This Operation Hernia mission was part of a joint mission to St Vincent Hospital, Aliade and to St Marys Hospital. Peter Nussbaumer was lead for the overall mission, and headed up the St Mary’s team and Richard Stephens the St Vincent’s team.

Travel: The teams met up in Terminal 5 Heathrow Airport for the 03.01.2011 22:15 Departure: LHR London – Heathrow BA 002 Flight to Abjua.This flight is most suitable as it arrives early in the morning allowing day light travel to destination, which takes up to 6 hours allowing for stops and visits on the way. British airways staff are most helpful allowing extra weight for equipment, which included diathermy machines x2 for St Marys which was picked up and packed in terminal 5.Team members came from Switzerland, England and Ireland and Australia. Emigration at Abuja was very easy this time (everybody however finds getting the visa difficult and time consuming in the first place.) Our passage through the airport to the customs was OK, but there our host Dr Austin Ella had a deal of difficulty, as we were not registered with the Nigerian Medical council. This is becoming quite an issue at this point and may become a block in the future.

Travel to Aliade was very cramped indeed and was the worst part of the trip for many team members. Teams must travel together and booking coordination is essential. The SSS took an interest in us at the Airport and visited us twice in the hospital. We were welcomed by young local dancers. The St Vincent’s Team Brian Lamont Anaesetist (Irish) Elvira, Claudia Theatre nurse (Swiss) Denis Mehigan (Irish),and Richard Stephens (Irish), John Garvey (Australian) and J?rg Wydler, (Swiss),

Accommodation at St Vincent’s: The accommodation at St Vincent’s is secure and very adequate indeed. Food is very good and we were well looked after and made most welcome. Temperature was reasonable, and this is a suitable time to visit the region, while March is to hot. Water for washing was from the shower some of the time, or from the ‘big bucket’. Electricity was unreliable, but much more available that March 2010. Bottled water freely available. A bottle of beer was welcome in the evening. There were no mosquitoes at this time of year, but nets are available, for when they are plentiful.This is a Malaria area. The cost of accommodation and food at St Vincent’s was higher than at St Marys. I felt it was however most reasonable, but perhaps they should be the same. Goodbye party on the last evening was appreciated by all.

Operating Theatre: The team of nurses/theatre operatives are lead by Peter who is experienced at surgery himself as to varying degrees are other members of his team. Peters Team worked very hard while we were there and are most helpful. The instruments especially the scissors are now becoming quite blunt, and we encouraged them to get these sharpened locally I doubt if this will happen and new instruments will need to be brought by future teams. Sterility is an issue and having a nurse with us brought these lapses more clearly to our attention. The drapes are too short and the holes to operate through to big, these could and should be remade locally. The theatres need to be cleaned daily and this is not done, dust is lying on all the surfaces and could easily be cleaned and a lot of unused junk remained lying around. I met with the Matron and brought these issues to her attention, Peter feels a cleaner should be allocated to the Theatre. These simple matters need to be attended to locally. We were unable to use the mosquito net for our repairs in either hospital as the gauges on the sterilisers did not work at all so we really did not know if the instruments were sterile either.

Patient selection: Very large numbers attended daily to be reviewed they were outside the theatre in large numbers and at times towards burst in! We saw patients in the theatre change room in between cases, and in sessions, by the one not operating, we estimate we saw well in excess of 400 patients and felt bad that we would not be operating on them. I am not clear if the patients were aware of this but they were very keen to be seen by us. The local plan was that they would be operated on after we left by Peter et al. We said some particular problems must be operated on by the next Operation Hernia team.

Antibiotics: We engaged in discussions with Dr Austin in relation in relation to antibiotic administration, and he moved to pre op dose rather than post op.This was also more cost effective andfuture teams might bring antibiotics with them, we used ‘left over’s’ from the Spanish team. We all found the trip rewarding, enjoyable and interesting and any negative comments are intended to be constructive!

Richard Stephen

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

Anglo-Irish and Swiss Team

Anglo-Irish and Swiss Team, Aliade, Nigeria 17-27 FEBRUARY 2010

Annyar You’re welcome. With a touch to the forehead and chest followed by a slight bow, each colourfully dressed greeter would then take our hand and shake it. Regardless of social or financial station, the heartfelt greeting was the same annyar.

Anglo-Irish and Swiss Team

Anglo-Irish and Swiss Team

Four European surgeons (Richard Stephens, Shorland Hosking, Peter Nussbaumer, Andrew Kingsnorth) and one anaesthetist (Richard Salam) bumped for six hours in a very full minibus from the airport to our hospital base for the next week. Presentation of flowers, singing and dancing greeted us as we stepped into the 41°C heat. Posters around the town (photo) had heralded our arrival Operation Hernia by Professor Kingsnorth and team . Boxes of instruments, diathermy machines, gloves and sutures were hoisted onto porter s heads and taken to the operating theatre for unpacking and sorting. No electricity for 24 hours a day is normal, necessitating a new generator being installed to provide continuous (African style) power for theatres.

And so we started. By dawn patients with hernias started arriving; young, old, fit, HIV negative, HIV positive, pregnant, curious. Following confirmation of a hernia(s) they made their way to the theatres where they waited their turn. Nobody seemed to mind waiting for as long as it took word on the street came back that this was a small price to pay for a well performed procedure as a day case. Like the children of Israel they kept coming and we kept operating two tables on the go from 8 til 5. Eighty patients and one hundred hernias later we reached full time and still they kept coming. Names were taken with the promise that the next hernia team arriving three months later would see to their hernia.

The Team - Operating

The Team – Operating

Training the local medical team

Training the local medical team

By day two an important discovery was to change our approach in a significant way. Initially, the hospital s medical officers came to theatre for training but it quickly became apparent that their surgical skills were considerably less than those of the theatre scrub nurses. Furthermore, these nurses interest and enthusiasm to learn the mesh repair (they were familiar with the Bassini technique) was impressive. And so they began to assist, progressing naturally into performing under supervision. As they were taught (see photo), their enthusiasm visibly increased, work rate and efficiency improved further and the whole team worked so well. What a difference empowerment makes. It needed to, for it was the Europeans who began to wilt by mid-afternoon. Despite three air conditioners, theatre temperatures reached 30°C during the afternoon session.

Armed with mesh generously donated by several companies the pile of mesh nonetheless shrank rapidly at the rate of 20 hernias per day. The solution was simple but brilliant. Mosquito net was cut to size and sterilised. Initial attempts at high temperatures were rapidly modified when the net melted in the autoclave. The right temperature was found and the problem of sterile mesh was solved easily and cheaply.

Boys swimming, Aliade, Nigeria

Boys swimming, Aliade, Nigeria

Stepping outside the theatres onto the wards revealed a much bigger problem. HIV. Sub-Saharan Africa has been devastated by this virus. In our area of Nigeria forty per cent of the population are affected. In our hospital eighty per cent of the work load is HIV related. Thanks to huge inputs by overseas charities, antiviral drugs are now available free of charge. The effort in education and community is impressive.

As we said our goodbyes at the Hospital, “annyar came at us from all directions. How strange, until we learnt that annyar not only means welcome; it means thank you.

Shorland Hosking