Port-au-Prince, Haiti, 2017

Mission Summary                                                                                                                                                   St. Francois de Sales – October 2017

Hernia Repair for the Underserved                                                                                                                                                                   Nick Carter

 

Introduction

From 10/1/2017 to 10/7/2017, The Centre-Hospitalo-Universitaire Saint Francois de Sales (CHUSFS) welcomed a group of 16 American medical providers for a training mission in hernia surgery.  The visitors included two surgeons, two surgical residents, a pediatric anesthesiologist, a critical care pulmonologist, CRNA, four OR nurses, and five PACU nurses.  The intent of the mission was to train Haitian surgeons in Lichtenstein hernia repair for adult patients, pediatric inguinal hernia repair, and laparoscopic inguinal hernia repair.  The mission also presented an opportunity to establish proof of concept for laparoscopy and complex ventral hernia repair at   the CHUSFS.

Summary of events

In total, 77 patients received operations including 25 children.  There were 15 ventral hernia repairs and 10 laparoscopic cases performed.  Haitian trainees included Dr. Jacklin Mertus, an attending surgeon from CHUSFS, and Dr. Rolph Richeme, chief of surgery at Hospital Raoul Pierre Louis in Carrefour.  Trainers included Dr. David Chen of UCLA, Dr. Robert Cusick of Children’s Hospital and Medical Center in Omaha, and Dr. Jean-Fritz Jacques of the Hospital of the State University of Haiti (HUEH).  Two surgeons from HUEH, Dr. Jacques and Dr. Silvio Augustin, underwent additional training in advanced laparoscopic techniques.

Fig 1. Dr. Richeme performing a Lichtenstein hernia repair with Dr. Jacques.

Anesthesia and nursing providers from the CHUSFS and HRFU collaborated to provide safe perioperative care for all patients.  Surgery and anesthesia residents from HUEH also participated in clinical care and training.  There were no reoperations or immediate complications.

Fig 2. Ms. Chantal Corrioland (CHUSFS Head OR Nurse), Dr. Cynthia Ferris (HRFU Pediatric Anesthesiologist), and Dr. Johanne Duchatellier (CHUSFS Anesthesiologist)

Discussion and Future Opportunities

This visit represented the first Hernia Repair for the Underserved (HRFU) clinical mission to the CHUSFS.  A brief discussion of opportunities for future collaboration:

Creating a Center of Excellence

The CHUSFS administrators expressed continued interest in hosting a permanent national referral center for patients with complex hernia disease.  The infrastructure at the CHUSFS supported a busy clinical week.  Overall, the laparoscopic equipment is in good condition and image projection is satisfactory for safe performance of operations (see Fig 1).  The biggest challenge was maintaining an adequate supply of CO2 for insufflation as well as compatible tanks, regulators, and hoses.  We found this problem to be surmountable through teamwork, communication, and reducing our CO2 consumption by using a hand-pump for insufflation as much as possible.

Fig 3. Dr. Jacques performing a laparoscopic inguinal hernia repair

Elevating the profile of the CHUSFS in Port-au-Prince and provinces

the CHUSFS leadership arranged for a visit from a television crew from Radio Tele Soleil, the television and radio station belonging to the Archdiocese of Port-au-Prince.  Msgr. Aris expressed an interest in planning increased media exposure and perhaps a formal press conference during future missions.

Fig 4. Drs. Eustache, Carter, Telemaque, and Chen prepare for a television interview with Radio Tele Soleil.

Skills Lab and Additional Collaboration

Dr. Jean Gary Doucet, president of the Haitian Association of Surgery, expressed interest in developing a skills lab that would allow Haitian surgeons from various institutions to develop laparoscopic and open surgical techniques.  Low-tech laparoscopic trainers could be sited at HSFS to simulate intracorporeal suturing, knot-tying, and other fundamental skills.  There may also be an opportunity for increased collaboration between HUEH and the CHUSFS surgeons to identify patients who are candidates for laparoscopic repair.  A weekly hernia clinic, historically held on Saturdays at HUEH, might be transitioned to the CHUSFS to develop laparoscopic experience for surgeons from both institutions.

Additional Items and Next Year

Haitian staff feedback will be obtained and future trips will be planned.  A Memorandum of Understanding between CHUSFS and HRFU is in discussion.

Ouanaminthe, Haiti, November 2015

2015 HRFU Haiti Ouanaminthe Trip Summary

Hernia Help’s trip to Haiti last November was full of the usual adventures and misadventures customarily encountered on such missions to desperately poor countries. Two of them are worth the retelling as they bracketed both the beginning and the end of our journey.

Can you imagine our surgical team checking 30 supply bags at Newark New Jersey airport to find that only 29 of them had arrived in Santiago in the Dominican Republic on our way to Haiti. Of course it would be the very one containing all of our suture material and mesh. Fortunately a prescient member of our team (Dr Kern) had packed a “little extra” in his personal luggage and all was well. I wish I could remember the name of the delightful United Airlines agent who managed to find our bag in New Jersey and have it delivered to us within 36 hours. Without the two of them we would have had a very unproductive week indeed.

The real highlight of the week however occurred on Friday afternoon as we were packing to leave and head home. Barging in the door at exactly 1 o’clock came 2 man carrying a 20-year-old pregnant woman unconscious having an eclamptic seizure. Had they arrived one hour later both mother and unborn child would have died. However I’m delighted to tell you that by 1:50 PM both mom and little baby girl “Jersey”, delivered by emergency cesarean section, were coming along nicely in our recovery room. The professionalism and teamwork of our volunteers and the Haitian staff was awesome during that vital three quarters of an hour.

In the meantime 50 procedures were done for hernias and hydroceles with which many of our patients had suffered a lifetime of misery, discomfort and indeed embarrassment. They were readied preoperatively, put to sleep, operated upon, woken up safely and efficiently dispatched home. This was a remarkable achievement considering the conditions my team worked under, and it left everybody including our patients deeply satisfied.

Great care is taken by Hernia Repair for the Underserved in its selection of volunteers and each of them are top class in their chosen fields.  Karen Batchelder and Kara Crawford, respectively circulating nurse and scrub tech, worked so well together with Dr. Bob Fitzgibbons, a world renowned surgeon and editor of the journal Hernia,  that it was hard to think of them separately.

Edith Marquez and Amy Campeau, both scrub techs, were wonderful. I hope the surgeons they work with Stateside realize that they are sharing the operating room with real gems.  Scott Muttel was the life and soul of the team. Only I realize how this trip was in large part due to his efforts in the enormous preparation required beforehand to make it a success. This man can fix anything with duct tape.

Rachel Dowd, pre and post-operative nurse while teaching, arranging discharge and follow-up was ever vigilant constantly on team recordkeeping, necessary administrative work to preserve the Preferential Option for the Poor; that is to maintain high quality of care.  .  Neena Philip, our preoperative nurse, worked with Rachel Dowd deep in the recesses of the hospital, without air-conditioning. Laboring always with a good-humored laugh, joy and a twinkle in her eye.

Dette Kutch, postoperative nurse, jumped right on board only days before the trip after an unexpected family emergency with one of our volunteers. John Dowd, whose quite gentle help and willingness to do anything made working with him a delight.  Austin Philip, was our youngest member at 17.  His enthusiasm, good humor and attention to detail bode very well for this young man’s future. He was also our official photographer and I can guarantee you he has the largest collection of hernia photographs of any teenager in the United States!

Drs Guy Salomon and Vadim Galkin, anesthesiologists, both first-timers to Haiti, neither seemed to break a sweat under daunting conditions that could be described at best as spartan.  Dr Steven Kern’s, a snowman of a gent from Minnesota, winning wit and wisdom entertained us all mightily, all this along with his remarkable surgical skills.  Dr Dwijen Misra, without missing a beat joined us mid-week to provide support when Dr. Fitzgibbons left for a teaching appointment in Argentinian. Dr. Misra’s infectious gregariousness impressed us all.

Such kindness, care, compassion and competence has left both myself and our 60 patients all the better for having known these outstanding professionals.

Kevin Buckley

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Pediatric patients ready for surgery

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Staff members at the CODEVI dining area

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The Post Op Area

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Surgery in Room 1

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A salutation from the Pediatric patients

Haiti, November 2013

Pignon Haiti Hernia Repair for the Underserved Mission Trip summary

The team of Cynthia Ferris MD, Rachel Dowd RN, Theresa Alvarado RN, Libbie Choquette RN, Mary Drouillard RN, Bob Cusick MD, Bob Fitzgibbons MD, Hal Kaftan MD and Lesly Manigat MD traveled to Pignon via the ILAC center in Santiago Dominican Republic.  Here they are pictured upon arrival in Pignon.

Pignon2013

The purpose of the trip was to train two Haitian surgeons, Dr. Emmanuel Regis and Dr. Arlet Isma on Pediatric and Lichtenstein hernia repairs.  Unfortunately there were insufficient Pediatric patients (3) for training.  Dr. Cusick was able to do one orchiopexy on a patient with cryptorchidism.  Dr. Fitzgibbons, was able to complete 12 groin hernia operations with the trainees and was very pleased with their operative skills.  Both surgeons were given mesh and will be part of general plan for training many Haitian surgeons in the near future.  Below shows a training procedure.

Pignon2013-002

Data was kept on the operations performed and scores were tabulated. This will be utilized for further analysis and publications. An additional patient with multiple groin hernia recurrences was operated upon laparoscopically by Dr. Fitzgibbons.  See below.

Pignon2013-003

Plans for future training include:

  1. Signing a memorandum of understanding between HRFU, the Haitian Surgical Association and the Haitian government for extensive training of Haitian surgeons in Pediatric and adult Lichtenstein repair
  2. Training the trainees on how to teach the procedures to other Haitian surgeons
  3. Eventually publish results of the training program featuring the benefits of the rating forms and feasibility

Haiti, September 2012

Overview

Thirty six patients were operated upon and three Haitian general surgeons were trained to do Pediatric inguinal hernia repairs and the adult Lichtenstein repairs for inguinal hernias.

Team

Cynthia Ferris, MD; Rachel Dowd, RN; Theresa Alvarado, RN; Bob Cusick, MD; David Chen, MD; Lesly Manigat, MD

HRFU-Haiti2012 from Charles Filipi on Vimeo.

Summary

The team, in conjunction with Dr. Paul Severson of Promise for Haiti, did an outstanding job operating upon 36 patients and teaching 3 fully trained Haitian general surgeons to do Pediatric inguinal hernia repairs and the adult Lichtenstein repairs for inguinal hernias. Eight demonstration cases with the trainee as first assistant were followed by 28 cases performed by the trainee with the proctor assisting or supervising. There was a consensus that Dr. Jeudy and Dr. Devidson are satisfactorily trained and ready to perform the operations but studies should be completed and mesh needs to be provided for their future repairs. Dr. Jean Luis needs to be encouraged to do more hernia repairs in the Pignon hospital. It was agreed that the Lichtenstein repair is a good model for teaching.

Dr. Filipi, president of HRFU has spoken with SafeStitch Medical and Davol and both have promised free 3” x 6” flat pieces of packaged sterilized polypropylene mesh. SafeStitch has 35 pieces and Davol will give 200 pieces through Americares with a possibility of providing more in the future. These commitments come from high level officials in both companies.

Data was kept on the operations performed and scores were tabulated on a new surgical technique rating form.  This will be utilized for further analysis and publications.

Possible Studies

Dr. Cusick, Dr. Chen, Dr. Manigat and Dr. Jeudy are now in discussion about hernia studies. Eventual presentations are expected with the intent of publishing findings on prophylactic hernia repair antibiotics and the development of hernia centers of excellence. Hernia Repair for the Underserved will assist these projects. It appears to be the intent of all team members to return to Pignon to provide follow-up and training of other Haitian surgeons. The overall project appears to be a success if we can now facilitate the performance of the operations by the trained surgeons and keep records to document use of the training provided.

Site Attributes

  1. Pignon is the best place for a further course
  2. Port au Prince is still dangerous
  3. Sterilization is satisfactory
  4. The CRNA Maseline knows where everything is and is very helpful
  5. The road to Port au Prince when improved could change Pignon significantly