Paraguay, June 2014

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Haiti, November 2013

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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.

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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.

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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.

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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

Dominican Republic, November 2013

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2013 Dominican Republic ILAC Trip Summary

The most recent Dominican Republic trip was a success.  One hundred and eight hernia operations were performed and numerous other patients were examined and treated medically. As always the team members were grateful for the experience.

Dr. Robert Cusick and Dr. Lao were the Pediatric surgeons, Dr. Campanelli and Dr. Fitzgibbons plus Dr. Ed Buckley, Dr. Steve Kerns and Dr. Jarrod Kaufman were the adult surgeons.  The later three were there for Hernia Repair for the Underserved (HRFU) team leader training.  Dr. Manion led the anesthesia team followed by Dr. Guy Giroux, Theresa Keefe CRNA and Dr. Carl Heine.

The entire team performed well under Barb Elliott’s leadership.  Welcome back Barb.  There is continued enthusiasm on the part of the team members and ILAC staff members to continue our work at the ILAC surgical center.

There were many good moments and below are but a

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Below one of our post operative patients going into her home.

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Surgeon Training:  One fully trained surgeon, Dr. Jean Fritz Jacques from Port au Prince Haiti was trained by Dr. Cusick on pediatric hernia repair and Dr. Campanelli on the Lichtenstein repair.  Dr. Jacque did well and was awarded 20 pieces of donated mesh for future Lichtenstein repairs on poor patients.  Below are pictures showing the beginning of training with Dr. Campanelli operating and the two surgeons after completion of 5 other groin hernia operations performed by Dr. Jacque with Dr. Campanelli first assisting.  After each of the 5 operations a written rating form was used to assess surgical performance by Dr. Jacques.

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Training has become an important part of the HRFU mission.  Many hernia repairs need to be performed but surgeon training and eventually if protocols are followed, training of those surgeons to be trainers will occur.

Ecuador, October 2013

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Archidona, Ecuador

 

Background

Hernia Repair for the Underserved collaborated with Timmy Global Health on a hernia repair mission in October 2013 with the dual focus on providing care to the underserved and fostering sustainability through training and collaboration with local Ecuadorian surgeon partners. This was our second trip to this site in Archidona, a city of 4000 within Napo Province.

Access to quality healthcare in the Amazon Basin is extremely low. The public hospital in Tena, operated and funded by the Ecuadorian government, is consistently understaffed and over capacity. The Timmy Foundation has developed an organized, well-run network providing primary care services to the indigenous, Quichua patient population. Hospital based services are delivered at the private, non-profit Stadler Richter Hospital which provides high quality care and outreach to the poor. While there is modest poverty in this location, these patients have limited access to care due to socioeconomic, cultural, and geographic factors.

 

Participants

Our surgical team was a collaboration between UCLA, Denver Children’s Hospital, and the Timmy Foundation and consisted of three surgeons, three anesthesiologists, one internist and six nurses. Our local partners from the Timmy Foundation arranged in-country logistic support, identified potential patients, partnered with local surgeons and government, and facilitated training.

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Trip Details

The team was on site for 6 days with 5 operating days. Over 80 patients were screened and evaluated. 55 operations were performed in Archidona and Dr. Partrick assisted on a complex pediatric case at Tena Hospital. Patients were between 1 and 78 years old and  11 pediatric cases were performed. 30 umbilical, 24 inguinal, 3 recurrent, 2 femoral, and 1 ventral hernias were repaired. There have been no complications reported after 2 months of follow-up with our local surgeon.

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Training

Training in Lichtenstein technique and mesh based repairs in Ecuador is different from that in many of our other HRFU sites.  The Ecuadorian surgeons are highly skilled, well-trained in tension free technique, and do have access to mesh. Limitations come from diminished availability and quality of mesh and the lack of capacity to care for the burden of disease in the public system. Our training with Dr. Patricio Moretta Suarez and Dr. Jose Llumuca focused on optimizing technique for challenging cases, performing surgery utilizing only local anesthesia, recurrences, and remediation of pain. Dr. Moretta from Quito and Dr. Llumuca from Tena participated in our training collaboration with 17 cases performed together over 2 days.

Fortuitously, the higher complexity of cases selected for our training was better tailored for this circumstance. Our Ecuadorian surgeons felt that it was not feasible to operate under local and were clearly convinced otherwise, doing both scrotal hernias and extraperitoneal ventral repairs under local. Three recurrent hernias all had prior mesh based repairs indicating the utilization of tension free techniques in country. Two large femoral hernia repairs were performed demonstrating modifications to standard Lichtenstein technique to address this anatomy.  Two triple neurectomies were performed for coexistent inguinodynia. For both trained surgeons, it was more appropriate for them and helpful to deal with these advanced scenarios.

 

Providing mesh to our affiliated surgeons would be helpful and allow them to continue operating and teaching with optimal materials. Both surgeons practice in systems to care for the poor and have the ability and desire to train others. The Timmy Foundation’s local coordinators can help to ensure that our mutual goals are met by providing local contact and support to our affiliated surgeons. Both Ecuadorian surgeons “greatly enjoyed the collaboration between the teams and very much look forward to the opportunity to work with Hernia Repair for the Underserved in the future.”

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Support and Acknowledgments

The local government of Napo Province and its local public health affiliate Patronato generously extended its hospitality to our team facilitating all governmental, customs, and local logistics. The Timmy Foundation is an incredibly valuable partner with similar goals and vision and was instrumental in ensuring the success of this mission. Covidien Hernia Solutions generously donated all mesh for this trip allowing us to train and operate with some of the highest quality products available. Americares generously provided material and logistic support donating over 1000 pounds of equipment, supplies, and medications making our operations possible. Hernia Repair for the Underserved is immensely grateful to the donors that support our mission to provide the highest quality care to the poor and train others to continue this work. The kindness and concern of all of those that support us made this trip and our other HRFU missions possible. They are without a doubt good for all involved.

 

Dajabon, October 2013

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HRFU Dajabon hernia team trip summary – first draft

Our mission in Dajabon started on Sun. Oct. 10th 2013.  On the way to Dajabon, on an ILAC bus, we met Dr. Lesly Manigat and together with him we arrived at the guest house of the textile factory CODEVI.  The textile factory is located on the Haitian Dominican border between Dajabon and Quanaminthe Haiti.  Our accommodations at CODEVI were prepared and absolutely decent as well as the refectory and the quality of the food prepared by them.

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On Sunday afternoon we immediately went to the Ramon Menla Hospital in order to unload the huge quantity of supplies, medicines, instruments and meshes and to take a look at the operating sites.

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Upon our arrival we were able to get the OR and the adjacent rooms opened by a local nurse that was surprised about our presence there.  The rooms next to the OR were basically 4; one for sterilization and storage of the material, one for the pre-surgical stay of the patient, one for the doctors’ wardrobe and one as entrance.  The sterilizer was old but with the help of a local person we were able to provide safe sterilization

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The two ORs were illuminated only by the light coming from the windows without any electric light source so our surgeries were executed with a table light and the outside light.  The anesthesia equipment wasn’t working despite efforts to have it repaired.  In spite of the unexpectedly poor logistic situation we were able to set up everything in order to start the surgical session on Monday morning.

But on Monday morning there were no patients, no local doctors, no chief doctor and no chief executive and only in mid-morning, after a long investigation, were we able to talk to the chief executive.  However, thanks to the help of Dr. Manigat and the fact that the news about our arrival was spread out, on Tuesday afternoon we started with our first operations both on Dominican and Haitian patients but at the end we were able to do only 30 surgeries throughout the whole week.  In spite of all this we were able to do the training of a Haitian surgeon Dr. Lamah, using the HRFU validated rating forms for the Lichtenstein repair.  Upon completion is was given 20 pieces of donated mesh to be used on poor patients only.   See the below photographs.

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Thanks to Dr. Filipi, Dr. Manigat, Dr. Cavalli, Dr. Pelizzola, Dr. Pavoni, Dr. Shambhu, Dr. Boutrous, Dr. Piludu, Mr. Del Monte, Miss Minnick, Miss Fry and Mr. Maffioli.  The patients did well and the training was satisfactory despite the logistics being very poor with the local cooperation being practically non-existent despite previous assurances.  Therefore our organizational effort was out of proportion as compared to what were actually able to achieve.

Prof. Giampiero Campanelli

Paraguay, September 2013

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Hernia Mission to Paraguay

1st to 12 September 2013

Summary – compilation of all team member comments

Eight operation days: 6 in the Hospital Nacional and 2 in Luque Hospital.

A total of 76 patients were operated on.

Twenty operations in Luque hospital (mainly Lichtenstein repairs), Dr. Lurachi and Dr. Dubarry trained in Lichtenstein repair by Dr. Reinpold. Both surgeons passed.

Fiftysix operations in the Hospital Nacional de Itauguá. Dr. Carlos Pfingst passed training course in Lichtenstein repair. He was trained by Dr. Reinpold

The team:

Gabriele Behrend               Intensive care nurse

Janese Gerhard                   Nurse

Ingo Leiser                            Operating room technician

Dr. Wolfgang Reinpold      General and visceral surgeon specialized in hernia surgery

Alexander Schröder           Medical Student (final year)

Carsten Seebohm               Anaesthesiologist

Vera Sicking                         Anaethesiology nurse

Dr. Lutz Steinmüller           General and visceral surgeon specialized in hernia surgery

Initially the first hernia mission to Paraguay was designed for two teams with two hernia specialists in each team.

 

What went well

Very warm reception of Prof Cuenca and his residents at the airport in Asunción.

Very dedicated and professional team. The whole team highly skilled.

Five out of eight team members with experience in surgical missions in Africa and Latin America

The team was heartily received in both hospitals. Local people wonderful in both hospitals. Almost every evening social events organized by Prof Cuenca and his team: Dining out in Asunción, football match with barbecue (Asado), Visit of the National Football Stadium “Defensores del Chaco” for the Football World Cup qualifier Paraguay vs Argentina, etc.

Warm reception of Hospital Administration in Luque Hospital (local newspaper was present, report and team foto posted on the web!)

Very good patient selection in both hospitals. Most of the patients apparently poor.

Good patient preparation! Good medical chart! Good documentation of comorbidities, drugs, consent for operation.

OR hygiene and tidiness acceptable

Two ORs in both hospitals with very good light

Implementation of Team time out achieved!

Implementation of Operation schedule

Very good outcome after surgery: Except for some minor hematomas which did not need intervention no complications.

Very good team work within our team but also with the local staff despite different languages

Team transport from hotel to hospital well organized. Good food at both hospitals.

Dedicated documentation by Janese and Alexander

Breakfast Team meetings important

Good selection of materials which we brought to Paraguay: Instruments, mesh, suture material. Drapes, gowns gloves, etc supplied by local hospitals.

Very thankful patients

Very good travel and accommodation organization by Carsten Seebohm

Excellent patient outcome! No major complications. Outcome confirmed by Prof. Cuenca.

Very good support of the mission in Hamburg (charity event organized by Gross-Sand Hospital.

 

What we can improve upon:

Accomodation closer to hospital! Transfer at least 45 min was too long! Should be no longer than 10 to 15 min!

Language barrier was a problem! Fortunately at least one resident with reasonable German and/ or English knowledge in both hospitals.

Need of more translators, especially in recovery area.

Peace corps available in Paraguay?

Our anaesthesiology team was initially not well incorporated in both hospitals despite early information of Prof Cuenca and Dr Luraschi.

After first bumpy day very good cooperation between Paraguayan anaesthesiologists and Carsten Seebohm and Vera Sicking

Own anaesthesia team is crucial in future missions because local anaesthesia teams change very often which prevents standards from being implemented.

Coordinator between ward and OR unit especially in Hospital Nacianal de Itauguá necessary.

Local Instruments partly in deplorable conditions, especially scissors.

It was extremely important to bring own instruments!

Sterilization process was too long.

Hospital Nacional: Cleaning staff often slowly causing delays. Aparently due to conflict between administration and medical staff.

 

Conclusion:

Very good first hernia mission to Paraguay

Prof Cuenca and Dr Luraschi are very interested to continue project

Dr. Wolfgang Reinpold

Ecuador, November 2012

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On December 1, 2012, the HRFU team returned from Archidona and by all accounts the patients did well. Although it was the first surgery trip for the Timmy Foundation, lead by August Longino, they did an extraordinary job supporting the team.

Dr. Wexler, Dr. Campanelli, and Dr. David Partrick (a Pediatric surgeon) operated on 68 patients and there were no known complications. Dr. Cynthia Ferris, anesthesiologist extraordinaire, provided wonderful care. Flexibility, knowledge of underserved country conditions and competence are her hallmarks. Dr. Kevin Buckley examined patients pre-operatively and filling in where needed. Five nurses from Calgary, Canada ensured the standard of care was maintained and loving care was provided.

One important aspect of the trip was the welcoming and appreciation of the Ecuadorian people. They repainted the hospital for this trip and have expressed their appreciation in many ways.

Congratulations Team – Well Done!! 

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Dominican Republic, November 2012

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The most recent HRFU Dominican Republic trip was a huge success! Forty two US volunteers and many Institute of Latin American Concerns health care providers (cooperadores) and 4 Peace Corp volunteers cared for more than 200 patients. Two Dominican surgeons were trained as described below. One hundred and fourteen hernia operations and 18 lumpectomies were performed without complication and numerous other patients were examined and treated medically.

Surgeon Training

Two fully trained Dominican Republic surgeons were chosen–a Pediatric surgeon for Pediatric hernia training, and a general surgeon for Lichtenstein hernia repair training. Dr. Robert Cusick trained the Pediatric surgeon and Dr. Wolfgang Reinpold trained the adult surgeon. Both trainers used a validated surgical technique rating form designed by the University of Southern Illinois surgical department education division (with input from Dr. Filipi, Dr. Cusick, and Dr. David Chen of the UCLA department of surgery). The rating form is now being implemented in the U.S. for surgical residency training. The hernia rating forms are available upon request.

The rating form was reviewed and then the trainer performed the first operation and the trainee assisted. The trainee and trainer reversed their roles with following operations. The trainer then filled out the rating form in privacy then immediately reviewed it with the trainee giving him a numerical score and explanation for all of the step ratings. This was repeated immediately for four subsequent operation. Both surgeons passed with flying colors and Dr. Ramirez was given free mesh on condition that he would use it only on poor patients and that he would monthly fill out a spreadsheet on the patients receiving the mesh and send the spreadsheet electronically to Dr Filipi. Photographs below show the process.

 

Guatemala, November 2012

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Led by Dr. Dwijen Misra and his head nurse Dawn Porrit, the HRFU team traveled in early November to the village of San Juan Sacatepeguez about 1-2 hours from the Guatemala City airport. The name of the facility was Salud de Barbara and it is run by Partners in Surgery. Dr. Manuel Torres, a Pediatric surgeon and Dr. Hinshaw a general surgeon along with Dr. Misra performed 52 hernia operations and removed several lumps and bumps. There were no surgical complications.

This was the first trip for this team and to this location.

Dr. Misra reported, “The team and excellent local staff adapted very quickly to a routine. The love I’ve come to feel for the Dominican patients during D.R. missions was replicated with the Guatemalan patients. I cannot imagine not coming back to help the brothers and sisters, aunts and uncles, and the children of those we were blessed to help. When we left San Juan Sacapeteguez, we said ‘hasta luego,’ not ‘adios.’”

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Haiti, September 2012

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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