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

Home and away team

Takoradi March 2013 Report of the Belgian – Italo – Dutch team. Visit from March 9 – March 17 2013.

Home and away team

Home and away team

In March 2013 a team of four Belgian surgeons (Myriam Bruggeman, Paul Van Acker, Marc Huyghe and Casper Sommeling) accompanied by an Italian surgeon (Cecilia Ceribelli), two registrars (Stijn Heyman from Belgium and Annelien Morks from the Netherlands) and a Belgian nurse (Pina Orlando) again visited Takoradi in Ghana. Our main financial sponsor still is the Belgian Section of Abdominal Wall Surgery. 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 luggage. Local anesthetics, syringes and needles were donated by Bbraun an BD; only the lidocaine with adrenaline and heavy Marcain was bought by us in Belgium.

This way for Hernia Operation

This way for Hernia Operation

Recovery

Recovery

After arriving at Accra, late Saturday night, for the first time we stayed at the Ghana Baptist Mission. The following Sunday we made the trip to Takoradi, meanwhile visiting Kosa Beach.

Again “the girls” (Kate, Linda and Benedicte) took good care of us, although they had more difficulties than the years before due to the frequent power cuts. They even proposed us to switch to a hotel, but their “candle light suppers” were much appreciated by us. This year we were lucky to meet Brian Dixon again, who was on “holiday” in Takoradi; however this means trouble shooting for him as a second nature, or as he states it “there are no problems, only challenges”. He contributed again to our mission in several ways, mainly on a logistic level, but also on solving local problems. He even might have solved the problem of running water in Dixcove hospital.

Paul & Brian

Paul & Brian

During the week we organised three teams that rotated in the three different hospitals (Hernia Wing, GPHA and Dixcove). We performed 86 operations in 86 patients, of which nine were children. Again most of the adult patients presented with groin hernias. The total number of operations seems low for the total number of team members but we were plagued by power cuts and interfering caesarean sections. This year in the adult patients two-thirds (51/77) were operated under local anaesthesia, but loco-regional anaesthesia (26/77) 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 of course were operated under general anesthesia.

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 is of a reasonable level, but the Dixcove Hospital is in need of sharp scissors and new operation gowns. 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 the “Gilou” restaurant 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 again we spent a wonderful day. At Sunday morning our group split up. Marc started on a trip of ten days through Ghana. Paul and Myriam stayed another week in Takoradi for holiday; however they were motivated to operate on the patients that were left over from the first week in the GPHA-hospital, so the first two days of their holiday they operated eleven patients (included in the total of 86).

Pina stayed another two weeks in Takoradi to work in the hospital as part of her training to be a specialized nurse. Cecilia, Stijn, Annelien and Casper made the trip back to Accra with a stop at El Mina Castle. Conclusion: again a rewarding mission; if the future team will enclose again as much members as this year we might go to other places in Ghana. We once again want to thank Bernard Boateng for the organization at the local level: selecting the patients on forehand and helping us out during the week.

Special thanks to Brian Dixon, just because being there.

Casper Sommeling, on behalf of the Belgian – Italo – Dutch Mission

Grace, Lilian, Kate and Brian

Dutch Team, Takoradi, Ghana 10-19 JANUARY 2009

The Dutch team consisting of Maarten Simons (consultant), Frank Garssen (experienced tropical doctor and surgical resident) and Astrid Huiberts (surgical resident) operated at in Takoradi from January 10-19.

Grace, Lilian, Kate and Brian

Grace, Lilian, Kate and Brian

We had a wonderful time thoroughly enjoying performing the operations, meeting Ghanaians and visiting parts of the country. After arrival we drove to Takoradi arriving there at 2 a.m. being welcomed at the guest house by Brian Dixon and our hosts for the week Kate, Lilian and Grace. We are very grateful for all the effort that was put into making our trip a success. Brian was closing down his office but this did not stop him from worrying about our wellbeing 24 hours a day. On our final day when we were traveling back to Accra he called us 23 times informing whether the drive was OK, if we had found Rebecca our guide, if the lunch was OK and if enough salt was added to Frank’s sandwich. The girls were a delight. Cooking wonderful meals and joining us for trips to the market and the beach. We will not forget their singing on the way from the beach back to Takoradi. Beautiful songs and beautiful voices. We were sad the car drive was over. We hope that the girls will continue being part of Operation Hernia and certainly that Brian will stay involved. It is hard to imagine the stay without his help.

Sunday we met Bernhard Boateng and discussed the week. He thought we were with two teams and had planned 40 patients; 25 in the hernia wing and 15 in the Ghana Ports and Harbour Authority hospital. We agreed to try to help all the patients by spreading them over the week and working in two teams on the last day. In 5 days we managed to perform 40 operations in 38 patients. We had taken material for 40, so our suitcases were empty at the end of the week. Everything went very well. The Hernia Wing and GPHA are well equipped. The nursing staff are well trained and fun to work with. They work very hard without complaining and put the wellbeing of their patients first. We operated on five children, two women, two bilateral, two recurrences and almost all hernias were scrotal. Very educating for the two residents! We performed one orchidectomy for an ectopic testis and scrotal hernia and for a huge hydrocele a hemiscrotectomy in an old man. With Bernard the residents performed drainage and excision of an infected mesh with a fistula of two months. The patient had come quite late with this complication. This is of course the nightmare of operating with mesh and everything must be done to keep the complication rate at an acceptable low percentage. We gave prophylactic antibiotics and Bernard had chosen to give all a 5 day cure of Stafoxil. Sterility in the OR is good. Rules are abided by although lack of enough drapes and running water can be a disadvantage. We used large meshes that before the first patient were cut into 8 smaller meshes and kept them under a sterile drape during the day. Dr Frank and Dr Bernhard deserved and received our deep respect for their work in Takoradi. Running a hospital and being a generalist physician who treats all patients (children and adult) with all diseases (as surgeon, obstetrician etc) with relatively little is an immense responsibility. They deserve as much support as we can give.

We truly hope to hear if there are complications of our work. The infected mesh that we had to remove in a young adult was hopefully an exception and infrequent complication. It would be a good idea to have all patients put into a databank so that results can be monitored more closely. We spoke about this with Bernhard and he would come with a proposal for some research in this area.

We performed a small study into the EHS classification system. All hernias were independently by the three of us scored for type of hernia preoperatively (H classification) and peroperatively (EHS). We hope to publish the results in 2009-10.

The second weekend we stayed at Axim beach. Very relaxing. We played soccer with the local kids, swam in the wonderful sea and enjoyed the sunshine. Sunday we were picked up by Brian and the crew that sang us back to Takoradi. Monday we visited the rain forest, Hans Cottage and Elmina. Finally on Monday evening we were on our way home. We will be back.

Maarten Simons
Frank Garssen
Astrid Huiberts