In January 2017, the 8th mission of the Dutch team of Operation Hernia took  place. This year a team of eight surgeons and eight residents went to the Ghanaian towns of Keta, Wenchi and Bole. The teams had as goal to treat as many patients as possible.  A second equally important goal was to teach local physicians to perform inguinal hernia surgery with a mesh (Lichtenstein procedure under local anaesthesia), so they would be able to continue performing these operations after the mission had finished, and they eventually can teach others.

On Saturday the 7th January the members of operation hernia arrived in Accra.  The next day 8 surgeons and residents went by car to Takoradi and the other 8 took a domestic flight north to Kumasi.  There they split up and a team of four went by car to Wenchi while the other four drove to Bole in the northwest region of Ghana.

Since elective surgery and in particular hernia surgery is rare in this country, many patients travelled from near and far to be treated by the Dutch team of Operation Hernia.  An untreated inguinal hernia causes, besides effect on daily activities and cessation of professional activities, a substantial health risk.  In case of incarceration, mortality rates up to 80% are not exceptional.  So the goal of our visit is clear: treat as many patients as possible!  And, equally important, teach local physicians and nurses to perform hernia operation and provide care afterwards.

Takoradi team

After a drive of approximately 5 hours we arrived at Takoradi. During the trip we already got to know Ghana a bit and this made us more and more enthusiastic to start our mission. Since Takoradi has a fantastic coastline, we first visited the beach and ended the day with a dive and some drinks over there.  We speculated what the week would bring us.

The next morning, after the delicious Ghanaian breakfast, with Dutch peanut butter, we were split in three groups since we were working in three totally different hospitals.

GPHA is a private hospital.  Dr Bernard Boateng is the leading doctor in this beautiful hospital with even a CT-scan.  The theatre staff were friendly and very capable. Rapidly, an inguinal hernia was followed by a giant hydrocele alternated by an emergency Caesarean section. Days flew by, in total 27 operations were performed in this hospital.  The medical staff were well trained and a pleasure to work with.

The largest hospital, Takoradi hospital has its own hernia wing. The head of theatre there is Marian.  A great personality, she and her team made our mission even more special. Time flew, while working hard in the wing there was a lot of fun! In the Hernia Wing, a total of 29 surgical procedures were successfully performed.  The majority were adult male patients with inguinal hernias treated with a Lichtenstein procedure under local anaesthesia. The severity varied from H1 to H4 (large scrotal hernias), all treated with a mesh brought from the Netherlands. The Takoradi group operated on 9 children under the age of 9.  A herniotomy was performed with general anaesthesia.  In both the Hernia Wing and GPHA, young doctors were joining us to be taught about the Lichtenstein procedure. It was great to see their enthusiasm and we were convinced of their surgical skills.

Dixcove, a small hospital in the more rural area outside of Takoradi, was a great place to visit.  In this hospital, with an anesthetist known for his fast spinal anaesthesia technique, working was extraordinary. The theatre was used optimally, a Lichtenstein procedure was performed while a Caesarean section had to start.  No problem, in Dixcove they perform this at the same time in the same room!  A great experience!  We were very happy to work with the medical staff and hopefully the same applies for them. Working in this hospital was sometimes even a real party, especially when the scrub nurse started to dance to our music in between the surgeries.  The fact that we worked hard besides the fun is shown in the total of 20 surgeries performed. In total 76 patients were treated by the Takoradi group.

 

Bole team

Together with the Wenchi group we took an inland flight north to Kumasi. From there our groups split and the four of us were picked up by Baba, the Bole hospital ambulance driver. All the equipment we brought was loaded in the back of his pick-up truck and off we went. Our six hour drive was interrupted only for a short introduction to the Ghanaian cuisine: banku! (a mixture of fermented corn and cassava dough in hot water).  Along the way the setting changed into more rural scenery.  While listening to the car radio we heard a broadcast to invite patients with inguinal hernia to register for surgery at the Bole Hospital. This way, Dr. Josephat Nyuzaghl (Dr. Joe), one of the two local doctors of the Bole hospital and our contact person, had efficiently recruited patients for surgery!

After a long day of travelling we were welcomed by the hospital administrator and the medical director of the Bole hospital, and Dr. Joe kindly showed us around.  Many patients had responded to the radio broadcasts, so our days started early with the screening of patients that had queued up in front of the male ward.  After this we started surgery and worked together with the enthusiastic local operation team until all patients, that were put on the list that morning, were operated on.  The hospital has two functioning operating rooms and we therefore divided into two teams of a surgeon and a resident mixing the pairings. The vast majority of patients were operated on under local anesthetic, only some patients had a spinal anesthetic. We had the opportunity to use sterilized mosquito net meshes that worked very well.

Vitus, the pragmatic nurse anesthetist, organized the operation list and made sure everyone of the team knew exactly what to do.  Not a minute of our time there was lost. The whole team worked extremely hard, sometimes until late in the evening!  We had little chance to work together with Dr. Jatuat, the young local surgeon, who was kept busy with other patients since he and Dr. Joe are the only physicians in this region.  In total over the week we carried out 83 procedures in 74 men, women and children.  All patients stayed in the ward the night postoperatively and were discharged the next morning.

As a special treat after we finished Dr. Joe had kindly organized a send-off party with drinks and food (guinea fowl). We had the chance to thank the Bole Hospital staff for making us feel so welcome. We were presented with custom made smock, worn on special occasions. We would all like to reiterate our thanks to Dr Joe, Vitus and the staff at Bole Hospital. Finally we would also like to thank the Ghana Government for facilitating our mission. We will be visiting again.

Wenchi team

At Kumasi airport we were welcomed by Dr. Bibi Bosomtwe who took us on a 2.5 hour drive north through the beautiful Ghanaian landscape to the town of Wenchi.  Wenchi is the capital of Wenchi Municipal of the Brong-Ahafo Region in South Ghana with a population of around 40,000 people. On arrival we were greeted by Bernard Clement Botwe, the charismatic CEO of the Wenchi Methodist Hospital.  Afterwards we were brought to our accommodation for the upcoming week, a nice guesthouse just outside Wenchi. Here we were joined by Sarah, a Ghanaian scrub nurse with experience in assisting during the Operation Hernia Missions. She was asked specifically for this mission to come and assist, and to teach the scrub nurses of Wenchi Methodist Hospital.

On Monday morning we were picked up by the hospital bus and were taken to the Methodist Hospital.  It is a lovely typical Ghanaian hospital with approximately 300 beds. We met the anaesthesia medical officers, scrub nurses and the local physician we were going to train, Bismark Kubi.  After discussing our plans for the week we got acquainted with the two small but adequate operating theatres, which were going to be our work environment. The enthusiasm of the complete operating room (OR) personnel and everyone at the Wenchi hospital from the first second of our visit was impressive.

Every day started with screening of the potential patients. Numerous patients from the whole region surrounding the hospital had responded to the call for treatment. After screening, eligible patients were seated outside the operation theatres until surgery. Most patients were treated under local anaesthesia; they walked into the OR, underwent inguinal hernia correction with a mesh, and afterwards walked out of the OR by themselves. For exceptional cases, such as irreducible and bilateral hernias, spinal anaesthesia was available. Children with inguinal hernias were treated under general anaesthesia with Ketamine.

During our stay at Wenchi Methodist hospital, 45 patients with a total of 52 hernias were operated. Doctor Bismark Kubi, who was already well acquainted with hernia surgery but did not have any experience with the use of a mesh, was trained in performing the Lichtenstein procedure.  He proved to be a very skilled, kind and enthusiastic doctor who learned quickly. At end of the week, he was able to safely perform the procedure by himself. As we were able to donate a significant number of surgical meshes, adequate care of inguinal hernias at the Wenchi Methodist hospital can be continued.

We ended the week with a party on the final evening, which we organized to thank the staff of for their kind hospitality. Together with the OR personnel we looked back at a successful and enjoyable week. Kind words were spoken both from the Ghanaian and the Dutch side, and mutual hopes for future collaborations were expressed.

Acknowledgements

The Dutch Operation Hernia team gratefully acknowledges the MRC foundation for providing the necessary funds in order to be able to treat so many patients with such a large team.

Also the hospital staff of the anaesthesia, pharmacy and surgery departments of the Hospitals OLVG, St Antonius and Tergooi are gratefully acknowledged for providing materials and medication.

The surgeons performed the surgery on a voluntary basis in their own time.

Team Ghana 2017

Maarten Simons, Frank Ijpma, Eddy Hendriks, Nanette van Geloven, Bert van Ramshorst, Djamila Boerma, Wouter te Riele, Daphne Roos, Ernst Steller, Jasper Atema, Tjibbe Gardenbroek, Jip Tolenaar, Charlotte Loozen, Anne Loes van den Boom, Marjolein Leeuwenburgh, Joost Hoekstra

The Dutch Operation Hernia Foundation

Maarten Simons, Frank Garssen, Djamila Boerma, Nanette van Geloven and Eddy Hendriks

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

OPERATION HERNIA MISSION: 6TH – 13TH JUNE 2015. KETA, GHANA

So the journey started with three of us meeting at Heathrow Airport on the flight to Ghana; Andy Clarke (Consultant Colorectal Surgeon and team leader), Alex Clarke (A-level student), Dimitri Pournaras (Oesophagogastric Surgical Registrar). A few hours later we landed in Accra. A short taxi drive to our accommodation where we joined Arun Ariyarathenam (Final year Oesophagogastric Registrar) and the team was complete. It was already clear that it was going to be a great week and we were filled with anticipation and excitement as well as apprehension for the unknown for those of us who was doing this for the first time.

The next morning we set of for Keta, having met David, our driver. A man of a few words, but of incredible commitment to the hospital and personally to us. He made it very clear that it was his DUTY to ensure that we were safe and comfortable even if that meant that he would drive us back from the hospital at 22:00 after a long day. But more of this to come…

The route to Keta is scenic and is a great reflection of rural Africa. David’s African music made it even more atmospheric. Having arrived at our accommodation and settled, we went to the hospital for a tour of the facilities and the first introduction with the staff.

Keta Hospital is a local general hospital with three operating theatres. Surgical services are provided on an ad hoc basis with the medical staff being mainly general practitioners with some of them having a special interest in surgery. Caesarean section is the most common operation and other procedures are performed depending on the availability of the more experienced surgeon.

There had already been a campaign on the radio inviting patients with symptoms suggestive of hernia, highlighting the fact that treatment would be provided free of charge by Operation Hernia. The local doctors assessed most of the patients during the previous weeks.

The next morning, after an early breakfast, David drove us to the Hospital. We reviewed the first patients. The challenge was assessing without knowledge of the local language and often using a translator. Considering other types of medical or surgical intervention, hernia is more straightforward to assess in this type of setting where there is a language barrier. The hernias we saw were as expected reflective of rural Africa surgical practice. Very large inguinal and inguinoscrotal hernias in thin individuals, almost exclusively male doing intensive labour work was the most common pathology encountered. It soon became apparent that some of the patients will need to be postponed as they were unfit for surgery mainly due to malaria and uncontrolled hypertension. Knowing that another mission would take place in November and therefore these patients could be safely operated a few weeks later makes the decision-making easier and underlines the importance of establishing recurrent missions in the same region.

The anaesthesia used was either local anaesthetic or spinal anaesthesia provided by the experienced anaesthetic nurses. Their practice was very efficient with a quick turn around and we soon agreed to use spinal anaesthesia more liberally allowing us to take on some more challenging cases and also reducing operating time and maximising our capacity. There was definitely no lack of hernias in Keta!

The apprehension of operating in a different setting, miles away both geographically and culturally from the NHS, faded away at the first “knife to skin moment”. The operating table was low, the operating light was weak and unreliable due to unexpected black outs (we found the headlight used by cyclists very useful!), most of the instruments were worn out and occasionally inappropriate for the type of procedure we were performing with wide variation in the contents of different sets identically labelled. The scrub nurses were extremely keen to help and also learn from our practice. And their enthusiasm made up for any deficiencies.

As soon as we started operating we realised that the operating is pretty similar wherever you are doing it. We tried to use all three operating theatres “taking over” the entire capacity of the hospital and challenging the local team and ourselves. The patients kept coming… We were determined to deal with as many as possible if not all, but keeping safety as our primary concern. On Tuesday we could see that we would be overwhelmed. We performed 20 hernia repairs on that day finishing after 10pm. We had to defer some patients for the next day and we were reassured that the patients would be looked after. What was surprising for all of us was than not a single patient complained. They all stayed, most of them spending the night outside as they were travelling from far, and were very grateful to be operated the next day…

Nights were spent in the local hotel having been driven back by David. Reflection on the day’s activities and plan for the next took place over dinner. A special moment was Andy sharing stories about Shorland Hosking with whom he had a personal and professional relationship.

An effort to include training as an important part of the mission remained a priority. The local doctors found it challenging to attend the operating theatre due to their other clinical duties. However, when they were with us teaching of basic surgical skills, principles of surgery and the technique of tension-free mesh repair of inguinal hernia using were provided. We also used every opportunity to teach the two visiting medical students from Spain, scrub nurses, staff nurses and nursing students.

By the end of the second day the scrub teams were getting used to us, some of the training was paying back and the teams were working as a well-oiled machine. Most of the time… The focus on safety we are accustomed with in the NHS was not the norm in Keta, and this is completely understandable in a healthcare system which is overwhelmed and where the focus is to provide the best possible treatment in the largest number of patients accepting a risk for specific individuals.

What became apparent to us was the desire of members of staff to introduce safety measures, to improve quality, to learn. Doing operations without a WHO checklist felt initially surprising and eventually unsafe. We discussed with different members of the teams and it transpired that they had similar concerns, the most acute being the fact that swabs were not counted. Anecdotes of errors and near misses were shared. We identified the limiting factor was the lack of white boards. Making sure that everyone was in agreement including the management of the hospital we managed to buy three boards on the Friday, our last day. Within minutes they were on the walls with the aid of the estates team. By that time the team were very excited. We did the first procedures using the WHO checklist with needle, instrument and swab count on our last day.

We finished on Friday when all available patients had been operated on. Sixty-five hernia repairs were completed. We left the next day with great memories. We are grateful to the medical and nursing staff of Keta Hospital and Operation Hernia. Special thanks for the Shorland Hosking Fellowship.

Arun Ariyarathenam

Alex Clarke

Andy Clarke

Dimitri Pournaras (Shorland Hosking Fellowship)

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