Operation Hernia Report

UK Team to Aliade, Nigeria

September 2013

Hard at work

Hard at work

Nigeria, or the Federal Republic of Nigeria as it officially known, has a population of around 169 million people distributed amongst its 36 states and the federal capital, Abuja. Like many sub-Saharan countries the wealth, and therefore access to healthcare, is disproportionately focussed around a relatively small geographical area.

Our team from the UK consisted of: Maria Boutabba, a multiply experienced RODP and Clinical Team Leader, Tim Brown and Zoe Vlamaki who are both consultant surgeons, Paul Sutton and John Whittaker who are surgical trainees and Alex James the team’s anaesthetist. We spent a week at St Vincent’s Hospital, a primary care facility in Aliade, Benue state.

We landed in Abuja in a torrential thunder storm, predictable as we had arrived just at the end of the rainy season. We were met at the airport by our driver and the hospital’s pharmacist who were to accompany on us on our journey to Aliade. We stayed the first night at a convent in Abuja and once rested we began the 5 hour journey. We were loaded into a minibus just of sufficient size to transport us and our baggage and travelled by road. The road conditions were poor, although largely tarmac and we successfully traversed 5 states (and any number of road blocks) to arrive at Benue. We stopped briefly at Makurdi, the largest town in the state, to visit Reverend Peter who was the sponsor for our trip. We then travelled the last hour to Aliade and were met at the hospital with a traditional welcoming ceremony, including dancing and singing. Our first trip was to the theatre complex where we unpacked all of our kit, and fortunately found a great deal of other kit that had been left from previous missions. We then settled in our accommodation ready for the early start on Sunday.

A 6 30 breakfast followed by a stroll down to theatre marked the start of our first day. There were in excess of 100 patients waiting for us, each waving a green hospital notes folder. We began the process of ‘screening’, which involved seeing patients who thought they had a hernia however the yield was probably around 75%. We had the support of the hospital’s surgeon (non-medically trained) and his team, and under the guidance of our team leader, Maria Boutabba, they soon had the processes they needed for rapid turnover between cases. Our first case was a 32 year old lady who had a large incisional hernia from a previous laparotomy for appendicitis, followed by a 7 year old boy with an inguinal hernia. Many cases later we were well into double figures and happy that we were established for the remainder of the week.

The team’s senior consultant, Tim Brown, and the registrar, Paul Sutton, performed the paediatric cases over the subsequent few mornings totalling 14 by the end of the week. Our anaesthetist, Alex James, rapidly became proficient in balancing spinal anaesthesia, sedation (with ketamine, midazolam or propofol) and other regional techniques in challenging circumstances to permit us to continue with this work. In parallel there was another operating table (within the same theatre) where Zoe Vlamaki and Jonathan Whittaker continued with the inguinal hernias. In between these we were screening patients, rapidly turning over cases and preparing equipment and consumables.

Antiquated anaesthetic machine

Antiquated anaesthetic machine

Any ideas

Any ideas

Alongside the screening we were collecting data for a research study into perceptions of health and therefore impact of hernia surgery in a sub-Saharan patient cohort, which we are planning on comparing to the UK population. We also spent some time teaching the local staff how to repair hernias. It was clear that they had seen many hernia repairs previously, and technically were well equipped. There was however some disregard for the tissues and the patient (who on the whole had local anaesthesia only), and more concerningly there seemed to be an unwillingness of the local team to have their technique refined.

By our third day we were well and truly into the swing of things. We were by this point working over three operating tables and the local surgical team were also performing cases. We were shortly however to be hit with some difficulties. Whilst the local team were performing a hydrocoelectomy in an adjacent theatre they ran into some problems and the patient suffered a cardiac arrest. The cause of this was unclear, and despite concerted effort we were unable to revive him. He had been intubated, ventilated, received intravenous fluids, adrenaline and atropine however without access to a defibrillator or intra-lipid, nor facilities to transfer out to another hospital, we were somewhat limited in what we were able to offer. This event marked the end of the operating day and the local reverend and doctor were called who attended the hospital. They spoke to the theatre team and the local patients and the atmosphere was understandably sombre. We left reflective and unsure of how safe and appropriate it was for us to continue.

We decided to stay however, largely as we felt there was a great deal of good work we could still do. Despite the events of the previous day the crowds were still there in their drones keen for surgery. We continued with the cases, rotating surgeons to try and stave off fatigue. The trainees benefited from the guidance and expertise of Tim Brown, and also the opportunity to perform a number of similar cases in quick succession to consolidate experience. In between cases we conducted ward rounds of our post-operative patients, which were few given the extremely high threshold for admission. We used antibiotics extremely sparingly, although all had access to analgesia. On the whole patients were keen to leave the hospital, even if they had had a spinal and their motor function had not yet returned! Language was an issue, and so post operative instructions were extremely simple.

The biggest challenge of the next couple of days was the intermittent nature of the power supply. We had a large fan in theatre (aptly named ‘Ox’ as it certainly worked like one!) which kept the temperature at bearable levels. We benefited from intermittent lighting and diathermy and a variety of instruments, some more suitable to the cases than others. We all rapidly got used to Maria’s routine of securing the blades to the scalpel with steristrips prior to the case, and had quickly exhausted our supply of the most appropriate sutures. Tackling difficult hernias with local anaesthetic under difficult conditions, combined with the (presumably tuberculous) persistent coughing made for some challenging operating conditions.

The team: party night

The team: party night

By Wednesday we had screened more than enough patients for our visit, however agreed to continue for the benefit of future missions. We were brought a gentleman from clinic with an incarcerated hernia however on reviewing him it was clear he was unwell and strangulation was likely. He had a spinal anaesthetic and we proceeded (with a decision to incision time of around 15 minutes!) On opening the sac he had 25cm of non viable small bowel which was resected and the repair completed. He faired well over the first 36 post operative hours however by the time we were leaving it was clear he had developed an ileus and therefore we arranged his transfer to a secondary care facility at Makurdi. The remainder of the day proceeded uneventfully, and we retired again to our accommodation. We were always extremely well looked after by Sisters Helen and Rose, who kept us well fed and rested during the evenings.

Our penultimate day got off to an uneventful start, however we had set ourselves some fairly ambitious operating lists and so settled down into a busy routine. We had decided by this point not to screen any more patients, and therefore the day actually finished rather earlier than the previous day (18 30). In the evening we were treated to a party. A number of the hospital staff had come to have dinner with us and we were thanked for all of our efforts and each presented with a gift. It was a brilliant opportunity to socialise with the hospital staff and their gratitude was clear.

Friday was largely committed to tidying up the theatres, re-packing equipment and packing our personal kit. We had a couple of cases that had rolled over from the day before which we tackled within the first hour. We headed back to our accommodation to wait for Simon our driver and left shortly after midday for the long road journey back to Abuja (7 hours this time). Our bags were checked 3 times at the airport and the usual emigration, customs and security checks placed us firmly airside ready for our trip home. A successful and eventful week totalling 84 operations on 78 patients, as well as lots of experiences and friendships made and cemented.

Team Members (UK)

Maria Boutabba

Tim Brown

Zoe Vlamaki

Alex James

Paul Sutton

John Whittaker

Supported at the hospital by:

Reverend Sisters Helen, Rose and Grace

Pharmacist Dauda




Uncle Sam and not least our conscientious HSDU assistant.