Home and away team

Takoradi March 2013 Report of the Belgian – Italo – Dutch team. Visit from March 9 – March 17 2013.

Home and away team

Home and away team

In March 2013 a team of four Belgian surgeons (Myriam Bruggeman, Paul Van Acker, Marc Huyghe and Casper Sommeling) accompanied by an Italian surgeon (Cecilia Ceribelli), two registrars (Stijn Heyman from Belgium and Annelien Morks from the Netherlands) and a Belgian nurse (Pina Orlando) again visited Takoradi in Ghana. Our main financial sponsor still is the Belgian Section of Abdominal Wall Surgery. We brought meshes (kindly donated by Medri, Covidien Belgium, Bard Italy and Assut Europe), gloves (Cardinal Health/Medline), disposable drapes (Mölnlycke Belgium and Medline) and suture material (Johnson & Johnson). Resterilized polypropylene meshes and so called “Indian meshes” made part of our luggage. Local anesthetics, syringes and needles were donated by Bbraun an BD; only the lidocaine with adrenaline and heavy Marcain was bought by us in Belgium.

This way for Hernia Operation

This way for Hernia Operation

Recovery

Recovery

After arriving at Accra, late Saturday night, for the first time we stayed at the Ghana Baptist Mission. The following Sunday we made the trip to Takoradi, meanwhile visiting Kosa Beach.

Again “the girls” (Kate, Linda and Benedicte) took good care of us, although they had more difficulties than the years before due to the frequent power cuts. They even proposed us to switch to a hotel, but their “candle light suppers” were much appreciated by us. This year we were lucky to meet Brian Dixon again, who was on “holiday” in Takoradi; however this means trouble shooting for him as a second nature, or as he states it “there are no problems, only challenges”. He contributed again to our mission in several ways, mainly on a logistic level, but also on solving local problems. He even might have solved the problem of running water in Dixcove hospital.

Paul & Brian

Paul & Brian

During the week we organised three teams that rotated in the three different hospitals (Hernia Wing, GPHA and Dixcove). We performed 86 operations in 86 patients, of which nine were children. Again most of the adult patients presented with groin hernias. The total number of operations seems low for the total number of team members but we were plagued by power cuts and interfering caesarean sections. This year in the adult patients two-thirds (51/77) were operated under local anaesthesia, but loco-regional anaesthesia (26/77) was used as a standard in all three locations in the more demanding scrotal hernias, contributing to a better comfort of the patients. The children of course were operated under general anesthesia.

The motivation of the local hospital teams is good and the level of care of the nurse-anesthetics in the three hospitals is high. The equipment in the hospitals is of a reasonable level, but the Dixcove Hospital is in need of sharp scissors and new operation gowns. Although with three teams we still made long days, but once again it was rewarding.

After a long week hard work we had dinner at the the “Gilou” restaurant Friday night together with Bernard Boateng Duah and his wife. On Saturday we made a trip to Green Turtle Lodge, the nicest place to be at the Atlantic Coast, were again we spent a wonderful day. At Sunday morning our group split up. Marc started on a trip of ten days through Ghana. Paul and Myriam stayed another week in Takoradi for holiday; however they were motivated to operate on the patients that were left over from the first week in the GPHA-hospital, so the first two days of their holiday they operated eleven patients (included in the total of 86).

Pina stayed another two weeks in Takoradi to work in the hospital as part of her training to be a specialized nurse. Cecilia, Stijn, Annelien and Casper made the trip back to Accra with a stop at El Mina Castle. Conclusion: again a rewarding mission; if the future team will enclose again as much members as this year we might go to other places in Ghana. We once again want to thank Bernard Boateng for the organization at the local level: selecting the patients on forehand and helping us out during the week.

Special thanks to Brian Dixon, just because being there.

Casper Sommeling, on behalf of the Belgian – Italo – Dutch Mission

Members of the Team

David Messenger: First Shorland Hosking Fellow November 2012

The ASiT/Operation Hernia Shorland Hosking Travelling Fellowship to Takoradi, Ghana

David Messenger, ST6 in General Surgery, Severn Deanery

Background

In March 2012, I was fortunate enough to be awarded one of the first ASiT/Operation Hernia travelling fellowships. The funding for my fellowship was donated largely by Howard Eggleston, a former patient of Professor Andrew Kingsnorth’s, and was named in honour of Shorland Hosking, a consultant surgeon from Poole, who died tragically in an air accident shortly after returning from an Operation Hernia mission to Nigeria.

Operation Hernia is an independent, not-for-profit organisation, whose mission statement is ‘to provide high quality surgery at minimal costs to patients that otherwise would not receive it’. It was initiated in 2005 from Derriford Hospital, Plymouth, via the city’s cultural links with Takoradi, Ghana. Operation Hernia has since expanded and to date has repaired over 6000 hernias, at 18 locations in 11 different countries with teams originating from 22 countries.

I have had a long-standing interest in hernia surgery and have never failed to appreciate the impact that an effective hernia repair can have on the quality of life of the patient. It was this opportunity to undertake a humanitarian mission where my surgical skills would be of maximal benefit to a community where healthcare resources are limited that prompted me to apply for the fellowship.

I chose the mission to Ghana, as this was my first experience of humanitarian surgery and I wanted this to be in a well established setting. The prevalence of inguinal hernia in Ghana is as high as 7.7% of the population.1 However, less than 40% are actually repaired, resulting in many patients developing long-standing inguinoscrotal hernias that are associated with a high incidence of morbidity and mortality.2 Presentation is often delayed and approximately two-thirds of cases are repaired as emergencies.

Sekondi-Takoradi is located in the Western Region of Ghana with a population of almost 450,000 (Figure 1). Its principal industries are timber, ship-building and crude oil. The discovery of the latter has led to a dramatic expansion of the metropolitan area in recent years. Most of the adult workforce is engaged in physically demanding jobs where the effects of an untreated hernia can be debilitating. The stark reality is that if you are unable to work, then there is little means to support both yourself and your family. The value of the mission could not be clearer.

Preparation

The co-ordination of the mission was masterminded by Mr Chris Oppong, a consultant surgeon from Derriford and Director of Operations for Ghana. It soon became apparent that an anaesthetist was required and I duly offered the services of my wife (!), Dr Natasha Joshi, an ST7 anaesthetic trainee, who was supported by a travelling grant from the Association of Anaesthetists of Great Britain and Ireland. Our preparations included undergoing an extensive vaccination programme, obtaining visas from the Ghanaian High Commission in London, arranging flights and gathering together an array of gloves, gowns, sutures, laryngeal mask airways and portable pulse oximeters! We are grateful to the Spire Hospital, Bristol, and those colleagues who were kind enough to donate equipment for the mission. Operation Hernia has pioneered the use of polyester mosquito net meshes as a cost-effective means of hernia repair and these were pre-sterilised at the Derriford and Royal Gwent hospitals prior to our journey.

After arriving in the capital, Accra, the team assembled at a local guest house, before travelling on to Takoradi by road the next day. In addition to Natasha and me, our team consisted of two consultant surgeons from Dewsbury: Mr Shina Fawole, team leader and a veteran of three previous Operation Hernia missions, and his colleague Mr Harjeet Narula. They were accompanied by Melanie Precious, a Senior Operating Department Practitioner, also from Dewsbury, proving the old adage that a surgeon cannot operate without at least one member of their regular theatre team! In fact, Melanie’s scrub and anaesthetic experience were to prove invaluable throughout the course of the mission. The final members of the team included Mr Rafay Siddiqui, an ST4 general surgical trainee from the London Deanery, and Mr Roger Watkins, a recently retired consultant surgeon from Derriford, who joined us for the final two days of our mission after conducting a separate mission to the Cape Coast (Figure 2).

The Mission

On arrival in Takoradi, we were met by Dr Bernard Boateng-Duah, Chief Medical Officer of the Ghana Ports and Harbour Authority Hospital, who was in charge of the logistical arrangements of our stay. We had the exclusive use of a Ghana Ministry of Health Villa, which provided a welcome respite at the end of a long day’s operating (occasional disruption to the hot water and electricity supplies not withstanding!). The culinary skills of the catering team were superb who ensured that we had the opportunity to enjoy variety of Ghanaian dishes (Figure 3).

Bernard had already co-ordinated the not insignificant task of selecting patients for our mission. Recruitment had largely occurred through radio announcements, clinic visits and perhaps most pleasingly through word of mouth. A prime example of this was the patient who told me he had waited all year for his hernia to be repaired just so the British surgeons could perform his surgery! We operated at three sites during the week: Ghana Ports and Harbour Authority Hospital, Takoradi Hospital and Dixcove Hospital, located a one hour drive from Takoradi (Figures 4 a,b and c). At Takoradi Hospital a disused wing had been refurbished in 2006, with funding from the British High Commission, to create the Hernia Treatment Centre that incorporated an operating theatre and day-case ward.

On the morning of surgery, patients were pre-assessed and a decision made with regards suitability for repair under local, spinal or general anaesthesia. As a general rule, inguinal hernias that were manually reducible were repaired under local anaesthesia, with irreducible hernias or those with a substantial inguinoscrotal component being performed under spinal anaesthesia. General anaesthesia was reserved for incisional hernias and paediatric herniotomies. Over the course of the five-day mission, our team performed a total of 94 procedures in 87 patients (Table 1). Inguinal hernia repairs accounted for 71 cases (including 6 recurrent), of which 39 (55%) were performed under local anaesthesia. The majority of inguinal hernias were inguinoscrotal, or H3/H4 according to the Kingsnorth classification system (Table 2)3. Polyester mosquito net meshes were used for repair in 37 inguinal hernias with the remainder being repaired using brand mesh left over from previous missions. The handling of the mosquito net meshes was broadly comparable to that of brand mesh, although we found that bigger bites with each suture were required to adequately secure the mesh. There were no post-operative complications and all adult hernia repairs were discharged on the day of surgery. Only one patient who had undergone repair of a large incisional hernia stayed overnight.

Initially, repair of the inguinal hernias proved to something of a technical challenge, owing to the anatomical differences between those encountered in Ghana compared to in the UK. Most inguinoscrotal hernias were due to a longstanding patent processus vaginalis that commonly required transection of the sac to facilitate reduction. Furthermore, these hernias were embedded within a well developed cremasteric muscle and tended to encircle the cord structures, which made dissection of the sac more troublesome. In many instances, partial excision of the cremaster was required in order to effect sound mesh repair around the deep ring.

Personal Experience

I can honestly say that the experience of operating solidly for 12 hours each day, in an environment subject to power cuts, poor lighting, a lack of running water and frequently defective equipment has been the most rewarding of my career to date! I was especially proud of Natasha, who as the sole anaesthetist dealt effectively with a number of challenging anaesthetic situations, mainly related to leaking circuits and a limited oxygen supply.

During the week I performed a total of 32 procedures: 21 inguinal hernia repairs (three recurrent), six paediatric inguinal herniotomies, two incisional hernia repairs, two hydrocoelectomies and one epigastric hernia repair. Eleven of these procedures were performed independently with the consultant operating in another theatre. Many patients had travelled long distances for their surgery and I was humbled by the gratitude that they showed our team. I was amazed at how well the patients tolerated their procedures and it was often quite difficult to get them to admit that they were in any pain. In the UK, I could never imagine performing a sizeable inguinal hernia under local anaesthetic in a 30 year old male without any form of sedation.

The local nursing staff at all three centres worked tirelessly and were extremely welcoming. There was no need to rely on iTunes for entertainment in theatre, as we were often serenaded with gospel singing throughout the cases! Anaesthetic cover was provided by nurse anaesthetists who for the most part were highly skilled and keen to learn from Natasha. I was particularly impressed by the nurses at the Hernia Centre who were actively engaged in improving their practice and had implemented the use of pre-assessment proformas, antibiotic protocols and a handwashing policy. They were ably led by Sister Marion who had previously undertaken a one month elective placement at Derriford hospital (Figure 5). The only reluctance we encountered from the nursing staff occurred at Dixcove when we embarked on our final case of the day at 7.00pm. We later learned that the staff preferred to leave in daylight hours to avoid the snakes that would appear at night on their walk home!

It was at Dixcove that we encountered patients with the largest hernias (Figure 6). The community at Dixcove is less affluent than Takoradi with one doctor serving the needs of over 20,000 patients. Consequently, these hernias were longstanding and in one instance emergency repair of a hernia that had become obstructed was required. The reality of everyday life in this community was illustrated by the case of a 6 year old boy with an inguinal hernia who only weighed 13kg. We decided not to proceed with surgery as he had a right basal pneumonia and instead admitted him for intravenous antibiotics. Despite also having recently recovered from malaria, his mother was still desperate for him to undergo surgery as his hernia was limiting the physical contribution he could make to domestic tasks.

Social Aspects

Ghana was the first African nation to gain independence from the British in 1957 and is proud of its status as a stable parliamentary democracy in a politically volatile region. It is a majority Christian country, with a sizeable Muslim minority, and is compromised of over 100 ethnic groups. It is the relative inter-religious and inter-ethnic tolerance that has seen Ghana avoid the civil wars that have afflicted neighbouring states. Whilst in Accra, we visited the Kwame Nkrumah Memorial Park where we able to learn more about the birth of Ghana as a modern nation and the concept of pan-Africanism (Figure 7). This also proved to be a popular setting for newlyweds to pose for their wedding photographs! It is perhaps the following quote from Nkrumah that best sums up Ghana’s drive to achieve middle-income country status by 2015,

‘We have the blessing of the wealth of our vast resources, the power of our talents and the potentialities of our people. Let us grasp now the opportunities before us and meet the challenge to our survival.’

Summary

This was a thoroughly worthwhile mission for all those involved. Despite having never met each other before, I thought that the team gelled together well. Shina was an inspiring team leader, navigating us through several tricky situations (often related to Ghanaian taxi journeys!). Harjeet and Roger provided sound advice and were both excellent trainers. The contribution from Natasha and Melanie was immense who managed to instigate a change in practice with regards to the administration of spinal anaesthesia – tilt the patient head down, rather than perform a second injection of local anaesthetic if the spinal does not act immediately. I found Rafay to be a supportive and well-rounded colleague who like me benefitted tremendously from this experience. It was not until I returned to work in the UK that I realised that this mission has matured me both as a surgeon and as a person. It has taught me to be adaptable, more understanding of the limitations within the NHS and perhaps most importantly has given me a much needed perspective on life. I would recommend, therefore, that any trainee looking to broaden their surgical horizons should become involved with a humanitarian mission.

Recommendations

I have listed below two simple but achievable aims that would improve the quality of care received by the patients in Takoradi.

Routine adoption of the WHO pre-operative checklist at all hospitals.
The purchase of portable pulse oximeters for patient monitoring both peri- and post-operatively. We donated our own to Dixcove hospital. This may be best achieved through Lifebox, a not-for-profit organisation, that aims to put a pulse oximeter in every operating theatre throughout the developing world (www.lifebox.org)

Acknowledgments

I am grateful to ASiT, Operation Hernia and Howard Eggleston for providing financial support. Thanks must also go to Mr Chris Oppong, Dr Bernard Boateng-Duah and Mr Eddie Prah for ensuring such a memorable and well organised mission.

References

DL Sander, Porter CS, Mitchell KC, Kingsnorth AN. Operation Hernia: humanitarian hernia repairs in Ghana. Hernia 2008;12:527-529
Clarke MG, Oppong C, Simmermacher R, Park K, Kurzer M, Vanotoo L, Kingsnorth AN. The use of sterilised mosquito net for inguinal hernia repair in Ghana. Hernia 2009;13:155-159
Kingsnorth AN. A clinical classification for patients with inguinal hernia. Hernia 2004;8:282-284

Tables and Figures

Table 1

Table 2

German Team, Takoradi, Ghana 13-21 JUNE 2009

First of all I would like to thank everybody who was involved in establishing Operation Hernia, those who took part in our mission and all the companies and private donators who granted financial and material support.

wolfgang_reinpold

Without their help and sacrifice the mission would not have been possible and successful. A (hopefully) complete list is at the end of this short report. My special thanks go to Dr. Chris Oppong for helping us preparing and organizing the mission; lovely and warm hearted Lilian and Kate for cooking excellent Ghanaian food, brilliant housekeeping and making us feel at home in our accommodation, Dr. Bernard Boateng and Dr. Frank for their excellent patient selection, patient preparation and their support and help during our stay; the outstanding staff of nurses at Port Authority Hospital and Takoradi Hospital and last but not least the excellent team from Hamburg and Gifhorn that accompanied me: Veronika von Blücher, Hilde Kuiken, Janine Priebe and Ingo Leiser (OR-and anaesthesiology technicians), Dr. Corinna Meissner-Kuck and Dr. Rüdiger Lohr (anaesthetists), Dr. Ute Harte (general practitioner), Dr. Matthias Rohr (surgeon).

Our team arrived at Accra airport Saturday evening. We were happy that all 32 boxes with medical goods and equipment had made the trip without damage. It is absolutely advisable to bring medical goods and equipment with the same flight. We had marked the boxes clearly with a red cross. Our flight company had kindly agreed beforehand not to charge extra weight charges.After a short delay due to a traffic congestion in Accra our bus arrived and we had a safe 4 hour trip to Takoradi.

On Sunday Lilian and Kate took us to beautiful tropical Green turtle beach where we had a very pleasant, sunny, and relaxing afternoon. We swam in the Atlantic Ocean and took a short beach walk to a nearby village of fishermen.

In the evening Bernard took us and our equipment to Takoradi- and Port Authority Hospital. We decided that Matthias, Rüdiger, Hilde and Janine would operate in Port Authority Hospital while Corinna, Ute, Veronika, Ingo and I would work in Takoradi Hospital. The operating rooms of both hospitals are sufficiently equipped according to European standards. During most of our operating time we had no running water in Takoradi hospital. Clean water was stored in plastic buckets and tubs. For future missions I would recommend to bring alcohol-based skin disinfection agents. There is always a shortage of drapes and gowns. We brought only 40 sets of drapes, thus we had to use one set for two patients. The nurses were well trained separating a set of drapes in two while maintaining sterility.

From Monday to Friday we performed 65 operations on 61 patients. The vast majority were indirect scrotal hernias, some of them very big. About one third of the operations were performed under local anaesthesia. There was one emergency of a strangulated massive scrotal hernia which required a large omentum resection. Fortunately, a bowel resection was not necessary in any of the cases. We operated on 4 children who all got a high hernia sac ligation. There were 8 ventral hernias, some of them very big. The big ventral hernias were fixed with an open sublay repair, while small umbilical hernias were operated on with a nonabsorbable suture repair. All groin and scrotal hernias had Lichtenstein repair with polypropylene mesh. We had to operate on 4 hydroceles. There were no major complications. Recently Bernard told me on the phone that all patients were followed up and that fortunately there were no wound infections only some minor hematomas and seromas which resolved spontaneously.
The patients were all very well selected and well prepared by the local medical staff. The patients and their relatives were all very thankful, patient and pleasant. Most of them spoke only very little English but the nurses helped us to communicate. We learned some expressions of the local languages and some of the patients laughed about our wrong pronunciation.

Despite the fact that hernia repair is only one of many health issues in Africa, we feel that Operation hernia is an important project that is worth being supported in the future. For all of us the hernia mission was not only an outstanding and heart touching experience which we will never forget, but also a mission of friendship and partnership between Africa and Europe. We are all looking forward to come back to Ghana in the future.

Dr. med Wolfgang Reinpold
Surgeon from Hamburg, Germany

The first German Hernia mission to Takoradi was kindly supported by donations from:
Dieter Adelwarth, Anästhesie Zentrum Hamburg, Jeanette Azzaloni, Sigrid and Hans-Jürgen Beinhorn, Otto Binkele, Praxis Dres. Elke Brüning, Matthias Ewe and Petra Köster-Meyer, Wilhelmsburg, Covidien Deutschland GmbH, Irma Deschka, Deutsche Lufthansa AG, Fa. Freizeit & Hobby, Anita and Fred Gohle, Renate und Ingo Grundmann, Dr. Horst Haeberlin, Johnson & Johnson Medical GmbH (formerly Ethicon), Katholische Kirchengemeinde St. Bonifatius Wilhelmsburg, Margret Kaczmarek, Erika and Kevin Kilpatrick, Brunhilde Kirsch, Lohmann & Rauscher GmbH & Co.KG, Anke and Bernd Malik, Elke Matuszczak, Fa. Medic Zeitarbeit, Dr. Ute Moje, Marianne and Gerhard Nöthlich, Dr. Gerald Paschen, Hans-Jürgen Peschel, Anja Petersen, Ilona Reichwald, Semperit Technische Produkte, Anna Schilling, Thomas Schmidt, Martha and Johann Swoboda, Dietgard Ude-Zalik, Sabrina Wehrmeyer und Frau Wittneben (Reisebüro Wittneben, Gifhorn), Dr. Anke Witte, Barbara and Norbert Wolpers, Christel Wowtscherk, and many others who either didn´t want to be listed or donated anonymously.

Spanish Team, Takoradi, Ghana 16-23 MAY 2009

The Spanish mission 2009 is done!!!! Lots of satisfactions and lots of difficulties, but we feel again that our support to the people in Ghana is important and highly-valued by the Ghanaians.

Spanish Team 2009

Spanish Team 2009

Large hernias, hydroceles and different emergencies were treated by a very well-balanced team of nurses, anaesthesiologists, general surgeons and paediatric surgeons. Spain is excited about the Operation Hernia Project and about having the chance to help people in developing countries. In fact many professionals asked about the possibilities of going to Ghana and so we ended up by creating two teams, the first one being composed of 14 professionals, including 3 nurses, 4 anaesthesiologists, 1 paediatric surgeon, 5 general surgeons and 1 allergist who supported the local doctors and nurses as a general doctor.

First of all, we would like to thanks our institutions who supported the project with drugs and equipment and specially by letting 14 professionals leave for Ghana in the middle of the local situation in which we live nowadays in our hospitals, the University Hopsital Virgen del Rocío (Sevilla), USP-Clínica Sagrado Corazón (Sevilla), Hospital Rio Tinto (Huelva), Hospital Infanta Elena (Huelva) and Hospital del Mar (Barcelona). A total of 11 people from Sevilla, 2 from Huelva and 1 from Barcelona who were locally also supported with an investment of money for surgical equipment, air tickets, toys and cloth for the children by Diputación de Sevilla, Ludociencia, Viajes Atlanta, Sevilla FC, Ecija Balompié, Betis Moda, La Caixa, Fundación Roviralta and los amigos de Juan .

Secondly, we would especially like to thank the local people who looked after us, Dr Bernard Boateng-Duah for organizing everything in the three hospital were we worked, we are aware of the amount of extra work for him that means such a large group such as the Spanish one going to Takoradi: Michael Danso, by giving the support of the Takoradi hospital to the project and taking care of the luggage that did not arrive in Accra with us; the girls that looked after us at the house, the lovely Kate, Lilian and Barbara, who are inside everyone s hearts; and of course, to the local professionals of the health systems of Ghana, the nurses, who works together with us these days to perform 100 surgical procedures, always happy and making things easier for us, and to the two local doctors who were involves in the project, Ernest and our friend Dr Frank, who we are going to miss next year in case he move to other part of the country.

This year we had the chance to work in four operating rooms, at the two surgical theatre of Takoradi hospital, at GAPOA and at Nana´s hospital, a small rural hospital surrounded by the jungle with no running water in which doctors are able to help people with very low resources. One hundred surgical procedures in 83 patients were performed in 5 days by a team of Spanish professionals who are very involved in this project. We all are happy to hear that the number or giant hernias are decreasing in the area since the project starts in 2005, which means that things are working and that it is very important to keep supporting the project next years.

This is an analysis of what we did, what we saw and what we think about this year mission, but overall what it is in the deep of our hearts is two basic things: the face of the Ghanaians giving us thanks, with a smile in their face, after the surgery when they were still having pain; and the spirit of friendship of a group of 14 people who leave their family for 8 days and their hospitals and spend an important amount of money out of their own pocket to try to solve a situation to someone who s it. Ana, Fran, Miguel and Hilario, our 4 anaesthesiologists did an extra excellent work by handling very difficulties situations, especially with the little children since they did not have the anaesthetic drugs and only a oxygen needed for a general anaesthesia in these cases, it took more than five hours for a little child to wake up from a general anaesthesia, but they are top professionals and they know how to handle themselves in these situations. Paco, our paediatric surgeons, running from one hospital to another during these days, covering the cases scheduled in each operating theatres, performing the largest hernias he has ever seen, and showing the humanity with children of an experienced surgeon. Manolo, Rosa and Patricia, our 3 nurses, teaching the local nurses how to treat difficult wounds, assistant the surgeons in the OR, supporting the anaesthesiologists during the local, spinal and general anaesthesias and during the advanced cardiopulmonary resuscitation needed in some cases to solve very difficulties situations, especially with little children. Salva, Antonio, Juan, María, Marisol, the 5 surgeons, the ones always ready to operate any complex case, like the re-recurrent and giants Ghanaian hernias, and always ready to solve any surgical emergency during these days. And the lovely Virginia, who supported Dr Frank during these days by offering him different solutions to the different cases with the support of the drugs that we brought with us.

Everyone of them had an important mission, the only thing we missed was that it was an important group of professional that could support local nurses and doctors to teach them our knowledge to be adapted to what they have here, but we hope to do it next year, because our dream is to keep being involved in this project and continue our support for the people who need it.

Salvador Morales-Conde

Swedish team, Takoradi, Ghana 20-25 APRIL 2009

Members of the team were Par Nordin (surgeon), Eva Nordin (operation nurse), and Erik Nilsson (surgeon).

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We were kindly received by Martin, a co-worker of Graham Bell, when we arrived at Accra airport Friday evening. On Saturday Martin took us to Takoradi, with a stop at a crocodile park! Anita and Graham Bell were our hosts in Takoradi, and they showed us hospitality beyond imagination.

On Sunday we met Dr Bernard Boateng-Duah, who in his gentle manner supported us throughout the hernia week. He and his surgical colleagues had selected patients for surgery. On Monday morning we started operating at the Hernia Wing in Takoradi Hospital, and at the end of the week we had operated 33 patients from 8 to 75 years old, three with epigastric/umbilical hernia, one with incisional hernia, and 29 patients with groin hernia (three with bilateral hernias).

As expected, hernias in Ghana were more advanced compared to what we usually see in at home. However, all but four patients could be treated in local anesthesia. We had the possibility of using to operation theaters. It was a delight to work with the well trained nursing staff. The anesthesiology nurses were very efficient and managed to get an intravenous needle in the right place in a minimum of time. As the mission of “Operation Hernia” is to teach hernia surgery as well as to treat patients, we would have appreciated the attendance of a local trainee surgeon. However, it is easy to understand the difficulty in organizing surgical education in a country like Ghana, which has suffered an enormous brain drain in recent years.

After the hernia days we saw the local market and had a swimming tour in a wonderful beach west of Takoradi. On our way back to Accra we visited the Elmina Castle and considered dark history. As none of us had been to Ghana before, we took the opportunity to see the surroundings of Accra, including National Parks with animals we had read about, but never seen before.

We thank Operation Hernia for giving us the opportunity to work inside health care in Ghana. We met friends in a culture with colours and flavors more intense than at home. And surely, we want to return.

Par Nordin
Erik Nilsson
Ewa Nordin

The Cheshire team, Leighton Hospital, Crewe, UK – Visit to Takoradi, Ghana. 29 NOVEMBER – 10 DECEMBER 2008

Team Members: Magdi Hanafy (Consultant Surgeon), Selvachandran (Consultant Surgeon), Neil Brooks ( Consultant Anaesthetist), Virginia Long ( Theatre Manager), Janet Burrows (Theatre Sister), Emma Reay ( Theatre Nurse and ODA), John Kerslake ( Local GP), Rachel Kerslake ( Writer).

oh_image_67

The first step was to create a team of professionals, willing to give their own time and money for this purpose without pressures from work or families. They should know each other, work as a team, good communicators and aim to achieve common goals. These goals are, to treat as many patients as possible (and teach local doctors and nurses), and return safely back home. (May be visit schools and distribute stationary to children). A welcome addition to our team was our Local General Practitioner John Kerslake and his daughter Rachel Kerslake who works in the Local news agency. We managed to get articles published in local newspapers, and radios. Donations poured from patients, relatives, consultants colleagues, local GPs, practices, Rotary clubs, personal friends..Etc. Further collections achieved by members of the team (mainly Janet Burrows) through raffles, bag packing at supermarkets, duck races, ..Etc. The above team worked hard over six months before the trip. All in all we managed to collect £4,300.00 . We have spent £6,700.00.

The hospital managed to donate almost everything we needed for the operations from redundant equipment, sutures, dressings..etc. (nothing out of date). The hospital paid for all the anaesthetics, antibiotics, analgesics. We had to buy syringes, needles, venflons, and disposable scrubs. (Not a good idea in hot countries). In June 2008 we had a visit from The Presidents and council of the Royal College of Surgeons of England. Mr. B. Ribeiro (who is Ghanaian himself) praised our efforts and suggested to add footballs and sports equipment for the children as well. The hospital paid for our vaccinations, anti-malarial, and anti-retroviral prophylactic medications. They have paid for shipment of 39 boxes to a container in Plymouth heading to Takoradi. All these boxes were there when we arrived. British Airways waived fees for extra 12 luggages. The British High Commission in Accra offered support if needed. Bard supplied us with a box full of meshes (worth £9,000), other companies supplied us with boxes of gloves, gowns, drapes.. Etc.

Communications with Professor Kingsnorth, Chris Oppong, and Brian Dixon, answered all the questions. We planned to travel to Heathrow by a mini bus, and a van, kindly lent by Go Green cars, and driven by one of the team s husband and son (Janet Burrows). We arrived safely and had a nice luggage check in. 29 bags checked in. BA was as usual very efficient. We noticed their strict rules regarding bags number and weight and time. Plane was late taking off (55 minutes). Runway was too busy. Smooth flight, seven hours but plenty of entertainment. Arrived in Ghana, 10:00 pm. Warm weather. I started sweating once we got out of the plane. We cleared the immigration and customs very easily with all the boxes and bags. Pushing two full trolleys, one in each hand, down slope was not easy.

Once outside the airport, we had to deal with ten men appearing from nowhere trying to help. We could not differentiate between them and the two drivers sent to us with their minivan and truck. All cleared and on the way to Takoradi. 11:00 pm. Three hours drive arrived to the villa 02:00. Transferred 29 luggage safely inside, all counted for, luggage and personnel. We were met by Brian Dixon (our man in Ghana).

Brian and the girls (Kate, Lillian & Grace) gave us a warm welcome and explanations about how things are going. We resided in a local government villa with seven rooms, each one with en-suite and a large bed and air-conditioning. Everybody phoned home to reassure their relatives. Each one went to a room, and fell asleep. I could not believe the day passed without any problems. The next day Brian took us to visit a local village. Almost 80% of the children were staring at us with their tummies exposed showing an umbilical hernia. They are really nice full of smiles, surprise and interest. We went to the Turtle beach had a relaxing day and swam in the ocean, dangerous waters with strong currents.

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First day at work.
Woke up early, 5:00 am. Had breakfast and we started to empty boxes and redistribute drugs, stitches, drapes and gowns between two teams as we were going to work in two different hospitals. We saw children going to school passing by our villa, we went out and distributed some stationary. Dr Boateng came at 7:30 and took us to the Hospital. We went up to theatre, were introduced to all theatre staff, then shown around the department. We than began to open our 57 boxes which have arrived (with us and the container), and collected medicine and equipment needed immediately for the cases. We examined the patients, decided the procedures they required, and marked the sites. We were introduced to the Nurse anaesthetist, and we started working. Hernias, recurrent hernias, Hydrocoeles primary and recurrent, varicocoeles. Adult and children, Males and females. Electricity went off four times during one of the procedures, I had to have a torch light directed into the wound, and my reading glasses put on for me, my protective mask removed, to be able to safely continue the operation. A hand torch and headlamps would be handy. After our first day of operating, we all relaxed meeting up at Africa Beach bar for a beer! This is to be our after work meeting place for the rest of the week.

Further days at work
Woke up all together around 7:00 am and had Breakfast, the driver came and took us to the hospitals. Ginny collected some more stuff from the boxes, and off she went with Selva to the other hospital. No more electric failure. All the cases for today were presented to us, previously clerked in and screened for diseases like HpB and HIV, and consented. We only had to mark them and decide which type of anaesthesia we needed. We made sure they had prophylactic oral antibiotics. We continued until 2:00 pm when Selva and Ginny had their share of mega hernias (shown below) but finished early and came over to join us. Selva did our fifth case while I had lunch, met with the hospital Director, and marked my last patient. Each team did one patient until we finished.

We went with Brian to the Africa club for a beer and a swim, then back to the villa for dinner. We had to make arrangements for visiting schools, the next days. The responsibilities lied with Emma and Neil and the Kerslakes, for distribution, taking photos and video shots. We opened the bags, distributed contents in the four cases, hoping to visit four schools at least, one every day. The first school was for deaf children. It became apparent that distributing stuff individually to huge number of children was not a good idea. Also giving a football to a group of young children to play with meant that older kids will take it from them. We preferred to give the donations (Footballs, clothes, school stationary, chalks and board erasers) to the school principal, who will make sure donations will go to those who need them, and create some discipline and order. We went to other schools later on in the week, and followed the above advice.

We met some high ranking Ghanaian officials as well. Brian Dixon, Operations Director for Operation Hernia, has invited us and them to a dinner in a Chinese restaurant. We met Dr Bernard Boateng-Duah and The Honourable Edwin Phillips the Presiding Member of the Municipal Assembly for Takoradi and Sekondi the equivalent to the Leader of a local authority and extremely well respected in the area. They warmly thanked us and Brian and Operation Hernia . We responded by praising their hospitality and kindness.

Over five days of work we managed to perform 74 procedures, a respectable number, we are proud of, but it left us and the Takoradi team completely exhausted. Things that we take for granted like electricity and running water were not routine commodities there, we had to scrub by asking somebody to pour water from a bucket onto our hands. Without the air conditioning in theatre we could not have achieved half the above numbers. The diathermy kept disconnecting because the plate has been used on many patients beforehand and was not sticking and connecting properly. The diathermy stick was disinfected in fluid and would not work unless dry.

Further advice published on the site and written by Brian Dixon are first hand, important and worth considering. Unfortunately Brian Dixon is due to retire by the end of 2008. We were the last team he took care of and he did this job perfectly well. I am sure the local teams will do an impeccable job, but replacing Brian s position will be a hard act to follow. I hope the girls (Kate, Lillian & Grace) will continue serving the coming teams as well as they did with us.

Conclusion
Back safely we think we have achieved these goals:
1. Getting Leighton Hospital involved within the community of the European Hernia Society for its charitable Operation Hernia exercise.
2. Creating a successful team willing to give their time and money for this cause.
3. Collecting funds securely and professionally.
4. Getting as much advertisement as possible to help collecting the funds and to improve our hospital profile in the community.
5. Collecting and transporting as much as we can from donations, etc. that is not needed anymore by our hospitals, but is essential for our purpose.
6. Providing all possible protection to our team from vaccination and prophylactic medication.
7. Creating a charitable, happy atmosphere within the team and colleagues in the hospital.
8. Reducing expenditure to as little as possible. (Ex. Airline tickets, transports. etc..)
9. Achieving contacts to ease passing through customs in Ghana.
10. Safe arrival of all medical and school equipment (61 boxes and bags) to their intended destination. (Takoradi Hospital)
11. Achieving a respectable number of procedures (74) by two surgical teams and an anaesthetic team in five days, without immediate complications.
12. Leaving a good impression within the local and international Operation Hernia team .
13. Arriving back home safely, without accidents, incidents, or illnesses. Only extremely tired.

Thank you
On behalf of the Ghana Team
Magdi Hanafy

Czech Hernia Team

Czech Team Report JULY 2008

Stanislav Czudek, Luká Adamčík, Roman Bezděk, Jana Kosturová, Markéta Hanáková, Daniela Juraíková, Urszula Czudková, Kamila Adamčíková, Dorota Havlíková, Kazimír Grochol.

Sweet Welcome to Ghana

Sweet Welcome to Ghana

Many thanks to Brian Dixon, Bernard Boateng-Duah, Kate, Grace, Lillian, Barbara and of course Andrew Kingsnorth and Chris Oppong! We had a wonderful time during our stay in Ghana and Takoradi. Perhaps everything has already been written by the English, Belgian, Polish, and Spanish teams and there is nothing more to add nad we also enjoyed the beautiful beaches, Kakum, Kumasi, and Elmina Castle which were superb. Many thanks of course to the Ghanaian people who showed to us great hospitality and grace. And also the doctors and nurses we were working together with. It was an honour to perform THE FIRST LAPAROSCOPIC PROCEDURE IN TAKORADI I hope The Rotary Club will help and buy a laparoscopic set for the hospitals in Takoradi. Thank you. This is our vision and wishes, which will be very helpful to the Ghanaian people. I would be very pleased to see the laparoscopic set when I visit Takoradi next year.

We met the Czech Ambassador Mr.Křenek and his wife,who visited Takoradi Hospital.Especially thanks to the member of the Czech Embassy Mr.Bruna,who helped Luká Adamčík with organizing our mission. The idea of Andrew, Chris, Brian, Bernard, is wonderful. To continue their future vision we suggest teaching the Ghanaian surgeons in European countries for 2-3 months.We will invite 2-3 young surgeons from Ghana to our country for training.

Laparoscopic Hernia Repair in Sekondi-Takoradi

Laparoscopic Hernia Repair in Sekondi-Takoradi

 

 

Czech Hernia Team

Czech Hernia Team

P.S.
This is just to say thanks to Brian Dixon who arranged a special program for our wives (Urszula , Kamila) who are teachers: We took the opportunity to visit basic village schools – St. Gabriel Anglican Basic School, Norpalm Primary School and a private boarding school, where we took part in lessons and even taught the children. At these schools the welcome we received was very warm from the staff and teachers who were grateful and friendly, the pupils were enthusiastic and well disciplined and very nice. We brought about 100 kg of school things ( exercises books, slips of paper ,crayons, pens, pencils, scissors etc) and gave these to the pupils and their teachers in the schools as a gift from people working in our hospital in Nový Jičín, their friends, children , families and some companies.

Many thanks to Barbara, the teacher in St. Gabriel Anglican Basic School for giving us an unforgettable time at her school among the children. Many thanks to Kate with whom we visited a village and school on a palm farm and gave the children some small gifts . Many thanks to Teresa, the Headmistress of a Catholic boarding girl´s school , for her hospitality and for devoting her time to our visit . Finally , shortly before our departure Brian Dixon organized a brief meeting with the bishop of the Catholic church and we gave him a big box full of toys for children. Seeing how poorly the schools were equipped it amazed us greatly to see the smiling faces of the children and their enthusiasm. They were grateful for every little thing they have (a common soccer ball was the best gift and the greatest surprise for them). I m going to make a presentation about Takoradi schools and show it to my students in the Czech Republic. Thank you for letting us be with you.

Urszula and Kamila

I hope we will meet next year. We thank everybody who assisted us in our mission.

Stanislav Czudek

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.

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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.

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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