Magdi & Professor Narmandakh

3rd Annual Mission June 2012

Magdi & Professor Narmandakh

Magdi & Professor Narmandakh

As a Specialist Registrar in General Surgery, I was extremely fortunate to join the 2012 Operation Hernia mission to Mongolia through the great generosity of the Pitts-Tucker Fellowship. This Fellowship was kindly donated by the JPT charitable trust, which provides opportunities for young adults to travel in the exchange of cultures and to bring delivery of medical facilities in difficult to reach foreign areas, and awarded through Association of Surgeons in Training.

The Mongolian mission was led by Professor Juri Teras (Estonia), together with Magdi Hanafi (British), Fennie Wit (Dutch) and Kristjan Kalling (Estonian Anaesthetist). The Mission was also joined by Vahur Laiapea, a film-maker making a documentary on the Mission for Estonian television. Fortunately the filming predominantly focused on the Estonian speaking members of the trip!

We all met in Ulaan Baatur by Mrs Enkhtuvishin of the Swanson Charitable Foundation, who was again the tireless local co-ordinator for this third Mongolian mission, together with the Chief of the department of Surgery Professor Tsagaan Narmandakh. There was momentary anxiety as Magdy, together with all the meshes, sutures and local anaesthetic for the mission had missed the flight- he did finally make it a day later (minus the local anaesthetic, confiscated by customs). We immediately headed out to the Khustain National Park, a short distance but very long and bumpy drive from the Soviet-style sprawl of Ulaan Baatur into the vaste grassland steppes. Here, the Przewalski’s horse, once extinct in the wild and limited to 12 animals in captivity, was reintroduced via Dutch conservationists. They now number more than 300 in the wild, mostly in Khustain, and we were fortunate to be given a tour of the park by Piet Wit (Fennie’s father) who managed the reintroduction program for many years in Mongolia.

Przewalski's horses in Khustain

Przewalski’s horses in Khustain

The hosts and Operation Hernia Team in Hospital #2

The hosts and Operation Hernia Team in Hospital #2

We returned, inspired and enthused, to the capital for the first part of the mission, in the capital’s Teaching Hospital #2. This hospital has been host to two previous missions, and we were pleased to hear that they have regularly been performing tension-free inguinal hernia repairs in the intervening period, and had almost finished the stock of mesh left over from the last visit. They had arranged a pre-assessment clinic on Sunday afternoon, and we recruited a large number of patients for surgeries over the coming days. Most of these were very large incisional hernias, with many of the inguinal hernias having being performed by the surgeons prior to our arrival. We had access to two theatres with monitoring for general and regional anaesthesia, and a third more basic theatre for local anaesthetic repairs. Parallel cases allowed training to be provided to a wide range of staff, from medical students and residents to staff surgeons. The theatre equipment was very adequate, but all team members commented on the scrub nursing staff who were exceptional. Interestingly, there were some new laparoscopic stacks, and largely re-sterilised disposable laparoscopic instruments which are being used for laparoscopic cholecystectomies.

For the second half of the mission, we headed north, to the town of Erdenet, just a short distance from the border with Russia. This industrial town is centred on the fourth-largest copper mine in the world, and is the second largest city in Mongolia, with around 90,000 population. One specific local problem was that most local community healthcare workers would refer patients presenting with a hernia directly to Ulaan Baatur, an 8-hour journey each way, rather than to the local hospital. As in Ulaan Baatur, we were interviewed on local television which advertised our presence (increasing recruitment) and we hope ultimately serving to validate the surgical department in Erdenet. Unlike Teaching Hospital #2, the preoperative clinic was unscreened, and so we saw a number of interesting and varied non-hernia pathologies, such as penile hypospadias and undescended testes in adults. The hospital in Erdenet was well equipped, with a state-of-the-art high-definition laparoscopic stack in one theatre, whilst one of our patients became the first patient to undergo an abdominal scan in the newly installed CT scanner. The bulk of the surgical workload was inguinal hernia repair, predominantly paediatric. Again, we performed a large number of cases training both staff surgeons and residents. Perhaps the timing of the mission immediately prior to the Naadam festival, a three-day national holiday which sees almost every Mongolian taking to their horse and riding to their local village, limited adult recruitment, explaining the high percentage of children treated!

Wresters warming up at the Naadam Festival

Wresters warming up at the Naadam Festival

Alongside the surgery, we were very well entertained by our always generous hosts and included a concert featuring traditional Mongolian throat-singing. Dr Sanchin, a staff surgeon from Hospital #2, took us to visit his uncle’s ger camp where we sampled fermented mare’s milk beer and cheese, while elsewhere we gorged on an entire stewed goat. The highlight was a visit to the Naadam festival, where we watched Mongolian wrestling (the rules of which I am no clearer about now) and long-distance horse racing over a course of 40km with jockeys aged between 5-8yrs old.Overall it was an excellent mission to a rapidly developing country. The work that Operation Hernia has performed on previous trips was evident, and it is clear than in Teaching Hospital #2 use of tension-free meshes is becoming routine part of practice. Meanwhile I hope that we have provided some teaching and training to surgeons in Erdenet which can be built on during future missions. The success of the mission was due to the extensive planning and organization, both by Mrs Enkhtuvishin and the hosting surgeons, especially Professor Narmandakh- many thanks once again!

Adam Stearns

UK, Israeli, USA and Slovenian Team, Mongolia 1-15 MAY 2010

Mongolia is a country situated on the central Asian plateau wedged between China and Russia. It is classified as a low-income country, providing a healthcare system with poor infrastructure, old equipment and little money for basic supplies.

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The country has an average elevation of 1600 meters, a land mass the size of Western Europe and is situated at the headwaters of river systems that flow to Siberia, the Arctic, China and the Pacific. It has a dry climate yet affords 250 sunny days a year and is known as Land of the Blue Sky . Only 3 million people live in Mongolia and half of these reside in the capital Ulaanbaatar. Travel is best undertaken in a four wheel drive or by horse since there are only 1500 kilometres of paved road and most travel is via an improved earth surface or earth tracks. This gives wonderful opportunities to meet the hospitable herdsmen who tend the 40 million horses, goats, sheep and cattle that roam over the fenceless and treeless steppes. It is an exotic experience to visit a ger (a traditional round felt tent) and enjoy the hospitality of a nomadic family, which may include mutton stew, horse meat, goat s milk tea and khoomis (fermented mare s milk).

Our two week mission from 30th April to 15th May 2010, was undertaken with the very able assistance of the Swanson Family Foundation (SFF) represented in Ulaanbaatar (UB) by Mrs M Enkhtuvshin (Enkhee). Planning had begun more than six months earlier. Surgery and teaching took place during the first week in the central Teaching Hospital #2 in UB (under the leadership of the Chief of Surgery, professor Tsagaan Narmandakh) and during the second week at the central hospital in Moron, a distance of 800km to the north in Khuvsgol province. Surgeons from district hospitals attended for teaching and lectures in Lichtenstein inguinal hernia repair, incisional hernia repair with mesh and components separation, and some paediatric surgery. To reach Moron involved an unforgettable drive across the steppes and taiga to the still-frozen Khuvsgol lake adjacent to Siberia.

Our team consisted of myself, Professor Motti Gutman from Israel, Dr Todd Heniford and Dr David Earle from the USA (the first representatives of the American Hernia Society) and Dr Juriy Gorjanc from Slovenia. We arrived at the Chinggis Khan airport early on the morning of Saturday 1st May and were met by Enkhee, the Chief of Surgery and the Director, of Hospital #2. The remainder of the day was spent orientating in the city of UB and adjusting to the cheerful faces of Mongolians dressed in their exotic and colourful deels (three-quarter length gown that buttons at the right shoulder to a high round-necked collar), hats, scarves and sashes. Our clinical work began the following evening (Sunday) with pre-assessment of 20 or so patients who had a variety of hernias. On the Monday morning we attended a dignified official opening ceremony with appropriate speeches and then set to work. In 2 operating theatres we completed 10 cases, surrounded by up to 20 curious surgeons seeing modern techniques of hernia surgery for the first time. During the following week we were able to take several of these surgeons through hernia operations and then proceed to teach them under direct supervision. In the meantime we had a guided tour of the hospital, made occasional visits to the emergency room and on one occasion witnessed the expert treatment of a bleeding liver tumour. In the evenings Mongolian entertainment was laid on, including a visit to the Naran Tuul black market and a glimpse of ancient Mongolian culture at a presentation of the National song and dance Ensemble. We gave TV interviews to the national network which were broadcast during the evening and vastly increased the recruitment of patients. By the end of the first week over 50 patients had been treated and we celebrated with a farewell well dinner in a restaurant that had a copy of the famous painting of One Mongolia by Sharav, as a backdrop.

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In Moron each morning began with an 800 meter walk to the hospital from our small hotel, rubbing shoulders with colourfully-dressed school children on their way to lessons and ordinary citizens going about their business. During four working days we completed another 50 cases and taught the surgical staff techniques of mesh repair. We operated on fifteen children, some as young as 4 months. By doing this, we would have saved each family two days travel each way to UB, plus a 2 or 3 day stay in the capital during the hospital admission. The cost of a journey such as this would often be beyond the means of a herdsman living a hand-to-mouth existence. Finally, the hospital staff entertained us to an evening meal in a ger camp when the whole delicious carcass of a goat cooked by traditional methods was consumed with vast quantities of Chinggis Khan vodka, which greatly assisted the content of subsequent spontaneous speeches.

On return to UB and prior to our departure we visited the Zanabazar fine art museum to view the long history of Mongolian art outlining the history of this interesting and fast-developing country. The hospitality had been enormous, and the surgeon s thirst for surgical knowledge enviable. An invitation to return has been accepted. We departed with a rudimentary knowledge of the Mongolian language, including the phrase of greeting when approaching a nomadic ger – nokhoi khor (hold off the dogs!)

The Operation Hernia team members wish to express their deep admiration of the Mongolian doctors with their high level of professionalism, their committment to the traditional values of the art of surgery, their recognition that medicine in low-income countries is still a vocation,.and their appreciation that the craft of surgery is a continuous learning process. We also wish to thank them for: preparing the mission with Enkhee, recruiting the patients, being attentive and willing learners, looking after our patients postoperatively and providing a sustained and entertaining social and culinary programme. The Mongolian doctors who were involved in the success of the mission were: (i) At Hospital #2: G. Bayasgalan (Director), Ts. Narmandakh (Head of Surgical Department); the following surgeons B. Onon, U Sanchin, Ya. Altanchineg, S. Ulambayar, G. Bilguun, P. Tseden-Ish, Ya. Batsumber; A. Khandaa (OR nurse); and the following anaesthesiologists: Z. Tumenjargal, A. Saranbaatar, J. Munkhzul. (ii) At Khuvsgol Central Hospital: D. Erdenebaatar (surgeon), D. Chuluunbaatar (Head of Surgical Department); D. Chuluunbat (surgeon) and Tumenjargal (anesthesiologist). We salute them all!

Andrew Kingsnorth