Alan & Roland

Penny Howell reports from Chachapoyas, Peru 23 March – 5 April 2013

OPERATION HERNIA, CHACHAPOYAS, PERU

Operation Hernia ran 2 missions to Peru in 2012, both to the capital city, Lima. This was the first visit to a rural area of the country, run again in conjunction with Dr Jaime Herrera, President of the Society of General Surgeons of Peru. The local co-ordinator was Dr Rolando Ramos, Consultant Surgeon in Chachapoyas in the Amazonia region of Northern Peru.

Alan & Roland

Alan & Roland

The mission was based in Chachapoyas, a small town 650km north of Lima. For logistical reasons of patient transport, the first 3 days were spent in Bagua, a smaller town 160km away, but co-ordinated through the hospital in Chachapoyas. Bagua is at an altitude of 400m, was hot, with temperatures of 30 degrees and humid. Chachapoyas, at an altitude of 2,300m was colder, about 16 degrees, and still suffering from the rains of the wet season. It was also high enough to cause some altitude sickness in susceptible individuals.

The incoming team comprised surgeons Alan Cameron (leader), James Barnes and Ria Rosser from UK, Dan Scopetta from USA, Cea Cea Moller from Australia and anaesthetist Penny Howell from the UK. Dan Scopetta’s son, Andy, was the only non-medical member of the team, who had been co-opted for his Spanish language skills.

The Peruvian surgeons were Dr Jaime Herrera from Lima and Dr Rolando Ramos from Chachapoyas, with surgical assistants Drs. Enrico, Lucio and Jesus. An enormous amount of work had been done locally before the arrival of the team. 440 potential patients had been identified and about half the number had been selected for surgery. Many came from distant villages, some as far as 12hr travel away, and transport had been organised. The incoming team met in its entirety for the first time at Tarapoto airport, there to be greeted by Drs Herrera and Ramos, 3 vehicles and their drivers. We set off on the 260km drive to Bagua, arriving there at about 10pm after a very long day of travel.

At 7am the next morning we were taken to the hospital where the first stop was the ward, to examine the 27 patients for the day and mark them with operation site and type of anaesthetic.There were 3 theatres, only one with airconditioning, which was unfortunate with temperatures of 30 degrees. There were 2 operating tables in each theatre, except when one theatre was used for emergencies. Each table had its own scrub nurse, but often only one runner for both tables. The nursing staff worked extremely hard: several had come from Chachapoyas to help, along with the 3 surgical assistants. If spinal anaesthesia was used, the scrub nurse often assisted the anaesthetist, before prepping the patient, preparing the instruments and then assisting the surgeon.

Two tables in each operating theatre

Two tables in each operating theatre

Recovery

Recovery

Communication could have been a problem: two surgeons spoke a little Spanish, Dr Herrera was with us for 3 days and spoke fluent English. After he returned to Lima we relied heavily on Andy Scopetta, who was fairly fluent in Spanish. He also rapidly learnt the ways of the operating theatre, and was able to find sutures and mesh for the nurses and acted as an extra runner in theatre. The whole team learnt some rudimentary medical Spanish (dolor=pain, toser=cough, poncho=drape) and the enthusiasm of the nurses ensured that we eventually understood what they were trying to communicate.

We worked 2 long days in Bagua, finishing at about 9pm, followed by a beer, a meal and an early night. The last day was a half day, as we were due to move on to Chachapoyas: we finished the last patient at 4pm, celebrated with a pisco sour (a Peruvian speciality of brandy, lime juice and egg white, delicious!) with the theatre team, and then helped pack up all the equipment. After a late lunch we set off for Chachapoyas as darkness fell, arriving there at about 9pm. We were met by hospital and local medical staff, including the head of Health services for the Amazonas Region. After a brief tour of the surgical ward, where the 25 patients for the following day were in the process of being admitted, we went for dinner with all the staff. 2 of the team, already suffering the effects of altitude, went straight to the hotel: in all we lost 2.5 surgeon operating days to altitude sickness.

The next morning started with press conference with team members and representatives of the hospital and local health authorities. The mission was featured on local TV and radio programmes. Chachapoyas is a larger hospital with more staff than Bagua. Of the 4 theatres, one was only used when free from emergency operating, and two others had two operating tables apiece. Additional anaesthetic assistance was provided by Dr Laura, wife of Dr Rolando Ramos, who also helped ensure the paperwork was completed and kept in order.

It was good to work alongside members of the team who had joined us in Bagua, now on their home territory of Chachapoyas and it made our new environment seem less strange. Although the daily number of patients was greater in Chachapoyas, being a larger department the turn around time between cases was quicker so we finished slightly earlier in the evenings, by about 7pm. The system in both hospitals was that the patients were admitted the evening prior to surgery, and were clerked on the ward by the intern. The 3 interns were excellent and very hard working: they were expected to clerk the patients and then join us at meals and later, on sightseeing expeditions to act as interpreters (their English was good).

The pathology was inguinal, femoral, epigastric, umbilical and incisional hernias. There was one post-traumatic hernia from a stab wound. During the 8 days of the mission a total of 211 patients underwent 243 operations. Of the multiple operations, most were bilateral inguinal hernias, although one patient had 4 hernias repaired, bilateral inguinal, epigastric and umbilical. Local anaesthesia was mainly administered by the surgeons, sometimes with sedation. Spinal anaesthesia was performed for 44 cases, mainly for multiple or irreducible hernias. General anaesthesia, for 16 children aged 3 – 12, was with mask and airway, the one adult GA was intubated.

One patient returned to theatre for exploration of scrotal haematoma on the day of surgery, and no other complications have been notified to the team. The chief of the local health authority was interested in the work of the mission, and very helpful. She was also keen to audit the results, which will guarantee robust follow-up. A daily tally of patients treated by Operation Hernia was displayed outside the hospital in Chacapoyas for all to see.

The work done by the mission seemed generally appreciated. At the end we had a formal send-off from the mayor and various health authority officials, with speeches and presentations.

Daily Hernia Count:: Chachapoyas

Daily Hernia Count:: Chachapoyas

The middle weekend was Easter, and although we worked through the weekend, we witnessed and joined a procession carrying a statue of the Virgin through the streets on Good Friday, accompanied by crowds and a brass band. There was time for sightseeing in this interesting and less frequently visited area of Peru at the end of the trip.

The pre-Inca remains at Kuelap, 500 years older than Machu Picchu were fascinating, although the approach road was disconcertingly primitive and precarious (and since our visit has been washed away in the rains). The visit to the Gocta waterfall, reputedly the 3rd highest in the world was a very damp affair, with pouring rain and landslides causing road blockage on the way home, the waterfall only dimly glimpsed through the cloud and mist.

The museum at Lleylebamba, with the mummified remains of Chachapoyas dead was well worth the 2.5 hour trip into the remote mountainous region. The mission took place in the wet season, which is not a good time to travel in this region. Closure of the only road out of Chachapoyas due to landslides was a daily occurence, causing transport delays. The team left one or two days earlier than planned, to avoid missing flights, but then all managed a last meal together in Lima, with Dr Herrera, who had returned earlier for official duties.

Lasting impressions? From the patients and their relatives, the appreciation of and gratefulness for our efforts. From the staff, the warmth and friendliness, despite a lack of common language. The acceptance and the sense of humour, as always, carrying off the sticky moments in theatre. The team, working together across nationalities and cultures, for the benefit of those tremendously disadvantaged patients.

It was an unforgetable experience, hard work but enjoyable and the team, as well as the patients, all benefitted in different ways. We were all privileged to have been part of it.

Dr Penelope Howell

April 2013

The team: James, Scott, Andrew, Denis & Petr

Lima Peru 11th of February 2012 – 25th of February 2012

Operation Hernia travels to South America again, this time to Peru.

The team: James, Scott, Andrew, Denis & Petr

The team: James, Scott, Andrew, Denis & Petr

The Operation Hernia team was made up of 5 surgeons and a general practitioner. Dr Petr Bystricky travelled from the Czech Republic, Dr Denis Blazquez from France, Dr Scott Leckman from the USA, Dr James Brewer from the UK, and the team leader Professor Andrew Kingsnorth and Dr Jane Kingsnorth also from the UK. All members of the team apart from James had previously participated in a successful Operation Hernia mission to Nigeria in 2011, and were looking forward to working together again in Lima. The mission was lead by Professor Andrew Kingsnorth and co-organised by Dr Jaime Herrera, the president of the Peruvian Surgical Society, who from the very beginning overwhelmed us with his hospitality, enthusiasm and commitment towards the success of the project.

After our long flights, a good nights sleep at the three-starred Hotel “El Ducado” in Miraflores Lima was not difficult to achieve. We all gathered in the morning for an exciting guided city tour of Lima with Dr Herrera. We were then invited to the city’s country club for an exquisite buffet lunch with some members of the Surgical Society and the lead surgeons from the two hospitals taking part in our campaign. After a delicious lunch, which included our first Ceviche (a very tasty traditional raw fish dish) and a Pisco sour (a rather pleasant Peruvian grape spirit based cocktail), we all felt we had been spoiled with a fantastic welcoming reception. For a few hours we believed we had just begun an exotic holiday, until after lunch when we were gently brought back to reality as we were informed of our next day’s agenda! At 8:00am a welcome ceremony would take place, followed by an operating list that included 25 patients, some with multiple hernias, and at least 6 enthusiastic Peruvian surgical trainees each keen to receive training from the visiting surgeons. It was then decided that we should visit the hospital that first afternoon to hand over our 6 surgical instrument sets for sterilisation and our own “Special Mesh” in preparation for our busy first day. The Prof and James met the hospital staff and gave the instructions for cutting the mosquito mesh and organised its sterilisation.

North Lima shanty town

North Lima shanty town

Miguel, Jaime & David

Miguel, Jaime & David

Week one. Hospital Dr Carlos Lanfranco la Hoz (HCLH), 13th – 17th of February 2012

HCLH is an 82 bed district general hospital located in Puente de Piedra, an area on the northern outskirts of Lima. It is surrounded by arid hillsides populated by a community of 1 million inhabitants with a high degree of social deprivation. Their precarious housing constructions densely cover the hills of “Puente de piedra” and “Ventanilla.” The reality of the poverty present in this huge shanty town hit us even harder when we learned that the locals often refer to these hills as “the human sediment.”

The morning breakfast at the hotel at 6:30am consisted of a bread roll, butter and jam, coffee, and the unpopular phrase “no orange juice before 7:00am!” Transport pick up was at 6:45am followed by a 1 hour journey through the busy city traffic “skilfully” negotiated by Manuel our driver.

The welcoming ceremony at the hospital was an impressive occasion. We were welcomed by the hospital’s chief executive, and read official documents that included a governmental act that authorised the Operation Hernia team to perform surgery in Peru during the campaign. Words from both the hospital’s medical director Dr Ricardo Torrez Vazques and from Professor Kingsnorth generated a great deal of enthusiasm and excitement during the ceremony. Prof’s surgical trajectory and the voluntary participation of the OH surgeons were highly regarded by the local staff. James had undertaken his surgical training in England but had grown up in Venezuela. His fluent Spanish meant he was able to simultaneously translate the speeches given by Prof Kingsnorth and the Peruvian doctors.

Every morning, Dr Miguel Jorge, a driven general surgeon and key coordinator of the campaign waited for us at the hospital’s entrance. Miguel and the department’s chief Dr Pablo Pittar Arias had invested a great deal of time and effort preparing for the campaign. From patient selection and staff distribution, to allocation of training, documentation, and lunch arrangements, every aspect had been perfectly orchestrated by Miguel, Dr Herrera and Dr Pittar Arias. Every patient was selected, pre-assessed and consented by the local surgical team in the weeks leading up to the mission. Patients were instructed to attend the hospital at specific times of the day and were then admitted to the theatre area in groups of 3 or 4 to be assessed by a member of our team. Kingsnorth clinical classification of each hernia was documented, the hernia site was marked, and each method of anaesthetic was decided by members of the OH team. Each patient was then cannulated by one of the nurses and guided by the anaesthetist to one of the 4 operating tables available. Each Operation Hernia surgeon was assisted by either a fully trained surgeon or a surgical trainee allocated to that case. The hospital had 3 operating theatres, two for elective surgery and one dedicated emergency theatre. All other elective surgery was cancelled during that week, therefore allowing us to use two large theatres equipped with two operating tables and two scrub and anaesthetic teams.

The atmosphere in the hospital was very uplifting. The staff were very skilful and accommodating, the patients were humble and grateful for the service, and the surgeons and trainees were very keen to learn the surgical techniques. Doctors and staff from HCLH showed particular interest in local anaesthetic hernia repair techniques, principles of day case surgery, tissue handling techniques, Lichtenstein repair, component separation ventral hernia repair (Ramirez technique) and the use of the Mosquito Net Mesh.

Lunch took place at the hospital cafeteria and was sponsored by the Peruvian Surgical Society. The team’s favourite dish from this small canteen at HCLH was “Lomo salteado” (stir-fried strips of meat spiced with typical Peruvian flavours and white rice) which was really quite tasty!

In the evenings the team gathered in the hotel lobby for a chat, a refreshing drink (usually “Cusqueña” which was a delicious local lager) and a sandwich. We also went for a swim in the pacific sea close to the hotel and on occasion we went out for dinner and drinks, which was invariably stimulated by the phrase “let’s-go-pisco”!

Our work in HCLH meant that many patients were treated, local surgeons learned about our techniques and surgical concepts, and a very long waiting list for hernia repairs in this particular hospital was reduced by 6 months.

During this first week the team operated on 98 patients, performing a total of 111 procedures including 5 bilateral inguinal hernia repairs, 2 giant inguino-scrotal hernia repairs and a giant ventral incisional hernia repair using a “Ramirez” component separation technique.

Watching the carnival

Watching the carnival

The weekend

Prof, Jane, Scott and James left Lima on Friday to start a highly anticipated “adventure” to Cusco and Macchu Pichu, while Denis and Petr stayed in Lima and visited local attractions.

Cusco and the ruins

The plan was to land in Cusco and take local transport to Aguas Calientes the same day. We would then hike up to the ruins of Macchu Pichu on the Saturday morning. Unfortunately, and as predicted by the weather forecast, it rained heavily for 2 days resulting in severe flooding of the railways. This meant the trip to the famous ruins regrettably had to be cancelled. We therefore changed our itinerary and travelled to the sacred valley and the incredible ruins of Auyantaitambo. We spent time in Cusco discovering its fascinating ancient history and sampling its delicious foods, including the very traditional Guinea pig….. interesting!

The city of Cusco lies at an altitude of 3550m. It’s a culturally rich city with the local population’s ideology and commerce clearly revolving around the fascinating Inca culture. While we became accustomed to a mild version of altitude sickness we embraced the opportunity to visit local ruins, markets, fairs, peruvian gourmet restaurants, bars and street parties. It was a real treat.

Week two. Hospital Maria Auxiliadora (HMA). 20th-24th of February 2012

The second stretch of our campaign took place at HMA, a large teaching hospital located in the “San Juan de Miraflores District” on the southern border of the capital. It has 323 in-patient hospital beds and serves a population of around 2 million people. Dr Miguel Flores, the head of the surgical department, and Dr Humberto Vargas, an experienced local general surgeon dedicated most of his time to the coordination of the campaign during this week. This hospital was on a much larger scale and had 6 well-equipped operating theatres dedicated to general surgery, gynaecology and surgical emergencies, three of which had been reserved for our operating lists during the week. A total of 99 surgical cases were selected from a long waiting list and pre-assessed by Dr Flores and his team in the weeks prior to the mission. Between 22 and 25 patients were admitted to the surgical wards the day before their procedure. On their arrival to the ward each patient was clerked in by local surgical residents who each demonstrated a great degree of enthusiasm throughout our time at the hospital.

Again Manuel the driver picked us up every morning at 6:30am at the hotel and drove us to the hospital. This involved a 45 minute intricate trajectory through the centre of Lima, avidly avoiding collision with other intrepid drivers and especially with the small three-wheeled moto taxis. The first day we became lost and spent 30 additional nervous minutes looking for the sizeable hospital building, while our driver told us numerous terrifying stories about people being mugged, stabbed, shot at and kidnapped at every corner we passed along the way. He is probably still laughing at the memory of the look on our pale faces. Since only James could understand his stories in Spanish he did admit to censoring the information when translating to the group to avoid a state of panic on board!

On day one at HMA we had a short welcoming ceremony with the hospital authorities and the press. Professor Kingsnorth then divided our team in to groups for the start of the day. Peter, Scott, and Denis went straight to theatre and Prof and James visited the surgical wards to see each patient on the list. The patients were examined, classified and marked every morning at the bedside by two Operation Hernia doctors guided by a ward surgeon and several surgical residents, who distinctively wore pristine white scrubs and rather bulky hip pouches.

We quickly adjusted to the new routine and got on with the job at hand. This being a teaching hospital gave us the opportunity to engage in interesting clinical and scientific discussions with consultant surgeons and residents. The trainees and consultants were keen to observe and learn the Lichtenstein repair techniques, since the department’s preferred method tended to be a pre-peritoneal mesh repair or Stoppa repair, used specifically for recurrent or bilateral inguinal hernias.

Whilst walking around the surgical wards we were shown a few patients that had had appendicectomies using a locally trialled experimental method, a single incision transumbilical open appendicectomy. During our short sceptical period of exposure to this procedure we saw patients doing well and witnessed good cosmetic results.

Half way through the week we attended the bi-monthly Peruvian Surgical Society meeting as special guests. The meeting took place in a modern large auditorium close to the centre of Lima and was chaired by the president (and by this time our friend) Dr Jaime Herrera. The meeting had an impressive attendance of about 70 surgeons from all across the country. The talks were also transmitted live via video to other national centres. On this occasion the Operation Hernia team members were presented with official recognitions from the Peruvian Surgical Society and Prof Kingsnorth was made an honorary member. One of the highlights of the programme were the two lectures given by Prof Kingsnorth, which included the Lichtenstein Hernia Repair and Component Separation Ventral Hernia Repair Techniques, followed by a prolific round of questions and answers coordinated by Dr Herrera. These were simultaneously translated by James to the audience and to Prof using wireless headphones from a tiny glass cabin located at the back of the room. For James this activity was more tiring than a whole day of operating at the hospital. The team was also interviewed by the press and appeared in national television during the campaigne.

By the end of the second week the team had operated on 85 patients and 11 of these underwent bilateral inguinal hernia repairs. Prof performed and demonstrated a component separation repair and an interesting repair of a post-traumatic lumbar hernia. Only three cases were cancelled; one young girl with a very small (3mm) umbilical defect, one male patient who presented with groin pain in whom a hernia could not be found during our clinical assessment, and a lady who was unfortunately diagnosed with breast cancer after a highly suspicious breast mass was picked up during our morning pre-operative assessment. A further 11 patients did not attend the hospital on the day of their scheduled surgery.

Throughout the campaign patients were selected for different methods of anaesthesia. 61 % were done under local anaesthetic +/- sedation, 27% using an epidural, and 12% under general anaesthesia. The mosquito net mesh was used for all surgical procedures requiring mesh reinforcement. All patients received antibiotic prophylaxis. 95% of the patients were discharged home on the same day. No significant immediate post-operative complications were reported, however a more detailed immediate and long-term complication report is expected in due course.

Our departure

The Mission to Peru was an intense and very gratifying experience. We worked long days and had short but entertaining evenings. The team demonstrated a great level of professionalism, surgical skill and commitment towards this very special humanitarian work.

An incredible 183 patients with 211 hernias received surgery during our 10 days in theatre. 12 consultant surgeons and 40 residents from all around the country assisted and observed the operations. The Peruvian Surgical Society and the local health care professionals treated us with great respect and our efforts felt greatly appreciated and their hospitality was certainly enjoyed.

Our Peruvian journey ended with an invitation for dinner at an eminent restaurant in Lima with our new Peruvian friends and surgical colleagues. Lima, Peru, their people, their culture and this experience will certainly hold an important place in all of our memories. Operation Hernia has already planned another visit to Peru this year and envisages many more successful collaborations in the years to come.

Written By James Brewer

Acknowledgments

Operation Hernia, The Peruvian Surgical Society, Hospital Dr de la Hoz, Hospital Maria Auxiliadora, Dr Jaime Herrera, Dr Miguel Jorge, Dr Miguel Flores, Dr Pittar Arias, Dr Ricardo Torrez Vazques, Dr Humberto Vargas, Dr David Ortega, Prof Andrew Kingsnorth, Dr Jane Kingsnorth, Dr Petr Bystricky, Dr Scott Leckman, Dr Denis Blazquez, Dr James Brewer.

And with special thanks to all members of staff and residents working at both hospitals.