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.

Land of the Blue Sky

Fourth Year for Operation Hernia in Mongolia September 2013

Land of the Blue Sky

Land of the Blue Sky

Mongolia 8-20 September, International Team

Country

Mongolia is a country on the central part of Asian plateau situated between China and Russia. In Europe Mongolia is known as a low-income country, where the healthcare system has poor infrastructure and old equipment – in my opinion it is not truth in 100%. Mongolian people are also known as a very proud and brave nation – and this is absolutely true. The best chance to see all wonders of The Land of Blue Sky is to travel by car (better to take 4×4). What a traveller can see, meet and taste are beautiful and breathtaking landscapes, hospitable herdsmen who own totally 40 million horses, goats and sheep (the goats and sheep were very important for the team). The taste of a mutton stew, horse meat, tea with goat’s milk and especially khoomis is something what cannot be forgotten. Let’s say something about Operation Hernia in Mongolia – because it was the main goal of this trip for all of us.

Team

It was a pleasure to work with this truly International Team comprising Andrew Kingsnorth (UK); Maciej Śmietański Poland), Kamil Bury (Poland), Teresa Butron (Spain), Giorgio Giorgobiani (Georgia) and Martin Kriz (Sweden). We received huge support from every surgeon that we met on our route but especially we are grateful to Dr. Naraa and Dr. Sanchın and Enkhee

A herdsboy

A herdsboy

Performance at the National Theatre

Performance at the National Theatre

Journey

We landed at the airport of Chinggis Khan – Ulan Baatar (UB) on Sunday morning – as it turned out we all flew from Moscow on the same flight so there was no problem with the gathering. After breakfast we set off on a journey through the wilderness of Mongolia.

During the two-day trip we drove nearly 400km, we spent one night in the middle of nowhere and during the same night we took part in a Mongolian wedding. A lot of drinks and strange meals – but it was a marvellous experience. On the way back to UB at the special invitation of one of the surgeons we were able to take part in a horse race – a lasting impression and experience that we will never forget. After returning to UB we were divided into two teams. The team I was operating at the University Hospital and the other at the prison hospital. Operations performed at prison hospital resulted in three interviews for Mongolian TV and an invitation to dinner by the Head of the prison hospital. During our stay in UB, thanks to the hospitality Dr Naraa, we admired a fabulous performance in the National Theatre. The performance presented the culture and history of Mongolia in a magnificent way.

Teaching

Teaching

Operation Hernia

We operated on 78 cases, which included 20 children, 16 prisoners and 4 reconstructions including Ramirez and one cholecystectomy. We had a mixture of incisional and inguinal cases. The operating lists were tightly-organized but thanks to very good organization of work in the operating theatres we had no problems with performing all procedures. So we were able to do cases ourselves or assist and teach the Mongolians surgeons as appropriate. Andrew, Teresa and Martin gave lectures to the local surgeons. In the opinion of Mongolian surgeons the topics were well chosen and the knowledge gained will be very helpful in normal everyday work.

In a nutshell– the work was the same as on every Operation Hernia mission – early start in the morning for a post-operative ward round, followed by assessing into the new cases, then operating all day long and in the evening… night life in UB.

The great success of that mission was mainly possible because of the distinguished capacity for teamwork of every participant. All team-members expressed their wish to participate on the next humanitarian mission under the auspices of Operation Hernia.

We will be back…

For Operation Hernia from Ulaan Baatar

Kamil Bury

Maria & Stephen

Giants of Gambia return December 2012

Maria & Stephen

Maria & Stephen

Maria Boutabba (Registered ODP and Sister Maria to the team and hospital community) reports

Operation Hernia Mission, AFRPC hospital, Farafenni, Gambia – 8th December -14th December 2012.

This trip proved to be extremely profound for both professional and personal reasons. I had a fantastic time, was incredibly busy dividing myself between different roles, including surgical assistant… but was so in my element. It was and remains a great privilege to have worked with like minded professionals who value safe patient care and doing the right thing for the right patient at the right time in a clinical environment so different to what we are used to in our own familiar healthcare systems. We all bonded so well and enjoyed each others company, particularly in the relaxing evenings, listening to Brian’s very funny anecdotal stories and saucy jokes.

In surgical assistant role

The multinational (English, Welsh, Irish working in Scotland, Polish and Swiss) team comprised of Andrew Kingsnorth, Lead Surgeon, Brian Stephenson, 2nd in command surgeon, Alan Woodward, Surgeon, Stephen Brennan, Surgeon, Slawek Koziel, Registrar surgeon, Katharina Wentowski, Anaesthetist, Michael Wentowski, Medical engineer and myself. Andrew has fondly named us the ‘Giants of Gambia’ for achieving what we did under the conditions we worked in.

Michael's den (self-made EME department)

Michael’s den (self-made EME department)

Katharina taking her patient to recovery

Katharina taking her patient to recovery

We had an eventful arrival into Banjul, where one of Andrew’s small bags got whisked off in error to a resort hotel. After a delay and interesting police reporting process, it was returned intact, not something we would expect in the UK! We later made our way to Banjul port, where we waited in anticipation for the ferry that would take us across the impressive Gambia River to Farafenni.

Following what felt like hours and after polishing off some chicken and rice, our ferry eventually arrived. Amongst much local excitement, and eruption of frustrated tempers by queuing lorry drivers, we were herded on mass onto the ferry. We travelled the smooth, oil like river under the guidance of beautiful star constellations. We landed safely in Farafenni and made our way to what would be our very basic accommodation for the stay, Eddies Hotel, checking in somewhere around midnight on the 7th December 2012.

Throughout that initial experience we were looked after by the hospital communications officer, Saini. Saini would prove to be our valued friend easing our right of passage throughout our entire stay. Saini very efficiently organised our off duty entertainment time; we would sample an African music and dance evening, eat barbecued goat, visit the Senegal border, fishing village, women’s garden and eventually the Atlantic ocean waves on our last day.

The next day we met with the hospital administration. The hospital architecture is impressive but does not reflect what we were to come to accept as an under funded, under resourced, disorganised healthcare system. Following group prayer we discussed what we hoped to achieve during our stay. The administration was welcoming but hinted at the lack of resources at the hospital.

A lot of work was undertaken by the team to turn a ‘shell’ into an efficient, fully functioning mini day surgery unit. The ‘theatre’ developed into 3 operating spaces, with all surgical equipment, instruments and make shift operating tables scrubbed clean and organised to be fit for purpose. We set up a sterile storage area, scrub and gowning area and mini sterile services unit. We had one working diathermy machine that had travelled with Andrew. A startling Gambia fact is that in the whole of the country there are only 4 surgical diathermy machines!!

The transformation of the ‘shell’ would prove to become the pride and joy of the team and the few local staff who joined us to help. Of benefit to our clinical work, was our magical medical engineer, Michael, who fixed life saving equipment, we so often take for granted in the UK. Without this repaired equipment, which included suction and a couple of abandoned pulse oximeters, we would have found it difficult to achieve safe anaesthesia for the 16 children we later treated.

Katharina and I quickly realised we would not have a functional anaesthetic machine, despite several modern machines being available. Sadly these were all in need of spare parts to put them back in working order. However with Michaels help, we had proper basic monitoring, an ambu bag, suction and access to cylinder oxygen. We trawled abandoned equipment from previous missions to retrieve IV access and airway management devices. Katharina is a brilliant and committed anaesthetist, who showed so much maternal compassion for the children. Together, we carefully planned how we would safely pre medicate, anaesthetise the children and recover them post operatively – We went right back to clinical basics which we both found professionally satisfying.

We operated on 29 adults, the majority having local anaesthetic, with or without the support of Ketamine and Midazolam. A small number of adults had spinal anaesthesia. We operated over 4 days, with an efficient turnaround, with a ratio of approximately 1 child to 2 adults. All 3 operating spaces were kept fully utilised. An average operating day would typically reflect up to 9 patients operated on before lunch around 2pm and then 3 more complex cases in the afternoon and tidying up time ready for next day operating.

Brian, Michael, Andrew, Alan, Maria, Stephen & Katharina (picture by Slawek)

Brian, Michael, Andrew, Alan, Maria, Stephen & Katharina (picture by Slawek)

Child ready for postop care

We saw and operated on large paediatric inguinal and umbilical hernias. The adults had primarily very large inguino- scrotal hernias. We had a couple of complex umbilical hernia repairs which became mini laparotomies to repair them! We also operated on femoral hernias including, rather unusually, a mother and her two daughters. All the patients, where screened using the Kingsnorth classification, with Andrew, booking the patients to the operating list which was reviewed with me on a daily basis.

We had little chance to teach and train the local hospital community – there were no surgeons apart from one Obstetrician from Cuba. I did some basic theatre training with the few local nurses who were assigned to help us in theatre, and I hope to bring one particular nurse to the UK for an exchange visit. We had a Scottish medical student, on overseas placement join us for 2 days, and she found the exposure within our team rewarding. On a couple of days, 2 volunteers joined us from the schools for Gambia project – this assisted us tremendously as they helped bring patients to theatre, reassure them and they also helped wash and pack instruments.

We all acknowledged that Farafenni is very reliant on mission teams to assist with elective surgery. It is a sobering fact that once mission teams leave, there is no sustainable system in place to allow the local health community to carry on. We were humbled by how far patients will walk to access surgical care. The patient’s appreciation was immeasurable but the smile said it all.

On the last day we met the hospital administration again and exchanged niceties. Each member of the team was rewarded with a hand made shirt and letter of appreciation. We were reminded that we had been absorbed into the hearts and minds of both the hospital staff and local community.

I hope that the ‘Giants of Gambia’ team will make another visit to Farafenni in 2013 as per the wishes of the hospital administration.

Giants of Gambia OH team

Frank McDermott’s Second Mission November 2012

Team Ghana

Team Ghana

OH Mission to Volta Regional Hospital, Ho. (3rd – 10th November, 2012)

This was my second mission with Operation Hernia having returned from an amazing experience in Mongolia in 2011. I flew with a registrar colleague and friend, Mr Surajit Sinha, and we arrived into Accra to be greeted by Godwin, a hospital administrator from Volta Regional Hospital. Godwin was very welcoming and demonstrated throughout the week what a useful asset he is to the Hospital. Unfortunately one of my bags had not made the journey with me on the airplane which made for a challenging 48 hours in a hot and humid country!

Sunday

We spent the first night in the Baptist Guest House in Accra before travelling to the Volta Regional Hospital. On Sunday morning I met the rest of the team. Mr Chris Oppong I already knew as I had just completed a surgical rotation with him as a Colorectal Registrar in Derriford Hospital, Plymouth. He co-founded the charity with Professor Kingsnorth and as a Ghanaian was the perfect guide for my first adventure in this fascinating country. Joining us on the mission was an American team headed up by Dr Pedro Cordero, an Attending Surgeon based in New York. Pedro runs his own charity that has provided surgical care to Haiti and Philippines and we shared many interesting stories about providing surgical care in the developing world. The rest of his team comprised Aida St John and Carol Turner (American Theatre nurses), Peter Dixon (surgical trainee) and Alyssia McEwan (medical student). We all jumped on the hospital bus and began the 3 hour drive to the Volta Regional Hospital in Ho. You learn so much from driving through a new place. It gave the team the opportunity to gel and also see the captivating scenery fly by. We passed many small towns and witnessed the hustle and bustle of Ghanaian life with many street vendors selling some staple produce such as cassava, plantain and Tilapia freshwater fish interspersed with electronic stores selling sim cards for your mobile phone! Crossing the toll bridge over the Volta River gave stunning views of the region. I was not sure what to expect having never been to Ghana before but the hills were lush albeit the victims of deforestation over many years.

Eun balancing

Eun balancing

We arrived in Ho in the afternoon; it is the fifth most populous town in Ghana with a population of around 100,000. We drove to the hospital for a formal introductory ceremony with management from the hospital, the lead surgeon Geoff and a representative from the Ghanaian Royal Family, Mamma Tratto. This was all filmed by Ghanaian TV! The introductions all done we went to the ward to meet our patients and assess them prior to starting the real work the next day. Professor Kingsnorth has developed a scoring system for hernias grading them between H1 and H4. H1 being a small hernia that reduced on lying supine and H4 a recurrent or irreducible inguinoscrotal hernia. This scoring system is very useful for planning the list from a point of view of resources, type of anaesthesia proposed and for on-going data collection and audit. We assessed all the patients, checked blood pressure, Haemoglobin and sickle cell status and then planned the lists for the next day.

Monday – Friday

We were allocated three theatres in the surgical block for the 5 day mission. The theatre staff were very welcoming and we quickly developed a good rapport. We all stuck our first names on a label which broke down any barriers and emphasised that we wanted to work as a team to maximise the work we could do in this short time. We set a goal of operating on 100 hernias. We donated a diathermy machine to the hospital as well as 6 suitcases full of equipment that Pedro had brought. I operated with Sinha in Theatre 3 alternating cases. Our theatre team included ‘Old Sam’ an anaesthetic practitioner who was an expert at spinal anaesthesia, Eunice and Felica our theatre nurses and Gloria a circulator. The conditions were sweltering and even the Ghanaian staff said it was hot. On that first day I had to change my scrub top 7 times! As well as the heat we had some serious hernias to contend with. A lot of the hernias had been neglected for many years and were very large and stuck to cord structures. This made a big difference to the small hernias I’m used to operating on in the UK. We worked from 7:30 am when we were picked up from our hotel until the last case was done which was usually anywhere from 8-10pm. All patients had an operation note completed by the operating team and were sent home with a 5 day course of oral antibiotics and analgesia. We kept a prospective database of all the patients that we operated on. One of the main aims of OH is frugal innovation. Surgery is expensive but potentially lifesaving as Mr Oppong found out when two of the patients that were due to come in electively turned up with strangulated hernias. OH uses sterilised mosquito net as alternative to the expensive alternatives although we still rely on industry support for their kind donations. As mosquito net is very cheap it allows the local surgeons to perform an economical tension free mesh repair with consequent low recurrence rates.

Patient safety is the most important factor when we operate and something that has been in the spotlight over the last few years. We used a simple ‘timeout’ on the theatre whiteboard with patient details, operation proposed and who the team was for each day. This is something that the local staff found useful and was beneficial to us as Surgeons in a different environment. Aida and Carol also spent the week acting as scrub nurses but also sharing the benefit of their experience from working in the USA with the local theatre team. Some small changes could lead to a great improvement in patient safety. This was brought into focus when we met the local Governor whose brother had died following hernia surgery when a surgical glove had been left inside the abdomen.

Adapted ‘time out’

Over the 5 days we made many friends in theatre. We worked 13 hour days from Monday – Friday but were well looked after with beautiful local dishes. Sister Josephine, the theatre matron, deserves special mention. There was a stern side to her and she ran a tight ship but as the days went on we all developed a fondness and respect for her management and people skills. We managed to perform 99 procedures including 80 inguinal hernias, 50% of which were inguinoscrotal. 21 cases were performed under local anaesthetic, 2 under general anaesthetic and the rest were spinal. On the last day we shared a bottle of champagne with all of the theatre staff. There was an amazing feeling of accomplishment but also an immersive sensation of friendship and team work. I looked around at the American team, my friends from the UK and the Ghanian staff and found it utterly bizarre that I had only met a lot of them 6 days before. This is what OH does, it brings likeminded hard working and resourceful individuals together who want to make a difference and I hope this is what we’ve done.

Hernia Tutorial

Return to Malawi September 2012

Hernia Tutorial

Hernia Tutorial

Report on Operation Hernia visit to Thyolo District Hospital, Malawi 8th -15th September 2012

This was my 2nd visit to Thyolo as part of Operation Hernia following a successful trip last year. On this occasion I went on my own but I had the assistance of Francis, one of the clinical officers who was on the course last year. Eight new clinical officers from Thyolo and adjacent District Hospitals attended the course. They already had basic surgical skills and were providing the obstetric service under the supervision of the Senior Clinical Officer Steady Vinkhumbo. I am grateful to Professor Kingsnorth for supplying me with enough mosquito mesh to repair the hernias and enough for many years in the future! I am also grateful to St Anthony’s Hospital in Cheam for assisting with sterilization I took enough mesh, suture material and other supplies to cover the course and subsequent repairs as from last years experience they have very little stock. I would also like to thank my Trust (Epsom and St Helier) for giving me professional leave and Ruthie Markus of AMECA, a charity working in Malawi, for assistance with accommodation.

The trip was coordinated well in advance with the assistance of the District and Local Medical Officer. Francis planned for 8 patients a day in advance but we could have done more this year as I had access to two theatres for much of the time usual NHS story of competing with obstetric emergencies. There was a clinical officer who provided a spinal anaesthetic in the majority of patients. This is an advantage after last years experience when we repaired most of the hernias under LA or regional blocks. African hernias are more difficult than we see in this country and the surgery is definitely easier for the larger inguino-scrotal and recurrent hernias some had had previous darn repairs or herniotomies at the Central hospital!

Each day I attended routine rounds starting at 0800 followed by a teaching session for all staff shame we cannot replicate this at home. Apart from the Medical Officer and a visiting MSF doctor there are no qualified doctors in Thyolo. I would then do a teaching session on hernia surgery that was reinforced on each day of the course. The principle of the course was ‘see one, do one and teach one’ along the lines of Training the Trainers course in UK. I was amazed how quickly the trainees picked up the mesh technique. Each candidate was able to do 2 supervised hernias by the end of the course and we performed some simple herniotomies in children.

It was an intense week and I would strongly recommend providing the course if the opportunity arises. I think it is important to structure it as a teaching course and go back to the same place to provide consistency and encourage sustainability. I was very impressed that Francis was so good at teaching his colleagues within the course environment. It is my intention to return to Thyolo next year.
I also had the opportunity to visit Queens in Blantyre and I hope to run a Thyroid course along similar lines next year. I would be happy to advise anyone who is considering reproducing the course at other sites. Once again many thanks to Andrew Kingsnorth for giving me the opportunity to work with Operation Hernia.

Paul Thomas

Hands on Teaching

Hands on Teaching

Ravi Tongaonkar donating Indian Mosquito net mesh to Andrew Kingsnorth for Operation Hernia usage

Wednesday 23rd May 2012

International Federation of Rural Surgeons meeting in Eruwa, Nigeria, October 2011 at which Andrew Kingsnorth was elected a Council member.

Anna Young of USA explaining her Solar Autoclave to Delegates

Anna Young of USA explaining her Solar Autoclave to Delegates

Traditional Ruler of Eruwa and Delegates

Traditional Ruler of Eruwa and Delegates

Dr Gabi Holoch (President, IFRS) Dr R Tongaonkar (President-Elect), Dr Awojobi (Secretary) and Prof Kingsnorth

Dr Gabi Holoch (President, IFRS) Dr R Tongaonkar (President-Elect), Dr Awojobi (Secretary) and Prof Kingsnorth

Lima, Peru

Thursday 12th April 2012

The President of the Society of General Surgeons of Peru, Dr Jaime Herrera organised Operation Hernia’s first mission to Peru, during February 11-25. The team (Andrew Kingsnorth, Dr Scott Leckmann, Dr Denis Blasquez, Dr Petr Bystricky and Dr James Brewer) operated in Hopital Punte Piedra (HPP) situated in the poverty-stricked settlements to the North of Lima, and in the Hopital La Maria Auxiliadora (LMA)serving the deprived area to the South. At HPP the team were very ably assisted by Dr Miguel Jorge and at LMA by Dr Miguel Flores. An incredible 183 patients with 211 hernias received surgery, 40 residents assisted and observed the operations, lectures were given to the Surgical Society, terrific hospitality was enjoyed and Peruvian culture indulged to the full.

AWARDS: Dr Chris Oppong, Malcolm Carmichael, Plympton Rotary Club President, and Prof Andrew Kingsnorth

Thursday 12th April 2012

An award has been made to two non-Rotarians, the first time in the club’s history of Plympton Rotary Club, writes Nicola Tapp.

Rotary clubs in Great Britain and Ireland use the Paul Harris Fellowship, named after Rotary’s founder, as a mark of outstanding contribution above and beyond the norm.

The two fellowships have been awarded to Professor Andrew Kingsnorth and Dr Chris Oppong for their work with Operation Hernia.

Launched in 2005 by the two Plymouth-based consultant surgeons, Operation Hernia aims to provide sustainable surgical treatment of hernias to patients, along with training to local medical personnel, in developing countries in Africa, particularly Ghana.

Mr Oppong said: “A hernia is a surgical condition which can be very debilitating for patients in the Third World who don’t have access to the medical care we have in the UK. The painful swelling makes it difficult, and in some cases impossible, for the local farmers and fishermen to work and provide income for their families. Surgical operation to treat a hernia is therefore life changing; improving the quality of life for patients and allowing them to become earners again.”

Since its inception, more than 6,000 hernia patients have benefited from this humanitarian project in Ghana.

Professor Kingsnorth, said: “This recognition is very important to both of us as it has come from within our own community.

“We have received many awards but this will take pride of place.”

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

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

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

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

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

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

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

North Lima shanty town

North Lima shanty town

Miguel, Jaime & David

Miguel, Jaime & David

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

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

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

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

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

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

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

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

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

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

Watching the carnival

Watching the carnival

The weekend

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

Cusco and the ruins

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

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

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

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

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

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

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

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

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

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

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

Our departure

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

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

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

Written By James Brewer

Acknowledgments

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

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

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.