Eruwa, Nigeria, June 2009

The Operation Hernia first “mission” to Nigeria has come and gone but the experience and the lessons learnt will always be remembered by all participants for the rest of our lives. I was a part of the Nigerian contingent that met with Professor Andrew Kingsnorth on his initial ‘survey’ visit to Eruwa. So I was very happy to jump at the opportunity to come and participate in the Operation Hernia project when the date was announced.

I arrived in Eruwa on Saturday 27th June, 2009 as part of a group of four residents (3 registrars & 1 senior registrar) from the department of surgery of the Olabisi Onabanjo University Teaching Hospital (O.O.U.T.H.), Sagamu, Ogun state. We initially made a stop-over at the General Hospital, Igboora to pay our homages to Dr A.C. Sagua,FRCS(Ed), FWACS, who is the consultant General surgeon there and the initial point of contact for the reality called Operation Hernia Nigeria.(It was he who met with Prof Kingsnorth in Ghana and suggested the idea of Operation Hernia Nigeria to him). We arrived Eruwa at about 4:30pm by road. We were warmly welcomed by Mrs Awojobi (Dr Awojobi’s amiable wife). We were shown to the doctors’ flat where we would reside for the duration of our stay in Eruwa and we settled in as quickly as we could.

Later that evening, we met with Dr Awojobi, Professor Kingsnorth & Dr deKoch (from South Africa). After preliminary introductions and pleasantries, we fixed a meeting for 9p.m. that night for a formal de-briefing about the schedule of activities for the following days. At the meeting we were given a pre-exercise questionnaire to fill and we were told about the daily time-table of the programme. We were expected to resume for work by 7:30a.m. the next morning.

Teaching session

Teaching session

The Operation Hernia started ‘proper’ on Sunday 28th June, 2009 and the venue was the AM eye clinic complex located within the premises of ACE(Awojobi Clinic Eruwa). It began at about 7:45a.m. with a lecture on the Lichtenstein tension-free mesh repair technique given by Prof. Kingsnorth. After this, we proceeded to examine the patients that were already present for surgery. A total of forty(40) patients had been booked for the expedition. There we learnt hands-on classification of hernia types to determine the duration of the surgery and type of anaesthesia to be used. We then proceeded to the operation theatre where we had a series of photo sessions to commemorate the epoch making event of the first mission of Operation Hernia to Nigeria. There were two operating tables so that two surgeries could be going on simultaneously. Three doctors scrubbed for each patient; the surgeon, assistant surgeon and ‘scrub doctor’, I mean ‘nurse’. This was so because there was only one nurse available who served as a running nurse for both operating tables, hence a doctor had to scrub in as the scrub nurse. However, as the day progressed the surgeon decided to be picking up the instruments himself from the sterile tray hence the duties of a scrub nurse was no longer required.

We were taught how to effectively administer the local anaesthetic(LA) agent to achieve optimal neural blockade in the inguino-scrotal region. I must say here that though Prof. Kingsnorth and Dr deKoch used different methods to administer the LA, both methods were equally highly effective. The local anaesthetic used was 0.25- 0.5 % xylocaine with adrenaline.

We took turns at assisting Prof Kingsnorth and Dr deKoch initially then later they assisted the younger doctors. Emphasis was spent on outlining the anatomy of the inguinal region, the hernia sac and appropriate technique of mesh repair. I also learnt a principle of hernia surgery from Prof Kingsnorth when he said that “treat the hernia and not the age of the patient”. Hence, herniotomy can be done for an adolescent or middle aged male will a tiny hernia and strong posterior wall.

We took a lunch break and we went to buy food at the restaurant within the hospital premises. At the end of the first day we did a total of ten surgeries comprising herniotomies and mesh hernioplasties. Other doctors arrived that day, although most went back home that same day too.We finally closed for the day at about 6p.m. Later at about 7p.m, we had a meeting to assess the days’ work. In attendance were Prof Kingsnorth, Drs Awojobi,Sagua, Villalonga (Spain), Adekoya (OOUTH), Adebanjo (OOUTH), Obe (OOUTH), myself, a doctor from Korede clinic, Abeokuta and two residents from the family medicine department of the University college Hospital, Ibadan.After the meeting we were taken on a night tour of ACE by Dr Awojobi to showcase his innovations to generate and supply light at night with a locally manufactured inverter and lamps. We then retired to our flat.

We resumed work at 7:30a.m. on the second day of the expedition i.e Monday 29th June, 2009. I assisted Dr deKoch at an hydrocelectomy in the morning session.He took time to explain to me as well as assist me in every step of the surgery(I must say I did almost everything!) while every other person was busy either doing, assisting or listening to the teaching sessions during the surgeries. Dr Sagua then took all the residents on tieing of surgical knots which was a hands-on exercise,each doctor had a nylon suture to practice with. A new set of doctors joined us that day from Gboko, Benue state which is in the middle belt of Nigeria.

We took a lunch break and filled a post-exercise questionnaire to assess the program and profer suggestions. We then took our leave home in order to enable another batch of residents from OOUTH to come and resume at theprogram.

For all that it was worth, I will say that it was a very educative and fulfilling experience. The patiens benefited from the exercise not only because they had access to highly skilled manpower but received a modern repair technique at an affordable price of N6,000.00(six thousand naira) as compared to the regular cost of a hernia repair which is about N10,00.00 to N20,000.00(ten to twenty thousand naira).


Registrar in Surgery,
Olabisi Onabanjo University Teaching Hospital, Sagamu Ogun state, Nigeria

South Africa Team Report JUNE 2008

The initial request to participate in Operation Hernia in Ghana was through the British Hernia Society from its President Professor Andrew Kingsnorth.

He approached me because of a previous contact we had had when I hosted him as our visitor at the SAGES Annual Gastroenterology Congress several years ago. He also did part of his post graduate studies in Cape Town. I agreed that we should look into the feasibility of participating and he forwarded me details of the initial teams visits during 2005 and soon after details of the web site where more comprehensive details were provided.

One of the prime movers in the UK is Chris Oppong. He is an ex Ghanaian, now working in the UK and is really the man in charge of logistics from the UK side. I did not wish to make this a private arrangement and as such wrote to the Association of Surgeons of South Africa to see whether or not they would give it their support and whether or not they would help with funding the project. Simultaneously, I approached several parties in industry, those particularly involved with hospital care and with repair of hernias. The matter was discussed at the ASSA where mixed sentiments were expressed regarding the distance involved to participate in the workshop and the fact that similar situations occurred in neighbouring countries to South Africa where currently there were no similar projects going on. My own view on this situation was that with no existing projects being available, one should explore how this project worked and perhaps try and use it as a potential model for doing things on a more local basis and to this end I agreed to formulate the team. ASSA gave it their support and asked its constituent societies to contribute to the financial support which indeed they did in the form of the Vascular Endoscopic and Trauma Societies

Several individuals were approached and eventually we settled on a team of 4 individuals. The members were myself, from the Department of Surgery at the University of KwaZulu Natal, Mr Simon Maseme, the Chief Surgeon at Prince Mshyeni Hospital, the theatre matron from Addington Hospital, Linda McKenzie. The most senior member was Mr Roy Wise from private practice, These individuals gave up their free time and agreed to go. We finalized the date and it was to be a ten day trip. This was based on availability of flights into a Accra from South Africa which were costly at approximately R11000 each. We had to route via Lagos to meet our predicted period in Ghana. The sponsorship from industry came from Life Care Hospitals, Johnson & Johnson from their Ethicon Division, Perryhill International. I am extremely grateful to the individuals from these companies who supported the project. In total they contributed R25000 to the project. In addition, they also contributed a variety of different mesh products and sutures for use in Ghana for repairing inguinal and incisional hernias worth a similar amount of money. AstraZeneca kindly donated a significant quantity of local anaesthetic which again was put to good use during the project. These accessories were packed neatly in two boxes.


We set off on what we knew would be a lengthy trip because of our routing. First stop in Central Africa was the Lagos transit lounge where we had the dubious privilege of watching South African (0) being beaten by Nigeria (2) in Abuja. Next stop Accra a short haul which left only an hour late. On arrival we raised the ire of the customs officials as there was no import certificates for the medical goods and chattels we were carrying. However, with Simon Maseme s charm and my silver hair, we managed to get the boxes through without the need for a back hander or a huge paper trail. Meanwhile Mr. Wise was reporting his lost luggage, fortunately the only item which went missing in transit. This was despite booking all our belongings directly through to Accra together in Durban. This took the edge of what had been rather a long and arduous trip which still had a four hour road trip to go. When we emerged from Accra Airport a whole crowd of people , taxi drivers included, were watching the Ghanians beating Libya 3 0 they were ecstatic. Fortunately, our driver was looking out for us. The four hour evening ride, fortunately in our air-conditioned 4X4 was rather tedious so on arrival at 11pm we were all dead beat.

We arrived at the government villa which initially lacked some creature comforts and had a hot water geyser which was temperamental to say the least. This invigorated us all at various stages with a cold shower. Fortunately, the overall temperature of the cold water was well above zero and so it was refreshing rather than too much of a hardship.

It is important to say something about logistics. Our every need was catered for by Mr. Brian Dixon an oil man who knows how to get things done. He was the Canadian Natural Resources Limited, (A senior independent oil and natural gas exploration, development and production company based in Calgary) man in Ghana taking care of their business off the Ivory Coast. He is a huge asset to the hernia project. He employed three young ladies to look after us in the villa. They were Kate, Grace and Lillian. Lillian is training to be a welder, Kate is training to be a nurse and Grace is their best friend. They cooked for us prepared our packed lunches and pampered to our every need . It cannot be emphasized how much he continues to contribute to the whole ethos of the project. He does make it work and obviously it will be important that there is a transition to whoever provides logistic support in future years when he may have moved on. He had arranged a meeting with the acting Regional Medical Director, Dr Linda Vanotoo and I gave her feedback on our early experiences. The medical discussions focused on the need for provision of more Ghanaian trainees surgeons to assist and to be taught in the procedures. This would extend the potential benefit to create expertise locally which in my mind is essentially the true aim of the project to empower the health system improve the lot of their hernia patients.

We worked at two hospitals, a district hospital with a rather dilapidated exterior Takoradi Hospital. It is the home of the hernia project and on the second floor there is a converted ward which serves as a reception assessment area, operating theatre and recovery room . it has a well equipped small operating theatre and the staff , were to say the least, exuberant in their whole approach to life and to the project in general. The other hospital was the Ghana Port Health Authority Hospital (GPHA) which is a semi-private institution, a small hospital run by two doctors, one of whom is the main local instigator of the project and Chief Medical Officer Dr Bernard Boateng-Duah. He dedicated his operating theatre to the project for the week. His staff were also a delight in a more traditionally manner.

We serviced both hospitals simultaneously which meant we had to split into two pairs. We altered the pairings daily so we all worked with one another We had three trainees at the GPHA who participated and performed part of the hernia repairs that we did there. They were Dr George Tidakbi, MD Diploma in Anaesthesia West African College of Surgeons, Dr Owusu Adjei, MBChB Member West African College of Surgeons, and Bernard Boateng-Duah MD, Diploma in Obstetrics and Gynaecology University of Dublin.

Over the 6 working days we did a total of 61 procedures. We did 3 incisional hernia repairs, one bilateral hydrocele and 57 inguinal hernias, 4 were in young children and all but 2 were indirect hernias. The age ranged from 2 right up to 90. There was one return to theatre, of a large incisional hernia repair, for evacuation of a haematoma. This was 48 hours after the repair which we had fortunately done on our first day of our visit. It highlighted the need for suction drains, which we had not brought, but would have been an asset. My pièce de résistance was a 90 year old who had half his intestine in his right inguinal scrotum, I decided that discretion was a better part of valor and to sacrifice his right testicle. Fortunately, he made an uneventful immediate recovery, and when I saw him the next day he had a very broad smile on his face. It might have been because he had a very pretty nurse on his arm but I liked to think it was because his appendage had been returned to its rightful location. I very much hoped he remained complication free.

After a full weeks work from Monday to Friday, we had a relaxing time on the Saturday and Sunday. The Saturday trip was more hectic and we set off the rain forest and a canopy walk. There we were hosted by Rebecca who is one of the guides who had spend time in the U.K and her botanical knowledge greatly enhanced our trip there. It really was quite an experience and something unique for all of us. On the way back we had the privilege to watch a huge Ghanaian with a panga chop up a coconut so that we could not only drink the milk but also eat the coconut meat within. They also opened a Cocoa Pods which was a novelty for all of us. The cocoa beans within carry a sort of fructose – slime around them which is very tasty and edible. Of course the cocoa from the cocoa beans Ghana main exports and when we visited Takoradi port we found no fewer than 250 trucks full of cocoa beans waiting to be shipped out to make Cadburys chocolate. The port itself had also been the main logistics port for development by CNR of the Baobab oilfield in neighbouring Cote d Ivoire waters . A short ride took us to Hans Cottage where we had refreshments and observed crocodiles in the lake on which the restaurant was built.

The second part of our excursion was a visit to the slave castle at El Mina. This fortress had a long history of involvement in the slave trade. Our guide clearly outlined mans sustained inhumanity to man as a result of Portuguese, then Dutch and then British occupation. It appeared that not one of these pioneering nations had human rights on their mind when they were running the castle. It really was rather a sobering visit and emphasized how the colonial powers truly pillaged Africa in so many ways.

On the Sunday we went west towards the border with the Ivory Coast to a fantastic beach where we all braved the waves, had a leisurely time and a lunch. Again one needed a 4X4 to get to these beaches and we passed through some basic rural villages. The individuals seemed happy enough but one of the lasting memories for me was seeing two little naked infants defecating and urinating, in the company of goats, chickens, pigeons, and hooded vultures, on a rubbish tip. While we were trying to improve the curative services for hernia repair and improve the level of training of local doctors, their were obviously some basic health policy matters that will save many more lives than we can possibly sort out with our efforts.


We had a wonderful social evening at the Chinese restaurant on the beach and all the girls from the various teams participated to make it a memorable evening. Linda McKenzie had her birthday there and Mr Wise and Brian managed to conjure up some South African wine and a cake was baked by the girls. Her happy birthday song could have done with some more tuneful vocalists but we all enjoyed the evening she turned 22 again!!

On the Monday, we operated on a complication of a giant inguinal scrotal hernia which the Spanish team who finished their stint two weeks ago repaired. It reflects some of the problems with handing over these far from straight forward and long standing hernias to the local resources at the institutions. This aspect needs a more formalized commitment from the local surgeons. They had only two in a town of 500, 000 but they need to be involved in seeing and if necessary treating the complications. It is unrealistic with these types of hernias to suggest that they will all have an uncomplicated course.

On the Monday at lunch time, we had a wind up meeting to discuss the visit and have a two way dialogue on aspects which we felt would improve the interaction. Brian chaired and minuted the meeting. In essence, we were concerned regarding the short term follow-up of the patients and the timeous management of any complications. Obviously the long term follow-up is another issue which I am sure the founder members of the project are anxious to get meaningful data. We were concerned that the reusable drapes did not provide an adequate sterile field and that larger reusable drapes could be sourced locally.

The theatre lights at GPHA needed replaced as they were substandard. We felt also that opiod and local anesthetic drugs would be better sourced locally than brought in by the visiting teams. Even the importation of the meshes should have been more formalized so that import certificates can be achieved ahead of time. It was also felt that accurate stock record should be kept so that teams could be alerted as to the specific deficits in meshes, sutures and suction drains . The specific needs might also be based on the type and size of hernias an individual team would be treating. Hence details on the hernias to be treated should be sent to the team two to three weeks prior to their visit. It was also felt that an earlier start and restricting the number to a maximum of five patients a day would be beneficial. It would allow more time on each case for teaching purposes and to see the cases prior to overnight admission or discharge. In addition it would allow a bit of leeway for double procedures on certain individuals.

The girls at Takoradi decided that we should have some Ghanaian shirts and hats and a little Ghanaian Sarong was duly produced for Linda McKenzie. They really were a delightful bunch and were appreciative of our participation in their project. They had nicknamed Simon, Obolobo which means the large one or if you are being kind it means cuddly one He really related to the girls as the cuddly one. It was a really touching send off.

We set off early on the following morning on our final ride on Accra. We made record time with our new driver and fast vehicle but we were rather anxious when we checked in that we would arrive with our luggage at the other end. On this occasion we had to pick it up in Lagos and so we all got back to Durban with our belongings. Once again washed out after 24 hours on the road. Mr Wise still had the energy to take his dogs round Greyville Race Course before retiring.

I was proud of the whole team in Takoradi and the extent which the local girls went to ensure that we were welcome, well fed and comfortable . All of the South African team which I had the privilege to bring thoroughly enjoyed the trip. We all participated fully and the younger members took our hats off to Mr Wise who s senior participation as he approaches 80 was something for us all to behold. He retains an enthusiasm for his craft that has long deserted and jaded many lesser mortals in surgery. He sustained losing his case and having to wear my underpants and tee-shirts for several days with great aplomb.

It was a worthwhile trip whether it is a sustainable trip or whether it will provide us with an impetus to do things on a local basis remains to be seen. My own view is that it would certainly be worthwhile approaching our current and other funding sources for consistent backing for a project like this. If not for this particular venture, then for other projects where a small team can go on a recurring basis to develop the skills of local doctors. I hope this document kindles some interest in the concept amongst the ASSA executive.

Acknowledgements: I would like to thank all the individuals, companies and societies below for their conceptual support for the project and by translating this into both the financial and product support necessary to make it a reality. Roger, Vash and Sioban from Johnson and Johnson; Michiel from Astra Zenca; Ludwig and Geraldine from Perry Hill; Mike and Ruth from Life Care Hospital Group: SATS from ASSA and the councils of VASSA, SASES, Trauma Society.
I compiled this report on behalf of the Team

Sandie R Thomson