Waiting in line

UK team in St Vincents hospital, Aliade, Nigeria – February 2014

Operation Hernia – St Vincent’s Aliade, Nigeria

February 1st- February 10th 2014

The time was not long since I first visited St Vincent’s Hospital, Aliade in Nigeria, September 2013 with the team from Operation Hernia.

February 2014 I was the leader and founder of the next mission.

Waiting in line

Waiting in line

The need of help is ongoing as the nr of people in need is very high in the region.

I had short time to prepare my team but I had the trust on the people I left behind, the operating theatre staff, Peter, Benjamin, Lawrence, Francis and Simon to be part of the team.

The news to go back was very welcome by everyone at St Vincent, Sisters of Nativity, Sister Helen and Sister Rose as well as Dr Austin Ella, who organized the preparation, in Nigeria.

In the attempt to organize my team, with a surgeon with Pediatric surgery experience, I met Mr. Ogedegbe, Consultant General, Breast and Pediatric Surgeon in London, who he is Nigerian, one more reason to approach him and ask if he was willing to join the team. After few weeks he gave me a positive answer.

Preparing the theatre

Preparing the theatre

Pre-op inguino-scrotal hernia

Pre-op inguino-scrotal hernia

The team was made of two Consultants Surgeons, Mr. Ogedegbe and I.

We were planning to use the local anesthetic cover.

We arrived in Abuja Sunday morning 2nd Feb. Welcome by the Pharmacist Dada and our driver Simon, who they help us to take our staff and drove us all the way to St Vincent’s, Aliade.

We had a very warm welcome by Sister Rose, Sister Helen, all the local theatre staff and the locals, as they know how to welcome their visitors.

The work started Monday 3rd February, 08:00 am, a crowd of people was already waiting to see us.

We started seeing them, to create our day’s list. Most of the people did not know the exact date of birth, their age was guessed; the dry season easy left the white earthy dust on their body, easy to guess the distance and the way they had travelled to reach us.

Mr. Ogedegbe and I with the local theatre staff, Peter, Benjamin, Lawrence, Francis, Simon and Pharmacist Dada, coordinated our work and started operating by 10 am. The following days, to Saturday 8th/Feb. from 08:00 to 18:30.

Sister Rose and Sister Helen they were making our stay comfortable, as much as possible, with plenty of food and cool drinks to keep us going.

Spigelian hernia

Spigelian hernia

The six days of work we accomplished 75 operations, repairing hernias. 7 cases were bilateral, 15 were women and 8 children from age of 2+ to 15 year old. 8 cases were done under GA. One of the cases, a recurrent inguinal hernia on a yang man early thirties needed, team effort work and was converted form LA to GA, he was admitted to the word and discharged well two days latter.

All the rest of the patients were discharged on the same day.

To build this mission in a short time a number of people and companies supported me.

1)Ansell Healthcare Europe, for the Gammex surgical gloves. We thank Mr. Garry Brinn for his assistance.

2) Swan – Morton, for the supply of Disposable Surgical knifes. We thank Miss Tracy Liggins for her assistance.

3)Mr. Andrew Kingsnorth, Operation Hernia Charity, supplied us with the Mosquito Mesh.

4)NHS Trust.

5)Senior Theatre Nurse Margaret had gathered some of the essential materials, she sent to me, after she had to postpone her trip for family reasons. An extra luggage, I had to pay at BA of 117 pounds. The payment was raised from the financial support of my Greek friends from UK, who their help made this mission easier to be accomplished. Their names are following.

Father Andreas and Presvitera Alkmini, Father Damianos, Mr. and Mrs. Loizou,

Mrs. S Katsarou, Mrs. M Stelianou, Serafim and Andrie Kyriakides from St Panteleymon Greek School.

I am happy to know, Mr. Ogedegbe will continue his support to St Vincent’s Hospital.

Sister Rose, Sister Helen, the Operating theatre team with the Pharmacist, and all their people, all are congratulated on their efforts for improvements they achieve.

We hope, in future, Operation Hernia and Mr. Andrew Kingsnorth to support more Surgeons towards, this destination.

Zoe Vlamaki MD FRCS

Team leader and founder of the mission.

Operation Hernia Report

UK Team to Aliade, Nigeria

September 2013

Hard at work

Hard at work

Nigeria, or the Federal Republic of Nigeria as it officially known, has a population of around 169 million people distributed amongst its 36 states and the federal capital, Abuja. Like many sub-Saharan countries the wealth, and therefore access to healthcare, is disproportionately focussed around a relatively small geographical area.

Our team from the UK consisted of: Maria Boutabba, a multiply experienced RODP and Clinical Team Leader, Tim Brown and Zoe Vlamaki who are both consultant surgeons, Paul Sutton and John Whittaker who are surgical trainees and Alex James the team’s anaesthetist. We spent a week at St Vincent’s Hospital, a primary care facility in Aliade, Benue state.

We landed in Abuja in a torrential thunder storm, predictable as we had arrived just at the end of the rainy season. We were met at the airport by our driver and the hospital’s pharmacist who were to accompany on us on our journey to Aliade. We stayed the first night at a convent in Abuja and once rested we began the 5 hour journey. We were loaded into a minibus just of sufficient size to transport us and our baggage and travelled by road. The road conditions were poor, although largely tarmac and we successfully traversed 5 states (and any number of road blocks) to arrive at Benue. We stopped briefly at Makurdi, the largest town in the state, to visit Reverend Peter who was the sponsor for our trip. We then travelled the last hour to Aliade and were met at the hospital with a traditional welcoming ceremony, including dancing and singing. Our first trip was to the theatre complex where we unpacked all of our kit, and fortunately found a great deal of other kit that had been left from previous missions. We then settled in our accommodation ready for the early start on Sunday.

A 6 30 breakfast followed by a stroll down to theatre marked the start of our first day. There were in excess of 100 patients waiting for us, each waving a green hospital notes folder. We began the process of ‘screening’, which involved seeing patients who thought they had a hernia however the yield was probably around 75%. We had the support of the hospital’s surgeon (non-medically trained) and his team, and under the guidance of our team leader, Maria Boutabba, they soon had the processes they needed for rapid turnover between cases. Our first case was a 32 year old lady who had a large incisional hernia from a previous laparotomy for appendicitis, followed by a 7 year old boy with an inguinal hernia. Many cases later we were well into double figures and happy that we were established for the remainder of the week.

The team’s senior consultant, Tim Brown, and the registrar, Paul Sutton, performed the paediatric cases over the subsequent few mornings totalling 14 by the end of the week. Our anaesthetist, Alex James, rapidly became proficient in balancing spinal anaesthesia, sedation (with ketamine, midazolam or propofol) and other regional techniques in challenging circumstances to permit us to continue with this work. In parallel there was another operating table (within the same theatre) where Zoe Vlamaki and Jonathan Whittaker continued with the inguinal hernias. In between these we were screening patients, rapidly turning over cases and preparing equipment and consumables.

Antiquated anaesthetic machine

Antiquated anaesthetic machine

Any ideas

Any ideas

Alongside the screening we were collecting data for a research study into perceptions of health and therefore impact of hernia surgery in a sub-Saharan patient cohort, which we are planning on comparing to the UK population. We also spent some time teaching the local staff how to repair hernias. It was clear that they had seen many hernia repairs previously, and technically were well equipped. There was however some disregard for the tissues and the patient (who on the whole had local anaesthesia only), and more concerningly there seemed to be an unwillingness of the local team to have their technique refined.

By our third day we were well and truly into the swing of things. We were by this point working over three operating tables and the local surgical team were also performing cases. We were shortly however to be hit with some difficulties. Whilst the local team were performing a hydrocoelectomy in an adjacent theatre they ran into some problems and the patient suffered a cardiac arrest. The cause of this was unclear, and despite concerted effort we were unable to revive him. He had been intubated, ventilated, received intravenous fluids, adrenaline and atropine however without access to a defibrillator or intra-lipid, nor facilities to transfer out to another hospital, we were somewhat limited in what we were able to offer. This event marked the end of the operating day and the local reverend and doctor were called who attended the hospital. They spoke to the theatre team and the local patients and the atmosphere was understandably sombre. We left reflective and unsure of how safe and appropriate it was for us to continue.

We decided to stay however, largely as we felt there was a great deal of good work we could still do. Despite the events of the previous day the crowds were still there in their drones keen for surgery. We continued with the cases, rotating surgeons to try and stave off fatigue. The trainees benefited from the guidance and expertise of Tim Brown, and also the opportunity to perform a number of similar cases in quick succession to consolidate experience. In between cases we conducted ward rounds of our post-operative patients, which were few given the extremely high threshold for admission. We used antibiotics extremely sparingly, although all had access to analgesia. On the whole patients were keen to leave the hospital, even if they had had a spinal and their motor function had not yet returned! Language was an issue, and so post operative instructions were extremely simple.

The biggest challenge of the next couple of days was the intermittent nature of the power supply. We had a large fan in theatre (aptly named ‘Ox’ as it certainly worked like one!) which kept the temperature at bearable levels. We benefited from intermittent lighting and diathermy and a variety of instruments, some more suitable to the cases than others. We all rapidly got used to Maria’s routine of securing the blades to the scalpel with steristrips prior to the case, and had quickly exhausted our supply of the most appropriate sutures. Tackling difficult hernias with local anaesthetic under difficult conditions, combined with the (presumably tuberculous) persistent coughing made for some challenging operating conditions.

The team: party night

The team: party night

By Wednesday we had screened more than enough patients for our visit, however agreed to continue for the benefit of future missions. We were brought a gentleman from clinic with an incarcerated hernia however on reviewing him it was clear he was unwell and strangulation was likely. He had a spinal anaesthetic and we proceeded (with a decision to incision time of around 15 minutes!) On opening the sac he had 25cm of non viable small bowel which was resected and the repair completed. He faired well over the first 36 post operative hours however by the time we were leaving it was clear he had developed an ileus and therefore we arranged his transfer to a secondary care facility at Makurdi. The remainder of the day proceeded uneventfully, and we retired again to our accommodation. We were always extremely well looked after by Sisters Helen and Rose, who kept us well fed and rested during the evenings.

Our penultimate day got off to an uneventful start, however we had set ourselves some fairly ambitious operating lists and so settled down into a busy routine. We had decided by this point not to screen any more patients, and therefore the day actually finished rather earlier than the previous day (18 30). In the evening we were treated to a party. A number of the hospital staff had come to have dinner with us and we were thanked for all of our efforts and each presented with a gift. It was a brilliant opportunity to socialise with the hospital staff and their gratitude was clear.

Friday was largely committed to tidying up the theatres, re-packing equipment and packing our personal kit. We had a couple of cases that had rolled over from the day before which we tackled within the first hour. We headed back to our accommodation to wait for Simon our driver and left shortly after midday for the long road journey back to Abuja (7 hours this time). Our bags were checked 3 times at the airport and the usual emigration, customs and security checks placed us firmly airside ready for our trip home. A successful and eventful week totalling 84 operations on 78 patients, as well as lots of experiences and friendships made and cemented.

Team Members (UK)

Maria Boutabba

Tim Brown

Zoe Vlamaki

Alex James

Paul Sutton

John Whittaker

Supported at the hospital by:

Reverend Sisters Helen, Rose and Grace

Pharmacist Dauda




Uncle Sam and not least our conscientious HSDU assistant.

The team with Baba (Karim)

Eruwa June 2013

The team with Baba (Karim)

The team with Baba (Karim)

Operation Hernia Report – Mission to Eruwa, Nigeria, 8th-16th June 2013

The Journey

Months of preparation and e-mail contact had come to an end when the Operation Hernia (OH) Team for the mission to Eruwa, Nigeria, assembled in London’s Heathrow airport in anticipation of an exciting adventure. After an uneventful flight, and cordial welcome to Nigeria by the vaccination officials, we were delighted to be greeted by Dr Oluyombo Awojobi (Yombo) and his colleagues in Lagos. We continued our journey to Eruwa the following day and were grateful to the driver and our armed escort for avoiding vast amounts of livestock traffic and successfully negotiating large craters in the road. Having reached Eruwa, the impact and effort of the OH teams before us was evident by the warm welcome we received, the prior organisation by Dr Awojobi’s clinic, as well as the recently opened hernia centre. We had a lot of work to do, and a lot to live up to.

The Team

It was a pleasure to work with this truly International Team comprising Dr Aleksander Stanek (a Polish surgeon from Northen Ireland), Dr Constancio Marco (Surgeon from Barcelona, Spain), Dr Richard Salam (Anaesthetist from Nigeria now working in the UK), Dr Gregory Wirth (Urologist from Geneva, Switzerland), Miss Sophie Pitt (medical student, UK), and myself Dr Iestyn Shapey (Surgical Registrar from UK). The team gelled immediately and worked closely and very successfully throughout the project. Dr Stanek’s prior experience as consultant surgeon for two years in Abeokuta, the nearest large town to rural Eruwa, was invaluable as he led this international team. We were privileged to have Baba Karim, Yombo’s chief theatre nurse, and his staff working with us throughout the week, and without whom the day to day functioning would not have been possible. Finally, a great debt of gratitude to Yombo and his family, and his five surgical registrars who rotated in and out of the various roles of assisting, operating and anaesthetising.

Teaching the local registrars

Teaching the local registrars

Operating until late

Operating until late

The mission

Seventy patients underwent surgery over 6 days of operating with 100% discharge within 24 hours and no immediate complications. Most had large (Nigerian-sized) inguino-scrotal hernias, many with synchronous testicular pathologies, which demonstrated to us the value of our multi-specialty team. Initially, the days were long as we found our feet, and surgeries were being performed well after dark. However, we soon established a sound working-pattern and slick process by starting with a clinic review of all patients, producing an optimal running order according to anaesthetic requirements and pathology, and getting to work. In addition to providing high quality surgical care, the team also sought to teach and supervise the local surgical registrars in performing tension-free mesh (Mosquito net) repair. By the end of the mission three of the residents could successfully perform the procedures themselves from start to finish.

The team with Yombo & Tinu Awojobi

The team with Yombo & Tinu Awojobi


The distance that patients travelled to receive treatment at Eruwa (some came from Lagos) was testament to years of Yombo’s hard work, the establishement of the OH mission, and the previous teams’ legacy in building the hernia centre. What would be the legacy of the 2013 mission? We were delighted to learn from Yombo that the five surgical registrars were inspired to continue their experience of newly learnt techniques by utilizing the hernia centre facilities on a weekly basis outwith their regular clinical duties.

Iestyn Shapey

Surgical Registrar, UK

The Opening

Operation Hernia Team Inaugurates Hernia Centre in Eruwa, Nigeria December 2012

The Opening

The Opening

We arrived at Eruwa on Saturday 1st December. There were seven members from Madrid hospitals (anaesthetists: Francisco Duran and Miguel Lopez Vizcayno, surgeons: JA Pascual Montero, Teresa Butrón, Patricia Maldonado (resident), internist: Iñigo Espert, nurse: Ana belen Abenoja) who were joined by an additional member from the UK the following day.

The site was the Awojobi Clinic, which started at grassroots level in the 1980’s and has been steadily growing ever since. The clinic was set up to serve the local rural population but the level of care has reached a standard that attracts patients from as far away as Lagos, a 3-4 hour journey by road.

Surgeons & Supporters

Surgeons & Supporters

At work

At work

Work started on the Sunday and continued during daylight hours for five days. The patients would arrive from 8am and the 8 team members formed two surgical teams. Surgery was performed in the purpose built ‘Hernia Centre’ which was opened during the visit. The operations were performed under spinal anaesthesia and operations were predominantly Lichtenstein repairs using locally sterilised mosquito mesh. Workload varied each day depending on the numbers of patients who presented.

There was strong training ethos to the mission. Dr Awojobi has a total of five registrars who initially watched and later performed Lichtenstein repairs under direct Consultant supervision. The hernia centre will remain open after the end of the mission with the registrars operating independently.

Registrars attending for instruction in Hernia surgery

Registrars attending for instruction in Hernia surgery

On a couple of the afternoons we had finished the operating before nightfall and had the opportunity to visit other departments in the clinic. The emphasis is on delivering the highest possible level of health care using available resources. The results are impressive, with most of the departments present that one would expect in a far larger hospital. We also had the opportunity to observe some of the differences in presentation and treatment between European and Nigerian patients. One evening team members assisted local staff with completion of a traumatic amputation in a teenage boy.

The people of Eruwa and were welcoming and friendly and we made a lot of new friends. Over the week we performed at total of 44 operations on 38 patients. They were predominantly inguinal hernia repairs, but we also repaired two femoral hernias, one epigastric hernia, explored one groin for lymphadenopathy and removed a large lipoma without immediate complication. We left Eruwa not only satisfied with the procedures which we had performed but also enthusiastic that the training element of the mission will add to the ‘hernia centre’ and lead to ongoing benefit to the local population once we have returned to our home countries.

Chris Grocock

Surgical Registrar

Sunday 26th August 2012

Eruwa, Nigeria

Since the initiation of an Operation Hernia site at the Awojobi Clinic in Eruwa, Nigeria in 2009, six more successful missions have taken place, and Eruwa has become a centre of Hernia excellence in Oyo State. At the instigation of Operation Hernia volunteer Ramon Vilallonga fundraising was started in 2010, and enough money has been raised to build a Hernia Centre. The inaugural mission to the Centre will be lead by veteran volunteer from Spain Dr Teresa Butron

Welcome at the gates

Welcome at the gates

Welcome at the gates

Report by Francesc Marsal: St Vincent’s Hospital, Aliade. Nigeria. Spanish Team

Last 26th November 2011 we left from Barcelona airport to our destination in Nigeria.

The whole team met up at Heathrow Airport. We took 14 boxes each weighing 23 kilos. The boxes contained surgical material and presents for the local people. In Barcelona, British Airways helped us a lot with the customs issues and didn’t charge any extra weight.

We arrived at Abuja International Airport at 05:35 on the 27th where Dr Austin Ella was waiting for us. The procedure through customs was long but fairly agile. We then loaded the boxes and our luggage into a Toyota pick-up and a mini-bus and set off. After a 6-hour trip with many police controls, we arrived safety at St Vincent´s Hospital in Aliade.



2 tables operating

2 tables operating

We were received by the local team, headed by Peter. We met the Sisters of Nativity (Sister Helen and Sister Rose) and we were welcomed by the performance of a welcome tribal dance by the local residents. That afternoon the team set to work to prepare the theatres for the operations the next day.

We had brought new bulbs for the theatre lamps and two new boxes of surgical material for hernia repair. We had also brought a two new pulse oximeter which they didn’t have. We started to operate at 07:00 every morning after a good breakfast prepared by Sister Rose.

For 5 days the Spanish team of 5 surgeons and 2 nurses, together with the local team operated on 78 patients with 110 procedures.

Spanish Team and our hosts

Spanish Team and our hosts

The results were very satisfactory and for the first time ever we used “mosquito mesh” (59 cases). Friday was the hardest day when we operated on 24 patients. In all we experienced complex cases (14 bilateral hernia) and 9 large hydrocele. We used loco-regional anaesthesia in 57 cases, and the rest cases with local anaesthesia.

When we lefts Aliade on 3th December we felt very satisfied with our work and the friends we had made.

The team members were: Enrique Navarrete, Maria del Pilar Consejo, Juan Manuel Moreno, Francesc Marsal, Riverola Aso, Blanco Rodriguez, Arantave Caravaca, Candeal Haro.

Children waiting

A Report by Oluyombo A Awojobi, Operation Hernia Project Coordinator in Nigeria.

Police Escort

Police Escort

Introduction: The seed of the third front of OPERATION HERNIA, OH, missions to Nigeria was sown in June 2009 when Dr J I Umunna, a rural surgeon of Jasman Hospital, Limited, Udo-Ezihinitte, Imo State, Nigeria, participated in the first Nigerian mission of OH at Awojobi Clinic Eruwa, Oyo State, South West, Nigeria. He made a request to Prof Andrew Kingsnorth, director of OH, for the extension of OH missions to the South East of Nigeria, his home geopolitical zone. Rather than have the mission conducted in his hospital, Dr Umunna co-opted other members of the Imo State branch of the Association of Rural Surgical Practitioners of Nigeria, ARSPON, of which he was the chairman, and they decided on hosting the mission at the government General Hospital, Abor-Mbaise, GHA.

Preparation: Although a site inspection was usually conducted by Andrew, this was not the case this time due to his tight schedule in Cote d’Ivoire. In fact, the mission slated for Eruwa was shifted to the South East. As project coordinator of OH in Nigeria, I visited the GHA on 16th/17th October 2010. This was preceded by exchange of emails that included several pictures of the hospital and its facilities. Thus, a prima facie case for the suitability of the hospital was made. My inspection confirmed this. The hospital was built by the Catholic mission several decades ago before it was taken over by the government. As with other Catholic mission hospitals, this hospital was well laid out on an expanse of land. I recommended that the theatre be upgraded by tiling the floor and providing efficient autoclave and air conditioning system. I was assured the government was enthusiastic about the mission and would carry out the refurbishment quickly. Further preparation for the mission was set in motion with the recruitment of volunteers by OH and getting patients with inguinal hernia. The latter was achieved through the mass media operated by Imo State government. It turned out that many patients had travelled from far and near even from the neighbouring states. By the time the mission started, over 400 patients had been booked.

Reception of the Volunteers: The OH team included Drs Petr Bystricky (from the Czech Republic), Scott Leckman (from the USA), Denis Blazquez (from France) and the leader, Prof Andrew Kingsnorth (from the UK). I received Scott on Friday 25th February 2011 and we lodged at LaSal Hotel close to the Lagos Airport while Denis, Petr and Andrew arrived the following day. The team brought with it one portable Little Sister autoclave, four sets of surgical instruments for hernia repair, lots of gloves and suture materials. Earlier on Saturday morning, I took Scott on a brief tour of Lagos showing him the public park and avenue named after my elder brother, Prof Ayodele Awojobi, a mechanical engineering genius, mathematician and social reformer. We went to the department of mechanical engineering, University of Lagos, Unilag, where he taught and the alma mater of the Awojobis, CMS Grammar School, Lagos ending up at the international airport to await the arrival of the other three. At the Unilag, we observed the growing trend in Nigeria of replacing louvered windows that allowed 100 per cent ventilation with the sliding windows that looked more aesthetic but reduced ventilation by half. We felt this was unbecoming of a citadel of knowledge and relevance to the society in these days of global warming.

The Mission: The team flew into Owerri on Sunday 27th February into the warm reception of our colleagues led by Dr Jerome Afuka, national secretary of ARSPON and secretary of the Imo State branch. However, we were startled by the presence of five fully armed police men who would be our escort for the next six days. We quickly checked into the Mayfair Hotel on the outskirts of Owerri before proceeding on a 35-minute drive to the GHA where we were received by Dr Cosmas O Madu, the medical officer in charge of the hospital and scores of patients waiting for surgery. Andrew proceeded to examine the adult patients for surgery the following day and drew up a list of paediatric and adult patients which he handed over to Cosmas with the hope that work would start in earnest the next day. It was noted, at this point, that there were no proper case notes of the patients, just the list indicating sex, age and type of hernia. By 5.30pm when that first exercise was just being concluded, the security operatives were alerting us that it was time to depart for the hotel. And so, the team could not inspect the theatre facilities before returning to the hotel.

Financial Matters: During the preparatory period, it was decided that OH would be responsible for the internal flight tickets, the hotel accommodation and meals in Lagos and Owerri. Accommodation and meals in Owerri would cost N5000 per day per person. By the third day, Jerome informed the team of the huge expenses the association had incurred to get the mission going: N70 000.00 (?1 = N250.00) to obtain police protection, the hotel bill with one room reserved for the police who were fed, fuelling of the government bus allocated to the team and feeding the driver, allowances to the hospital staff, who were on industrial strike action, before agreeing to help with the mission. The hotel facilities were good enough but pretty expensive ? N11 000.00 per night with complementary breakfast. As a consequence of this expose, Andrew decided to double the commitment of the team while I waived the expenditure for the Lagos end of the trip amounting to N220 000.00. I advised Jerome to present any deficit incurred by the local branch to the national body for consideration since the Imo State branch had contributed more than any branch or individual to the sustenance of ARSPON. The doctors in the public service of Imo State were on strike before the mission started and a lot of pressure and persuasion was needed to get the striking doctors allow the mission to go on in the public GHA.

The Actions: Day 1, Monday 28th February Work started very late at about 10.00am. The team arrived GHA well before key members of the host team due to the fact that most of them resided in neighbouring towns about an hour and a half drive from the hospital. Jerome who lives a stone’s throw from GHA did not have the administrative power to influence the goings-on. By the time the mission was in full swing, Andrew realised many of the patients he had operated on were not on the list he prepared the previous day!! The hospital staff had hijacked the list before the arrival of Cosmas. The team left the hospital by 5.30pm having operated on 13 patients that included 6 children. At the hotel, Andrew handed to me the donations (?5 160.00) sent by Dr Ramon Vilallonga-Puy of Spain and Mr John Pickering of the UK in aid of the construction of a hernia centre and solar-powered lighting system respectively at Eruwa.

Day 2, Tuesday 1st March. The day started for me at 12.05am with a text message from my teacher, mentor and benefactor, Prof O O Ajayi, CON and it read: ?At 60 years of age today, you have carved for yourself an indomitable reputation for hard work and indisputable integrity and transparency in public service with love, charity, care and compassion. You are frequently misunderstood, not out of ignorance or intellectual barrenness, but because you outmatch all by a vision many cannot understand. The solution is in your hands. Yombo, many happy returns as you build on a God-given talent for an enduring legacy on earth and for His eternal glory in Heaven. May God continue to keep you and bless your family as promised for those who serve Him. Amen. Happy birthday to a loyal, generous, affectionate brother. Many Happy Returns. Jide Ajayi. At day break, I informed the team and my colleagues in ARSPON of that milestone and they all congratulated me and expressed their gratitude for the roles I had played in organizing the mission. Things worked out better on day 2 with some sanity restored to the list prepared by ARSPON members and the theatre system functioning well. The State Commissioner of Health, Dr F Ekwem, visited and was met by Drs Umunna, Madu and Andrew. The commissioner briefed the audience of the efforts of government in health care delivery in the state and thanked the OH team for coming despite the security situation. He promised a better reception the next time. Andrew, while reciprocating the complimentary remarks of the commissioner, observed that a three-year old maternity wing of the hospital built by the present administration with World Bank assistance was already depreciating due to disuse. I presented to the commissioner a set of books and booklets that included the third edition of Davey’s Companion to Surgery in Africa which I co-edited and published, the programme booklets of ARSPON 2008, 2009 and 2010, SURGEON IN THE BUSH by Dr Umunna and my other publications. I attached a copy of a paper I proposed to read if there was a formal reception. (Appendix 1) An hour later, I sent pictures I took on the occasion by email to his public relations officer.

Discussion with Dr Omunna

Discussion with Dr Omunna

Children waiting

Day 3, Wednesday 2nd March Just as the mission was gathering momentum, it was observed that the only heavy duty generator (60kVA) was malfunctioning and autoclaving of instruments was unusually long. The technician informed us the generator was old and was recently repaired. The theatre staff was bypassing the autoclaving by soaking the instruments in antiseptic lotion.

Together with Jerome and some of the patients, I organized that a mobile generator be rented for days 4 and 5 if things did not improve. The technician was brought into the picture. However, I observed that soon after our discussion, the performance of the generator improved such that work continued smoothly. Meanwhile, Andrew had opened up another makeshift theatre with two operating tables in the near-abandoned maternity wing so that he and Scott could deal with small hernias while Petr and Denis tackled the children and giant hernias in the first theatre. At about 5.00pm, I was informed that the nurse anaesthetist would not proceed with the children because there was no more intravenous infusion. I took over the situation, requesting Jerome to administer intramuscular ketamine while I performed herniotomy on four children assisted by a colleague. By now, several colleagues had assisted and been taught tension-free mesh repair of inguinal hernia by members of the team.

Day 4, Thursday 3rd March The day started well. The generator (7.5kVA) had been brought by the owner and placed at the appropriate place near the theatre for use if the big generator malfunctioned. It was to power the portable autoclave exclusively and not for the theatre section of the hospital since it was not powerful to do that. I paid the owner a deposit of N5 000.00. At 11.30am, Andrew, Jerome and I set out to visit Dr Umunna at his base. But before leaving, I reminded the theatre technician in charge of the autoclave and the owner of the generator of my directive as to the use of the generator.

At Jasman Hospital, Udo-Ezinihitte, we were cordially received by Dr and Mrs Umunna and the members of staff. A mini ward round was conducted on patients who had had modified radical mastectomy for carcinoma because there was no facility for radiotherapy in the South East, prostatectomy, hysterectomy, suprapubic cystostomy for impassable urethral stricture etc. We saw the conference room used for ARSPON 2009 and the adjoining cafeteria. Andrew was presented with an autographed copy of Dr Umunna’s book, SURGEON IN THE BUSH. I promised I would send him pictures of a simple operative procedure to treat the patient with urethral stricture. This I did some days later when I operated on a man with stricture.When we returned about three hours later, the situation was chaotic due to malfunction of the big generator and failure to use the rented generator. I was told the government technician had insisted that the rented generator be connected to the theatre. I was so furious I carried the autoclave from the theatre to be placed under a tree with the generator near it. In 6 minutes, surgical materials were being autoclaved and the mission continued in full swing. I did not seek for the technician since he had, by his action, identified himself as a saboteur. One of the patients, an elderly man who had worked in the hospital, assisted with operating the autoclave. He had his hernia repaired the following day. The team left the hospital at 6.30pm because our escort and we were getting more relaxed psychologically. I paid the owner of the generator the balance of N5 000.00.

During one of the evenings at the hotel, we were told about the spate of kidnappings in the state that included the former commissioner of health and one of our colleagues. Heavy ransoms were paid to secure their release. This explained the heavy security presence around our foreign guests. On this basis, Petr, who was billed to stay an additional week, decided to come with me to Eruwa where security issues were not so serious. Discussions were laced with the political happenings in the state and the country.

Day 5, Friday 4th March Scott was scheduled to return to the USA on this day and so, I accompanied him back to Lagos to await the arrival of Andrew, Denis and Petr the following day. Before setting out, my colleagues presented me with the traditional Igbo attire to mark my birthday and in gratitude for a mission accomplished. The generator was still available in the hospital for use. Jerome paid the rent for that day.

Day 6, Saturday 5th March I met Andrew, Denis and Petr at the local wing of the airport and moved on to the international wing where I bid farewell to Andrew and Denis while Petr came with me to Eruwa. At the end of the mission, 120 patients were operated on leaving over 300 to be taken care of by the local team at affordable rates in their respective hospitals.

The team left behind the autoclave, the four sets of instruments and the unused gloves and sutures. I had loaned the mission two diathermy machines and an autoclave meant for Eruwa centre. I hope to repossess them in time for the next mission in November 2011 during the joint conference of the International Federation of Rural Surgery and ARSPON. A 12-year old indigent boy had not had his hernia repaired since 2008 when the government launched a free-health programme. I handed him over to Jerome to fix his hernia on my bill. AT ERUWA Scores of patients had been waiting for me and throughout the next six days it was work from dawn to dusk starting with an obstructed inguinal hernia on Sunday 6th March. Petr and I performed 35 major surgeries in five days which included excision of giant tumors, torsion of ovarian cyst, drainage of 8 litres of pus from the peritoneal cavity, sequestrectomy of neglected chronic osteomyelitis, thyroidectomy, prostatectomy and some hernias which Petr fixed with the Indian mosquito mesh that was used exclusively at GHA.

Petr left Eruwa for his home country on Friday 11th March on a three-hour trip to Lagos by a chartered taxi. He reported safe arrival at home like other members of the team.

Comments: As noted in my proposed speech, I thought the Imo State Government was performing better than the others as far as health care delivery was concerned. But, this was not so as shown by the attitude and conduct of the hospital staff and the ongoing strike action in the health sector. Overall, the hospital staff did well but at great expense to ARSPON. The decision of my colleagues in ARSPON, Imo State branch, to choose the GHA was good. It was an opportunity to improve the image of the government and ARSPON thereby disabusing the minds of the populace who felt private doctors were exploiting them and so became targets for kidnapping. Although the patients were not charged any fee for the exercise, I was told by my colleagues that some still felt the doctors had collected large sums of money from our guests. I spoke to the patients on the rationale of the mission, the logistics and the expenses incurred by everybody involved in the exercises. I usually ended my talk with ‘If you were in my shoes, what would you do’. Their responses and comments indicated that out people would feel more at ease if they were carried along in the decision-making and execution processes.

In a five-day mission, 120 inguinal hernias were repaired and over 300 patients were still waiting. There are about five teaching/tertiary hospitals in that region. This shows their low level of impact on health care delivery in the region. The absence of proper documentation of the patients will make future review of the cases impossible. This is not good for the science of surgery.

Although, we knew of the security situation in the South East as in many parts of Nigeria, we (OH team and I) did not realize it was really that bad that a commissioner and a colleague had recently been kidnapped. However, we would recollect that Chief Bola Ige, the Attorney-General of Nigeria was assassinated in his room in Ibadan in the South West while being guarded by ten armed policemen some years ago and no one had been charged for it, then any crime could be committed with impunity in this country. So, it was understandable why our colleagues took such extraordinary precautions to ensure the safety of our guests. I must thank them most sincerely for still keeping faith with the Hippocratic Oath we swore to at induction into the profession despite the hostile situation they practice in. The administrative lapses observed were beyond their control and I quite appreciated the milieu in which Dr Madu was performing his onerous duty having been a public employee in the past. It was all praises for Andrew and his team for braving the odds in the spirit of Medicins sans frontier. However, it would take a long time before another mission is contemplated.

I want to thank the members of staff of Awojobi Clinic Eruwa for holding fort and Dr S Ogunsina who came in from Ibadan to perform some emergency operations and his usual Saturday round of hernia repairs. This has been the third side of the countless sides of a coin that is OPERATION HERNIA in Nigeria.

On the occasion of a short visit to St. Mary’s Hospital in Okpoga, Nigeria in February 2010 it was decided to open a new site for future Operation Hernia activities in this place. After some months of preparing everything was set up and the team, predominantly members of the Swiss Surgical Team, was put together. At the same time a second Irish – Swiss – Australian team was getting ready to spend a week in St. Vincent’s Hospital, Aliade.

After a night flight with British Airways we arrived in Abuja early in the morning. The airline had granted us a generous amount of free luggage which we used for bringing along surgical and anaesthesiological material and instruments. Despite the large number of boxes and suitcases we encountered only minor problems at Immigration and soon we could continue our journey. For six hours the two teams bumped in a very full minibus from the airport first to St. Vincent’s hospital where one team was to spend the next week.

Two hours later after a dusty drive and a visit at the bishops place the three Swiss surgeons (Martin Walliser, Hanspeter Notter, Peter Nussbaumer), one English surgical trainee (James Barnes), one Swiss anaesthetist (Warner van Maren) and one Swiss scrub nurse (Claudia Baur) finally arrived at St. Mary’s hospital. A large crowd greeted us with dancing and singing. Posters around the town and announcements in the church had prepared them for our arrival. In order to make the most of the short spell of the mission we decided to set up the operating theatre on the same evening. Boxes of instruments, diathermy machines, gloves and sutures were hoisted onto porter’s heads and taken to the hospital for unpacking and sorting. Fortunately we had electricity 24 hours a day, thanks to a new generator donated by Operation Hernia. So the next morning we started. By dawn patients with hernias started to line up. Following confirmation of a hernia(s) they were put on the list for having surgery the same day or later in the week. The lucky ones put on their colourful nightgowns and sat in front of the theatre where they awaited their turn. Nobody seemed to mind waiting for as long as it took – neither the patients nor their families sitting under a plastic sunshade.

For the next six days we continued operating from 8 a.m to 8 p.m, sometimes even longer. In between two procedures the two tables were vacant just long enough for cleaning. Eighty patients and ninety interventions later we reached full time and still the patients kept coming. Some had travelled for eight hours to reach the hospital and had to be turned down. How distressing to be the bearer of such bad news. Names were taken with the promise that the next hernia team would see to their hernia. Performing up to 18 procedures instead of the usual one operation per day was not only exhausting for the local scrub nurses, but also put the staff working in sterilisation to its limits. However having an experienced expat scrub nurse with the team improved the efficiency and quality of their work and increased the level of hygiene considerably.

One of the aims of Operation Hernia is to teach contemporary surgical techniques to the local staff, but the three Nigerian doctors working in the 100 bed hospital were busy working in the different departments. Since none of them was trained in surgery our intention to teach and train was somewhat limited. In the end we achieved having one of the doctors performing the mesh-repair under supervision.

It goes without saying that our accommodation was excellent and the hospitality of the matron and her team generous. They went out of their way to make our stay relaxed and convenient. And Austin Ella, the local coordinator made a big effort both before and during the mission and has thus contributed substantially to the success of our work. Altogether the team spent a very satisfactory and unforgettable time at St. Mary’s, and we thank everybody involved for their help and support.

Peter Nussbaumer

Rural surgery and Operation Hernia: reflections on a truly surgical elective
Phase 3b MBChB University of Sheffield.

Ceremony in Eruwa

Ceremony in Eruwa

At the beginning of my third year of medical school, I was jokingly challenged by a general surgery SpR that noticed my unusual interest for hernia operations, to have a look at the Operation Hernia Foundation website. So I did, and it has been ever since that I planned to join this NGO for a mission. When I planned my elective, I wanted to be exposed to general surgery, to travel to a developing country and to join a recognised charity. So the Operation Hernia Foundation projects seemed perfect! I took the courage and wrote to Prof. Kingsnorth, President of the European Hernia Society and in charge of recruiting volunteers for the Foundation. Not only I was allowed to join one of the teams, but I was put in contact with Dr O. Awojobi, Project Coordinator for the project in Nigeria, to be given permission to spend some time in his clinic in Eruwa, prior to joining the mission. I also spent the initial part of my elective in my own town, Sheffield, to learn some general surgery beforehand, to be sure that I could make the most of the experience.

And so it happened that in July I travelled to Nigeria, a few lectures on rural surgery in my bag to prepare me for the adventure, and a book on surgical techniques to study. Leaving the UK I thought I was prepared for what I would find in Nigeria: I had recently been exposed to general surgery in the Department of Colorectal Surgery in Sheffield, had some previous clinical experience and I had travelled to Africa before.
However, from the moment I was collected from the airport in Lagos by Dr Awojobi, I sensed that I was embarking in a very emotional journey. When, during the quite long drive to Eruwa, Dr Awojobi introduced me to some important and proud moments of the history of his family (Fig 1) I realised that I was being welcomed in his team and I felt a sense of honour that seemed positively old fashioned.

Scrubbed in an elective surgery with Dr Awojobi

Scrubbed in an elective surgery with Dr Awojobi

The team of the satellite mission in Isotan

The team of the satellite mission in Isotan

The following day I was introduced to the work in the clinic. Dr Awojobi s clinic (Awojobi Clinic Eruwa, or ACE) is a private hospital in the public service , and offers not only surgical treatment but also preventive medicine, primary care services, and medical treatments. But Dr Awojobi is primarily a surgeon, and of a special type: he is a rural surgeon. As such, he offers in his clinic a huge variety of surgical treatments, to patients that present with very complex and advanced diseases. Once over the surprise in seeing diseases such as a 6.5 Kg uterine fibroid, I still found difficult to adjust to the variety of surgeries offered; only in my first day the operation list involved: a myomectomy, an ORIF of a femur that had been shattered by a pellet gun 6 months previously, two prostatectomies and the debridement of a skin ulcer involving the whole forearm: gynaecology, orthopaedics, urology and plastics all in one day! I started wondering how it was possible to perform all these different surgeries, and what I was learning from this experience. Dr Awojobi, after long days spent operating, patiently spent long evenings discussing these concerns with me, reminding me that everything needs to be seen in perspective, that there are at least two sides to every coin. And indeed after some time, I had the proof that, as long as the basic principles are respected, things work even if they are done in a different way, their application suiting the local environment. After a while I actually started enjoying and admiring the innovations introduced by the doctor in the attempt to keep providing affordable services to his community, like the suturing needles obtained from sterilized fishing thread inserted in a sterile injection needle, or the manual centrifuge to analyse the pack cell volume (PCV). Where I felt frustration I was reminded once again of how it is necessary to make a structure work with the resources available: in the rural environment ketamine is an acceptable general anaesthetic and relying purely on clinical signs and symptoms even in the acutely ill patient is the substitute for the lack of complex blood investigations.

I also realised after a while that most of my questions and queries come from missing the bigger picture ! I kept concentrating on small details instead of considering the enormous infrastructural efforts that had been put in place long before I joined the clinic, that has free flow of water all the year round (thanks to wells that collect water in the rainy season), and an alternative energy supply in the form of a generator, that can be activated every time the national supply stops (and it happened in the middle of the night in the middle of an emergency operation!). This contrasts dramatically with the situation for example of the local governmental Hospital which I had the honour to visit, where there is no running water, only one toilet for patients in the whole hospital, and a desolated A&E Department with no medical equipment. So I appreciated even more the efforts made by Dr Awojobi to provide what is a very high standard of care in his Hospital.

When the Operation Hernia mission started in the final week of my elective this structural setting become even more apparent, as for example thanks to the generator, the volunteers had the chance to enjoy air conditioning in theatre (which is different from the one used by Dr Awojobi).

In contrast to Dr Awojobi that works alone, as the only physician (and surgeon) in the clinic, the UK team was composed by 8 members: two surgeons, 3 nurses, an anaesthetist, an ODP and me, delivering in the middle of Nigeria in the rural setting a standard of care comparable to the care offered to patients in the UK.

Operation Hernia team with Mrs Awojobi and members of her team

Operation Hernia team with Mrs Awojobi and members of her team

The Operation Hernia experience was fantastic, it was not only very productive in the number of surgeries performed but it was an excellent example of team work. After the first exhausting day spent unpacking the many boxes of material brought from the UK, the team performed 50 surgeries in five days of hard work. I was not the only student, as a local doctor participated in the training, under supervision of the surgeons in the team. I had the chance not only to see patients preoperatively, but also to scrub in and assist in 31 operations, receiving one to one teaching by Mr Hanafy, a very experienced consultant surgeon. It is difficult to explain how important and inspiring this opportunity is for a medical student.

In the Operation Hernia theatre between cases, with a local doctor in training and baba Karim, practice nurse in Dr Awojobi s team.

So when the team left, I resumed my long evening discussions with Dr Awojobi, and asked his thoughts about the differences between the Operation Hernia work and the work in his clinic. He explained that the local community has benefited greatly from the services of the Operation Hernia, but that some costs related to it (such as the cost to operate the air conditioning unit or to use the commercially available mesh for hernia repair) at the moment would make such structure unaffordable in the long term, were he to use the same methods. But Dr Awojobi is a very resourceful man, and he always strives to find a solution to every problem, for the benefit of his community and for the pride of the scientific African community, and so he will be looking to continuously improve the service offered, but at an affordable price.

But the Operation Hernia Society mission and ACE do not only stand out for their differences. They represent a very successful medical collaboration, in which the NGO, while possibly providing training for its own members (such as it was for me as a UK medical student) supports the local population both in terms of patients treatment, which can be free or cheap, and health professionals providing training and updates on clinical knowledge and technologies. The most successful NGO project is indeed the one that leads to the independent development of a health system locally.

It is impossible to recount all the activities and experience accumulated in Eruwa: for example I was involved in the retrospective collection of data on hernia repair performed with the use of sterilized Indian mosquito nets, I learnt to perform USS on pregnant women under the supervision of Mrs Awojobi (wife of Dr Awojobi, and a qualified radiographer and great teacher), met Nigerian students and doctors in satellite projects organised by Dr Awojobi and even met a real King!

With Dr Walker, pioneer of HIV treatment in Nigeria that collaborates with Dr Awojobi in providing HIV medications to the ones in need (top), the team of the satellite mission in Isotan (middle) and the Operation Hernia Team with Mrs Awojobi and members of her team (bottom).

When I left Nigeria, I felt that I had gained much more from this elective than clinical and surgical experience, which was excellent both in terms of hours and quality. The most important aspect of it was to receive the invaluable gift of finding excellent role models of professionalism and work ethics.

Cristina Frezzini