and were met with fantastic welcoming and gratitude and therefore generated a good spirit of cooperation and much satisfaction.

Maciej mietañski as always made an excellent work, operating on the most difficult cases and performing as many as 10 operations per day. In both Takoradi Hospital and GPHA Hospital we were met with good atmosphere that made the hard days of surgery pleasant and memorable.

The last few days of our mission we have spend recharging batteries on the beach near Akwidaa, beautiful place with long sandy beaches, huge waves and cold Star beer.

Unfortunately good times ends to fast and our pack had to leave Ghana and head back to Poland where thermometers were showing -15oC. We will surely return with some more help and a mission to the Northern Region.

We would like to thank Dr Boateng for all of his help and for being there for us in the difficult moments and also to Linda and Benedicte for taking good care of us in the Villa. Special thanks to the staff in the Takoradi Hospital, GPHA Hospital and Dixcove Hospital for their help and worm welcome.

Polish Team Takoradi.

Members of the Team

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

Background

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.

Preparation

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).

The Mission

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.

Personal Experience

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.

Social Aspects

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.’

Summary

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.

Recommendations

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)

Acknowledgments

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.

References

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

Table 1

Table 2

The Team

3-11 March 2012
In March 2012 a team of four Belgian surgeons (Myriam Bruggeman, Paul Van Acker, Marc Huyghe and Casper Sommeling) accompanied by an Italian surgeon(Cecilia Ceribelli) and a Belgian nurse (Pina Orlando) again visited Takoradi in Ghana.

The Team

The Team

We brought meshes (kindly donated by Medri, Covidien Belgium, Bard Italy and Assut Europe), gloves (Cardinal Health/Medline), disposable drapes (Mölnlycke Belgium and Medline) and suture material (Johnson & Johnson). Resterilized polypropylene meshes and so called “Indian meshes” made part of our overweight luggage. Local anesthetics were donated by Bbraun, only the lidocaine with adrenaline had to be bought by us in Belgium.

This year special thanks to the Ghana Ministry of Health presented by Dr. Kwesi Asabir, Deputy Director Human Resource, who welcomed us Sunday morning in Accra.

After arriving at Accra, late Saturday night, for the first time we stayed at a hotel in Accra. The following Sunday we made the trip to Takoradi, meanwhile visiting Elmina Castle and Kosa Beach.

At arrival Sunday night in “the Villa” a nice meal was ready for us. Again “the girls” (Kate, Linda and Benedicte) took good care of us. The food they prepared was fine and far better than the Western food served in the local restaurants.

During the week we organised three teams of two, that rotated in the three different hospitals (Hernia Wing, GPHA and Dixcove). We performed 88 operations on 81 patients, of which eight were children. Most of the adult patients, presented with groin hernias (in six bilateral). In almost all these cases a Lichtensteinrepair was performed. For the first time we did use sterilised mosquitomesh (or Indian meshes, as it sounds less charged) we brought with us, in about half of the Lichtensteinrepairs. The handling is surprisingly good and suturing works fine. Half of the patients were operated under local anaesthesia, but loco-regional anaesthesia was used as a standard in all three locations in the more demanding scrotal hernias, contributing to a better comfort of the patients. There were four patients operated on recurrent hernia, of which one with an acute strangulated hernia on Sunday-morning just before we were to leave for Accra. The children of course were operated under general anesthesia, as well as one patient with a large upper abdominal incisional hernia.

Again this year there were some challenging scrotal hernias, and also the age of the patients we operated on is still increasing. The oldest patient was 94 years of age and in good condition!

The advantage this year was that we could split up in three teams of two, so that we could assist each other and could share the frustrations in operation another challenging hernia. Even if you think to have seen it all, another situation presents itself.

Operating Takoradi

Operating Takoradi

The motivation of the local hospital teams is excellent and the level of care of the nurse-anesthetics in the three hospitals is high. The equipment in the hospitals (also in Dixcove) is of a reasonable level. There was probably a shortage of heavy marcaine in one of the hospitals, and maybe also of gowns. The operation table in Dixcove is waiting a repair, so that it can be lifted to normal height.

Although with three teams we still made long days, but once again it was rewarding.

After a long week hard work we had dinner at the Planters Lodge Friday night together with Bernard Boateng Duah and his wife.

On Saturday we made a trip to Green Turtle Lodge, the nicest place to be at the Atlantic Coast, were we spent a wonderful day. At Sunday morning we said goodbye to the girls; on arriving at the GPHA-hospital to say goodbye to Bernard he had a little surprise for us. While the rest of the team took a trip to discovery the Takoradi-harbour, Bernard and Casper did perform an emergency operation for a recurrent and now strangulated groin hernia. Luckily for the patient and also for us the strangulated intestine was still vital, so we could preform a Lichtensteinrepair.

After that we drove to Accra, and after a last meal in the Airport View Restaurant we arrived at Kotoka Airport to travel back home again.

Conclusion: again a rewarding mission; due to the fact, that we were with five surgeons and one nurse, we could in teams of two operate in the three hospitals. We know the work we do is a drop on a hot plate, but it is very worthwhile on an individual level. As Belgian-Italo team we will engage us to go back next year to Takoradi.

We once again want to thank Bernard Boateng for the organization at the local level: selecting the patients on forehand; helping us out during the week and operating the people afterwards, that were on the list at GPHA but could not be operated by us.

Casper Sommeling, on behalf of the Belgian – Italo Mission

The Dutch Team

14-24th JANUARY 2012

The Dutch Team

The Dutch Team

This Operation Hernia mission was a collaboration between the Diakonessenhuis Utrecht and the Groene Hart ziekenhuis Gouda. A team of 4 surgeons and 2 surgical residents arrived in Accra, Ghana on the 14th of January.

On the 15th we made our way to Takoradi, where we were warmly welcomed by the ladies in the Government Guesthouse. On Monday morning we could finally start with our Operation Hernia!

The upcoming week we would perform our operations in three different hospitals: The Hernia Wing and The Harbor in Takoradi and finally the local hospital in Dixcove, a small village which is a 45minute drive from Takoradi. Each morning breakfast was prepared for us and we were picked up by a driver to bring us to the different hospitals.

In Takoradi we usually performed five to six operations: patients were preselected by a Ghanaian surgeon. On the morning of the operation we saw the patients and judged if we would perform the operation. Most patients had an inguinal hernia and unless the patient was not fit or the hernia was irreducible we would operate them. There were children as well as adults and we also treated some prisoners. Surgery was mostly performed under local or spinal anesthesia.

Some patients had a bilateral hernia, an (para-) umbilical hernia or a hernia cicatricalis (= a scar hernia caused by a previous operation).

In Dixcove there were not as many patients as we had hoped for: usually two or three a day. We usually had time to visit the village with the fortress by the sea or go to the market in Takoradi if we were scheduled for an operation day in Dixcove.

Tarora Hospital

Tarora Hospital

In all hospitals the OR personnel was good and spoke English very well, unfortunately the patients usually did not speak English and communication could be difficult.

A Ghanaian surgeon performed one surgery with our team on a patient with a large irreducible hernia. It was very useful to see how he performed the operation. Since they usually do not use a mesh he asked our team to finish the operation by placing the mesh. The meshes we did not use were left behind for the local surgeons to use. In total we treated approximately 65 patients.

After the last day of operations in Takoradi, we drove to the north during the nighttime. The road was uneven and because it was pitch black around us it was a spectacular ride. We arrived at Turtle Beach and could hardly see where we had arrived. But most important, we heard the wild sea and saw thousands of stars! The next two days were for relaxing, running and visiting the nearby village.

On Monday morning we were picked up by the driver and drove back to Accra. Along the way we stopped at the Cape Coast fortress, built by the English and also used by the Dutch to ship out slaves. After a last Ghanaian meal we were driven to the airport and said goodbye to Ghana: It was a wonderful experience!

German American Team 2011

A German/American mission visited three regional hospitals in the area of Takoradi and Dixcove in southwestern Ghana from 14th to 25th July. The first team from Berlin consisted of Dr. Petra W?lkering (anestetist), Zhanna Bourtseva (OP-assistant and scrub-nurse), Manuale Menke (anestetist-nurse) and Dr. Ralph Lorenz (surgeon), who was leading the whole team.

German American Team 2011

German American Team 2011

The second team consisted of MD Timothy Napier (surgeon) from Mauston/Wisconsin, Dr. Karl Spitzer (surgeon) from Munich/Germany and Mario Frey (OP-assistant and OP-attendant) from Hamburg/Germany.

The suspected problems with the excess baggage (ca. 250 kg) on the check in desk where fortunately absent as well as the expected problems with the customs in Ghana. In Takoradi we were kindly accomodated in the Villa, the guesthouse of the Health-Department, where Kate, Lilly and Barbara expected us and supplied us lovingly with all we needed the whole mission through. A big heartfelt thanks to all!

The first two days were taken for acclimatisation and team-building and lead us to the sightseeing-points of the area. On Saturday already we visited on the way to a dreamlike beach of the Gold-Coast also the hospital in Dixcove, a small city westward of Takoradi. In that moment we were not aware that our humanitarian mission was also scheduled for this hospital. During our survey we were struck by the fact that no doctor was around ? he was attending an advanced training course in Accra for two weeks, we later heard.

During our survey in the hospital one patient touched us especially: a six year old boy was accommodated on the same day after a gas-explosion had caused third-degree burns in his face, both arms and both legs – the nurses did the wound treating meanwhile. This case would accompany us throughout the following week. We felt empathy and hoped passionately together with the nurses and attendants to save his life.

On Monday 18th July, we began with our work with two teams in Ports and Harbour Hospital (Takoradi) and in Takoradi Hospital. We performed surgery from 8 am to 8 pm treating as many patients we could. 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 three hospitals under the supervision of Dr. Bernhard Boateng-Duah for their perfect preparation and coordination!

Scrub Nurses, Dixcove

Scrub Nurses, Dixcove

Dr Ralph Lorenz

Dr Ralph Lorenz

The statistics added up to 77 operations on 67 patients within six days: All together 61 inguinal hernias were operated, including 32 inguinoscrotal hernias. 15 patients had a hernia with a 20 cm hernia sac (Kingsnorth classification H3/4-20 and 4 patients were treated with a large-size Hernia with a 30 cm hernia sac (Kingsnorth Classification H3/4-30). Futhermore 9 ventral hernias (6 primary -epigastric and umbilical and 3 incisional hernias) as well as 7 hydroceles were operated.

All of the three hospitals were attended by our teams within those six days. 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 additionally a hydrocele. Anesthetic methods included local as well as general anaesthesia, in certain cases spinal anaesthesia was the preferred method. Besides a postoperative hematoma in one case, all operations were successful without complications. The majority of the patients were outpatients. In addition, we assisted in one emergency-laparotomy and we supervise patients with chronic wounds, accident injuries and a thoracic drain. Mrs. Dr. W?lkerling however managed to give a lot of advices and tricks to the anesthetic nurses in charge. Our wish to instruct other local surgeons could unfortunately not be satisfied, since no Ghanaian surgeon could be present at that time.

The sustainability if our mission resulted mainly in giving away a lot of medicine materials the surgeons are now able to use. Without the generous support of numerous private and company donations as well as from the German Hernia Society this mission would have been unthinkable. We have gained a lot of positive insights through this humanitarian mission. Emotionally most touching was the deep thankfulness of the patients, and last but not least of the nurses and hospital workers.

The great success of that mission was mainly possible because of the distinguished capacity for teamwork of every participant. All team-members expressed their wish to participate on the next humanitarian mission. Furthermore, a lot of colleagues in Germany have a lot of interest for that project, and also uttered to participate themselves the next time. The small boy with the severe burns was at the same time attended by our team, especially through giving him urgently needed wound dressings and medicine. After initial fever, he was at the end of our mission ‘out of the woods’, free of fever and the large wounds were healing.

New hope for a new life! We are deeply thankful!

Ralph Lorenz f?r das Team Germany /U.S.

In March 2011 a team of three Belgian surgeons (Stefaan Poelmans, Marc Huyghe and Casper Sommeling) accompanied by an Italian registrar (Cecilia Ceribelli) visited Takoradi in Ghana.

Belgian Team, Ghana

Belgian Team, Ghana

We again flew with Lufthansa/SN Airlines, which company we have to thank for giving us the opportunity to bring 15 kg of extra luggage each, so that we could take enough medical material with us. We brought meshes (kindly donated by BBraun Medical NV Belgium, Covidien Belgium, Bard Italy and Assut Europe), gloves (Cardinal Health), disposable drapes (M?lnlycke Belgium), suture material (Johnson & Johnson), local anesthetics (Astra Zeneca and BBraun), analgesics, syringes and needles. After a wearing drive from Accra to Takoradi through some heavy thunderstorms, we arrived very late Saturday night at ‘the Villa’ were we had a good night sleep.

Sunday morning we took a cab to Green Turtle Beach Lodge, were we had a nice and relaxing day. Returning to Takoradi we made a stop in Dixcove were we observed and admired the return of a local fishing boat. In the evening we met Bernard Boateng, who again did the selection of the patients on forehand.The living circumstances in ‘the Villa’ are good. ‘The girls’ (Kate, Lilian and Benedicte) took good care of us. The food they prepared was fine and far better than the Western food served in the local restaurants.

During the week the three surgeons rotated in the three different hospitals (Hernia Wing, GPHA and also for the first time Dixcove), accompanied by Cecilia. We operated on 74 patients, of which seven were children. Most of the adult patients, presented with groin hernias (61, in seven bilateral), in some accompanied by a hydrocele. In most of these patients a Lichtensteinrepair (with standard middle weight polypropylene) was performed. We did not use mosquito nets. Three other patients only had hydroceles.

Most patients were operated under local anaesthesia, but loco-regional anaesthesia was used as a standard in all three locations in the more demanding scrotal hernias, contributing to a better comfort of the patients. The children ofcourse were operated under general anesthesia; in Dixcove the induction was done by the child relaxing on the back of the headnurse walking around.

Casper and patient

Casper and patient

Again this year there were some challenging scrotal hernias, and also the age of the patients we operated on is increasing. The oldest patient was 90 years of age and in good condition!The presence of a registrar is useful; firstly, because she could assist us, but secondly and more important, we could assist her in performing operations, that will lead to more experience for her. She performed ten operations. The motivation of the local hospital teams is good and the level of care of the nurse-anesthetics in the three hospitals is high. The equipment in the hospitals (also in Dixcove) is of a reasonable level, but although we were convinced that we brought enough material, again at the end of the week there was a shortage of drapes, gloves and sutures. As can be understood by the total of operations performed we individually made long days, but it was rewarding. Even the last Friday we operated in the Hernia Wing until after eight o’clock in the evening.

After a long week hard work we had dinner at the Planters Lodge Friday night. On Saturday we made a trip to Bushua beach, were we had a nice day at the beach. Sunday-morning we said goodbye to the girls and were brought to the Kakum National Park, were we made a quick trip to the forest and made the Canopy Walk. Entrance prices were threefold from last year and it starts to look like a ‘tourist trap’. Much more pleasure we had from a visit to the ‘Monkey Forest Resort’ near the Kakum National Park. This resort was founded by a couple from the Netherlands. They try to save left-alone animals, that are brought to them by the locals. A visit is worthwhile (at the right side of the road when you drive to Kakum). After that we had (like last year) a nice meal at the Birawa Beach Restaurant. After a challenging drive to Accra (we were getting a little late) we arrived at Kotoka Airport just in time.

Conclusion: a rewarding mission; due to the fact, that we were with three surgeons, we could operate in Dixcove Hospital, where there is a nice atmosphere and were patients are taking good care of. For this moment we think a mission to Takoradi should consist of three surgeons and one or two registrars. The participation of trainees should be encouraged. Also the presence of a nurse is valuable; a nurse can discuss and control some matters of sterility with the local staff. The presence of an anesthesist in the team seems not so important, because of the qualifications of the local nurse-anesthesists.