The team with Baba (Karim)

Eruwa June 2013

The team with Baba (Karim)

The team with Baba (Karim)

Operation Hernia Report – Mission to Eruwa, Nigeria, 8th-16th June 2013

The Journey

Months of preparation and e-mail contact had come to an end when the Operation Hernia (OH) Team for the mission to Eruwa, Nigeria, assembled in London’s Heathrow airport in anticipation of an exciting adventure. After an uneventful flight, and cordial welcome to Nigeria by the vaccination officials, we were delighted to be greeted by Dr Oluyombo Awojobi (Yombo) and his colleagues in Lagos. We continued our journey to Eruwa the following day and were grateful to the driver and our armed escort for avoiding vast amounts of livestock traffic and successfully negotiating large craters in the road. Having reached Eruwa, the impact and effort of the OH teams before us was evident by the warm welcome we received, the prior organisation by Dr Awojobi’s clinic, as well as the recently opened hernia centre. We had a lot of work to do, and a lot to live up to.

The Team

It was a pleasure to work with this truly International Team comprising Dr Aleksander Stanek (a Polish surgeon from Northen Ireland), Dr Constancio Marco (Surgeon from Barcelona, Spain), Dr Richard Salam (Anaesthetist from Nigeria now working in the UK), Dr Gregory Wirth (Urologist from Geneva, Switzerland), Miss Sophie Pitt (medical student, UK), and myself Dr Iestyn Shapey (Surgical Registrar from UK). The team gelled immediately and worked closely and very successfully throughout the project. Dr Stanek’s prior experience as consultant surgeon for two years in Abeokuta, the nearest large town to rural Eruwa, was invaluable as he led this international team. We were privileged to have Baba Karim, Yombo’s chief theatre nurse, and his staff working with us throughout the week, and without whom the day to day functioning would not have been possible. Finally, a great debt of gratitude to Yombo and his family, and his five surgical registrars who rotated in and out of the various roles of assisting, operating and anaesthetising.

Teaching the local registrars

Teaching the local registrars

Operating until late

Operating until late

The mission

Seventy patients underwent surgery over 6 days of operating with 100% discharge within 24 hours and no immediate complications. Most had large (Nigerian-sized) inguino-scrotal hernias, many with synchronous testicular pathologies, which demonstrated to us the value of our multi-specialty team. Initially, the days were long as we found our feet, and surgeries were being performed well after dark. However, we soon established a sound working-pattern and slick process by starting with a clinic review of all patients, producing an optimal running order according to anaesthetic requirements and pathology, and getting to work. In addition to providing high quality surgical care, the team also sought to teach and supervise the local surgical registrars in performing tension-free mesh (Mosquito net) repair. By the end of the mission three of the residents could successfully perform the procedures themselves from start to finish.

The team with Yombo & Tinu Awojobi

The team with Yombo & Tinu Awojobi

Legacy

The distance that patients travelled to receive treatment at Eruwa (some came from Lagos) was testament to years of Yombo’s hard work, the establishement of the OH mission, and the previous teams’ legacy in building the hernia centre. What would be the legacy of the 2013 mission? We were delighted to learn from Yombo that the five surgical registrars were inspired to continue their experience of newly learnt techniques by utilizing the hernia centre facilities on a weekly basis outwith their regular clinical duties.

Iestyn Shapey

Surgical Registrar, UK

The Opening

Operation Hernia Team Inaugurates Hernia Centre in Eruwa, Nigeria December 2012

The Opening

The Opening

We arrived at Eruwa on Saturday 1st December. There were seven members from Madrid hospitals (anaesthetists: Francisco Duran and Miguel Lopez Vizcayno, surgeons: JA Pascual Montero, Teresa Butrón, Patricia Maldonado (resident), internist: Iñigo Espert, nurse: Ana belen Abenoja) who were joined by an additional member from the UK the following day.

The site was the Awojobi Clinic, which started at grassroots level in the 1980’s and has been steadily growing ever since. The clinic was set up to serve the local rural population but the level of care has reached a standard that attracts patients from as far away as Lagos, a 3-4 hour journey by road.

Surgeons & Supporters

Surgeons & Supporters

At work

At work

Work started on the Sunday and continued during daylight hours for five days. The patients would arrive from 8am and the 8 team members formed two surgical teams. Surgery was performed in the purpose built ‘Hernia Centre’ which was opened during the visit. The operations were performed under spinal anaesthesia and operations were predominantly Lichtenstein repairs using locally sterilised mosquito mesh. Workload varied each day depending on the numbers of patients who presented.

There was strong training ethos to the mission. Dr Awojobi has a total of five registrars who initially watched and later performed Lichtenstein repairs under direct Consultant supervision. The hernia centre will remain open after the end of the mission with the registrars operating independently.

Registrars attending for instruction in Hernia surgery

Registrars attending for instruction in Hernia surgery

On a couple of the afternoons we had finished the operating before nightfall and had the opportunity to visit other departments in the clinic. The emphasis is on delivering the highest possible level of health care using available resources. The results are impressive, with most of the departments present that one would expect in a far larger hospital. We also had the opportunity to observe some of the differences in presentation and treatment between European and Nigerian patients. One evening team members assisted local staff with completion of a traumatic amputation in a teenage boy.

The people of Eruwa and were welcoming and friendly and we made a lot of new friends. Over the week we performed at total of 44 operations on 38 patients. They were predominantly inguinal hernia repairs, but we also repaired two femoral hernias, one epigastric hernia, explored one groin for lymphadenopathy and removed a large lipoma without immediate complication. We left Eruwa not only satisfied with the procedures which we had performed but also enthusiastic that the training element of the mission will add to the ‘hernia centre’ and lead to ongoing benefit to the local population once we have returned to our home countries.

Chris Grocock

Surgical Registrar

In the operating theatre

Spanish, Puerto Rican and Andorran Team, Eruwa 18-27 MARCH 2010

It was incredible! is all we can say. We began our project when I first came to Eruwa, in June 2009, when we decided to undertake part of our work after talking with Dr. Awojobi. The Foundation Dr. Ramon Vilallonga has been involved in many projects, but since we met Dr. Awojobi, we cleary decided to continue this colaboration. On this ocasion, we met, a group of five people, from three different countries, Puerto Rico (Dr. Vangie Teixidor), Andorra (Mr. Josep Maria Puy) and Spain (Dr. Candy Semeraro, Miss Cristina Andreu and myself, Dr. Ramon Vilallonga), at the airpot of Lagos.

Spanish, Puerto Rican and Andorran team

Spanish, Puerto Rican and Andorran team

We arrived late in the evening and we were met at the airport by the team from the Clinic who took us in the clinic’s bus to Eruwa the next morning after spending the night in Lagos. The same day of our arrival, we began surgeries. Hernias of course. Baba, the person in charge of the theater and assistant for us, has been working a lot, and in a very efficient way. Accommodation was very changed since the last time. We did not stay at the town s hotel anymore, but at the clinic. Two houses were fixed for us. Perfect! We have repaired many hernias. Cristina, our scrub nurse, has taught Shakira, a local nurse who helps with the surgeries. Candy and I have taught some trainee residents and specially Daso, who is now perfectly able to perform a hernia repair with mesh. We were very pleased about that. The Awojobi familiy, as usual, has been very helpful and kind. No need to say that again. We have been treated like kings. Vangie even wanted to taste the local food we did.

Laying the foundation stone

Laying the foundation stone

 

“Sweets, pencils and a ball were offered to the kids. We can still hear the shouts of happiness.”

“Sweets, pencils and a ball were offered to the kids. We can still hear the shouts of happiness.”

As usual, we did a nice visit to the neighbourhood school. All the kids were so happy and excited. It was a great experience and we enjoyed it a lot. Sweets, pencils and a ball were offered to the kids. We can still hear the shouts of happiness.

We have continued treating Kundus, the little boy who got burnt almost one year ago. With material from our hospital, we changed the dressing every two days and he is improving but it is going to be very slow, as the burns are so extensive. Candy made a fantastic doll for him and Joe, an ambulance.

We also had the opportunity to assist Dr. Awojobi in his elective and emergency surgeries: testicular torsions, recurrent laparotomy hernia repairs, humerus realignment, thyroidectomies an experience.

Finally, we also laid the first stone of the future Ramon Vilallonga Puy Ibarapa Hernia Center. An incredible experience. We wish to continue in this way, trying to improve heath care in Nigeria. We hope to come back soon.

Dr. Ramon Vilallonga

In the operating theatre

In the operating theatre

Spanish Team

Spanish Team Group 3, Eruwa, Nigeria 21-28 NOVEMBER 2009

This is the first Spanish Group to come to Nigeria. In spite of only a month´s notice, the preparations for the trip came along very well.

Spanish Team

Spanish Team

Within four weeks of knowing about the trip, the team of six (Teresa Butrón, Raquel Delestal, J.A. Pascual from 12 de Octubre University Hospital, Aleidis Caro, Carles Olona from Joan XXIII University Hospital Tarragona, Áurea Tartas from Getafe University Hospital Madrid) was assembled with financial aide and the necessary equipment. We want to thank Caja Madrid, the branch in 12 Octubre Hospital, Obra Social Caja Madrid, Ethicon, Smith and Nephew and Viajes Atlanta. We also want to thank the people in our hospitals, and Ethicon for collecting and handing over to us a good amount of materials.

The first time our team met was at the Madrid airport, hours before leaving. We brought 17 large bags of sanitary equipment. It took us a long time to wrap all of the materials in plastic wrap, and marked everything with red crosses. We want to thank Mano a Mano NGO for letting us each check one bag extra per person.

After a long flight, we arrived at the Lagos airport. Thankfully there were no problems with customs and we met Dr. Awojobi Yombo , who was very surprised to see 17 large bags. When we got outside, we weren´t sure if the bus would fit us, much less our bags, but there was no problem as the minibus was only for us.

The first night of our journey was spent in Lagos. The next morning, we awoke to loud music and singing. It turned out that a local Pentecostal church was having service with dancing and singing. What an experience! After this visit to the church and breakfast, we took a three hour bus ride to Eruwa.

On arrival we took a tour of the clinic we would be working at. When we arrived at the supply room, we found it was empty. Our first task was to stock an entire supply room. Fortunately with 17 large bags of medical material (two bags with toys and stationary for children), the room filled quickly and we had enough supplies. That night we had dinner in Dr. Awojobi´s house, and went back to the hotel to relax. We thought the next day would be a routine day in the operating room. But it was a learning experience that helped us to adapt quickly.

Spanish Team Operating

Spanish Team Operating

 

Spanish Team Operating

Spanish Team Operating

We started operating at sunrise because most of the light filtered through the windows. Our ´surgical light´ was four low-energy lightbulbs in an upside-down kitchen bowl, a felicitous local invention. The patients came to the clinic on foot, sometimes walking for miles to get there. There were two surgical tables in the operation room. From sunrise until well after sunset we operated on patient after patient. Finally, at 9pm, we finished our last operation for the day.

The following days became easier and easier as we adapted, and we began to finish earlier and earlier. From boys to old men, we worked on many different patterns. Some hernias were small, and others were quite large. After the spinal anaesthetic, they would stay for a day in our makeshift ward. We received quite competent help from the young doctors who have come from different places in the country to learn and practice new skills.

In our entire week of working with the patients, we never heard one complain or talk about their discomfort. They thanked us often and were heartily. By the end of the week, we were able to finish the surgeries quickly enough to walk around the community at the end of each day. We visited a school, where we distributed toys, pens and other writing materials. Another day, we visited different installations around the clinic. Dr Awojobi utilizes the local resources to function as autoclaves, a manual hematocrit centrifuge, patient trolleys, pedal suction pumps, water distiller, intravenous fluid and Histopathology service. The last day we visited the public General Hospital of Eruwa. We found that the installations needed updating. There was no water nor electricity in the whole hospital, and there was great lack of cleanliness everywhere except in the odontology section which the nurse in charge kept very clean, and we were told the lack of cleanliness was due to lack of official means or financial resources, but we also thought that in a great part this situation was due to carelessness on the part of the people in charge in the hospital.

The week was a very eye opening experience for us. We saw the difficult conditions that the Nigerian people live and work in, and we also saw the adaptability and ingenuity that can overcome many obstacles. We will never forget the people here, and thank everyone for their contribution in this great project.

We also give thanks to Peter John Acceturo whom we met at the airport and who helped us polish this English report.

In surgery, Eruwa, Nigeria

Leighton Hospital Team with others, Eruwa, Nigeria 8-14 AUGUST 2009

 Arriving in Nigeria with all our luggage

Arriving in Nigeria with all our luggage

MY DIARY: Saturday 8 August

I (Nicola Eardley) arrived at Magdi Hanafi’s house at 6:00 am to find him still asleep! After he hurriedly got dressed, we packed the car and set off for Manchester Airport with our luggage and three boxes full of medical equipment. We met Ginny Long (theatre sister) at the airport, and checked in without any problems, although some swapping of contents between bags was needed to ensure that we didn’t exceed our weight allowance! We flew to Heathrow airport where we met up with Professor Kingsnorth and Eyston Vaughan-Huxley, a surgical trainee who had just finished his F2 year. We boarded the plane and unfortunately were delayed for an hour on a hot day without air conditioning (hotter than we were in Nigeria!), but eventually we took off and had a smooth flight to Lagos.

When we arrived at Lagos Airport, we were relieved to see that our luggage had also arrived, having survived the transfer at Heathrow’s Terminal 5. Customs questioned their contents, but allowed us to pass without any problems. We were warmly met by Dr Oluyombo Awojobi and his son at the airport. From there they took us to a hotel near the airport where we were able to wash (in the dark due to a power cut!) and have dinner. Over dinner we briefly discussed the following day’s itinerary before heading to bed (again in the dark due to another power cut!). Many of us were then woken with a start during the night when the electricity came back on and so did the lights and television!

Sunday 9 August

We had an early start with breakfast at 7:00 am. We checked out and packed the cars and off we went. Dr Awojobi had a busy day planned for us. We drove through the traffic of Lagos and once we were at the periphery of the city we stopped to visit the town where Dr Awojobi grew up. He told us all about his family and visited the grave of his elder brother, a respected engineer. We then went to a church, which had been built by his grandfather, and visited his grave. We then travelled for another hour to visit Dr Awojobi’s mentor and teacher, Professor Ajayi. He made us feel very welcome, discussing with us the difference between the old and new schools of medical education, over a cup of tea whilst sat on the front lawn of his house. After an hour or so we set off again and then stopped at his brother s house where we had a fantastic lunch. We thanked him and his wife and then set off to go and pay a visit to Dr Awojobi’s mother-in-law before the last leg of our journey to Eruwa. It was a long journey and we could see why it was best to travel during daylight hours as some of the roads were in very poor condition. Ten hours after we set off from our hotel in Lagos we arrived at Dr Awojobi’s home. We were warmly greeted by Tinu, his wife, and the rest of the family, and sat down to a nice dinner before heading back to our hotel to rest before our work was to begin the next day.

The Leighton Hospital team

The Leighton Hospital Team

In surgery, Eruwa, Nigeria

In surgery, Eruwa, Nigeria

Monday 10 August

Another early start, meeting at 7am (apart from Magdi who overslept again and met us at 7.15!). We had met Richard Salam, an anaesthetist, at the hotel on the previous night and that morning he told us how he had crashed his car on the journey from Lagos to Eruwa. We were amazed when we saw the photograph of his wrecked car that he had managed to escape with only minor cuts and bruises! We were driven to Dr Awojobi’s house and had breakfast before walking across the fields to the clinic. We were introduced to Kareem, the operating theatre supervisor, whom we were to find invaluable over the forthcoming days, and also some junior theatre helpers. In the operating theatre we found two operating tables for twin operating. We unpacked our boxes of supplies, which included gowns, gloves, local anaesthetic, antibiotics, analgesia, sutures, dressings, finger-switch diathermy, diathermy plates, sharps boxes and surgical scrub fluid and skin prep, in fact pretty much everything we needed to repair the hernias!

We met up with some Nigerian doctors, surgeons and GPs, who had come along to get some experience of performing hernia repairs with mesh. Professor Kingsnorth gave a lecture to the local doctors about the Lichtenstein repair and then we set to work. We examined the patients in the consulting room (2 patients at a time stood in the room, naked except for a sheet which they wrapped themselves in) and then they walked into theatre and climbed onto the table. Here they were given oral antibiotics and analgesics before lying down.

The vast majority of our operations were adult inguinal hernia repairs and all but the biggest (and I mean big!) were performed under local anaesthetic. Even the bilateral hernias could easily be repaired under local anaesthetic as our patients were, on the whole, nice and slim. We starting operating, assisted by the Nigerian doctors who were keen to learn. They had varying skills and all had differing aims and objectives of what they wanted to learn from us. For some it was how to perform a Lichtenstein hernia repair well, for some it was simply a matter of learning all about aseptic technique, tissue and instrument handling and effective suturing and knot tying. We kept working like a conveyor belt, interrupted only by lunch which was brought to us in lunch boxes. After only a 30 minute break we were operating again! All in all in the first day we performed thirteen procedures on ten patients. During the course of the day and also at the end of the day we visited the patients in the ward area, where they were usually surrounded by many family members before we discharged them home. Many travelled home on a motorbike just a few hours after their surgery! After a long day we walked back to the house and sat drinking tea and talking about our day until dinner was served. We then headed back to the hotel to rest before another busy day.

Tuesday 11 August

Another early start. Professor Kingsnorth and Dr Awojobi headed off on a trip to look at potential locations in Nigeria for further Operation Hernia missions. Today was to turn out to be slightly more adrenaline filled! Magdi Hanafi had to deal with a patient who had a right neck swelling and bilateral inguinal hernias. He started with the neck swelling and immediately encountered a difficult dissection and lots of pus. The internal jugular vein was injured and he found himself in a situation where he had to control venous bleeding with no suction, bad light, pus filling the wound, no provision for extra swabs and as an assistant, a GP who had very little operative experience. Fortunately he managed to get control, suture the tear in the vein, dissect out and excise the cyst, all under local anaesthetic and sedation! The second case was no easier, a 40 year old lady with the build of Magdi and an incisional hernia from a lower midline caesarean section. After a failed spinal she had to have a general anaesthetic with ketamine. It proved to be another difficult procedure as bowel was immediately underneath the skin with no peritoneal covering. There were several Nigerian doctors around who wanted to learn and scrubbed with each case. It was a relief to all that the remaining cases for the day were relatively straight forward.

Wednesday 12 August

An early wake up call this morning as they decided to turn the generator on at the hotel at 5am. Another busy day in theatre. We saw a 65 years old man with a scrotal swelling reaching down to his knees. This didn’t appear to be a hernia as it was very hard in some areas and cystic in others and he had only had an inguino-scrotal hernia repair a month before. It turned out to be a giant haematoma which was evacuated and included an orchidecomy.

Thursday 13 August

Slight stress this morning as the patient who had had the giant haematoma evacuation was nowhere to be seen, He has already gone home, even though he had a drain in situ (the finger of a glove acting as a drain!). Other patients relatives chased him up in a car and brought him back from the road. We were able to remove the drain and redress his wound. Professor Kingsnorth and Dr Alowojobi arrived back this morning and operated with us. They operated together on another giant inguinal hernia. After another long day we had a tour of Eruwa and got to see the original clinic before it moved to its current site. We were also fortunate enough to meet the chief (Oba) of Eruwa in his palace.

Friday 14 August

All packed and ready to go but a few more operations to perform before we left. Our tally for the week was 49 operations, the vast majority being performed under local anaesthetic, and no major complications. We set off for the airport, thanking everyone for their hospitality and a few hours later we arrived at Lagos airport. A long journey back home and plenty of time to think about the next mission

Leighton Hospital Team: Magdi Hanafy, Nicola Eardley and Virginia Long.
Others: Andrew Kingsnorth, Eyston Vaughan-Huxley (surgical trainee), Richard Salam (anaesthetist)

Theatre Superviser Kareem

Theatre Superviser Kareem

Adhoc Team – Eruwa, Nigeria 27 JUNE – 3 JULY 2009

Servaise de Kock; South Africa, Ramon Vilallonga; Spain, Andrew Kingsnorth; UK

oh_image_60_m

Operation Hernia’s first outreach to Awojobi Clinic Eruwa (ACE), Oyo State in Nigeria (26 June 3 July) has been a remarkable experience. The outreach followed Professor Andrew Kingsnorth’s site visit to Eruwa earlier this year (see report). Nigerian visa complications at the eleventh hour unfortunately prevented Dr Dave Sanders (from Plymouth, UK, but at the time doing voluntary work in South Africa) from joining the project. The final team consisted of team leader and very able teacher Prof Kingsnorth, charismatic Spanish surgeon Dr Ramon Villalonga and myself from South Africa.

On arrival at Murtala Mohammed International Airport in Lagos on Friday evening I was met by Prof Kingsnorth and our Nigerian host, Dr Yombo Awojobi. We stayed over at the Lasos Hotel where we could discuss the week s programme over supper. Breakfast the next morning was had amidst at least five power cuts. Later we learned that the power has been off in Eruwa for 2 months and most houses have their own generators. Coming from South Africa, the Nigerian environment was not that much different from home. The lack of proper infrastructure for such a rich country as Nigeria came as a shock though!

Traffic in Nigeria is simply chaotic and I was extremely thankful that I did not have to drive myself. Motorbikes carried up to six people and South African potholes suddenly seemed very small to me. Dr Awojobi kindly took us on a sight seeing trip to his alma mater school, Lagos University (where a monument was put up for his late brother, Prof Ayodele O Awojobi, a distinguished lecturer in Engineering). We also visited the Olabisi Onabanjo University Teaching Hospital. We then headed to Eruwa where Mrs Tinu Awojobi and the rest of the family welcomed us and cared for our needs in a very special way throughout the week, including cooking special meals for us.

That evening we unpacked the new Codman surgical instruments donated by Atrium, the mesh donated by Atrium, the Valley Lab diathermy machines from Covidien and the suture material donated by BBraun. Thanks also to Ethicon SA and other sponsors for having made this project possible.

Over the next few days we operated happily using the AM Eye Clinic Theatre on the ACE premises (where beds, gowns and theatre lights are locally made!). Forty-four patients underwent surgery and 52 hernias were repaired, including bilateral femoral hernias in a male patient and a lumbar hernia. We also trained 24 local surgeons, resident surgeons and family practitioners in performing the Lichtenstein Mesh Repair. Most of them still do a modified Basinni repair for lack of mesh availability at a reasonable cost. Most of the trainees could get hands-on experience. We were kindly assisted by Dr Awojobi s staff and his clinic supplied most of the reusable equipment.

We were most impressed with Dr Awojobi s ingenuity in his hospital. His cleverly devised inventions include an autoclave machine, locally produced intravenous fluids, a self-made washing machine, a bicycle wheel driven centrifuge, etc. He is also producing interlocking bricks that are used for building an auditorium to host the 2011 Rural Surgeons World Congress. Rural surgery at ACE is practiced at its best. Much can be learnt from Dr Awojobi s resourcefulness. One gets the impression that patients are cared for in a special way.

Special events included a visit to the local king, an evening party with a live band and neighbours attending in their typical Nigerian attire, visiting a local school and just walking around the village streets. Nigerians are very hospitable and we were always greeted with a You’re welcome!

ADVICE to future teams:

1. Do take operative protective clothing (theatre shoes, plastic aprons and eye protection).

2. Take Malaria prophylaxis and Yellow Fever immunisation.

3. Make sure you have enough memory/batteries for your camera.

4. You will need lots of energy the working days can be long.

In conclusion, taking part in Operation Hernia was an enriching experience for me. I found Prof Kingsnorth’s input especially inspiring. Ramon Villalonga also proved to be a particularly pleasant team mate. I wish Dr Awojobi and the ACE all the best for the future. May Operation Hernia continue to contribute meaningfully to rural surgery.

Servaise de Kock
Surgeon, Ngwelezane Hospital, Empangeni, KwaZulu-Natal, South Africa.

Site visit to Awojobi Clinic, Eruwa

Eruwa, Nigeria

Nigeria has an intimidating reputation with concerns about security, corruption, traffic chaos, economic nihilism and unfathomable bureaucracy.

Site visit to Awojobi Clinic, Eruwa

Site visit to Awojobi Clinic, Eruwa

However, carefully following all protocols and negotiating the hawkers at Lagos airport, I struggled into the tropical humidity of the arrivals lounge at Lagos airport and instantly found my host Dr Oluyombo Awojobi with his son, Yombo Jnr and our friend from Takoradi Dr Charles Sagua. We headed north into the night for a 150km drive to Eruwa. The journey of 6 hours took us through shanty towns and slums, over potted and non-existent roads, districts teaming with road-side traders and the general crush of humanity, until at midnight we arrived to the relative rural tranquillity in the tropical savannah at Eruwa.

After a good nights rest Yombo Snr took me on a tour of the Eruwa community. Beginning at the primary school, we watched the assembly, including joyous singing and I gave a small invited speech of encouragement. Ward rounds began at 8am and 40 patients were assessed. The Awojobi clinic is a miracle in the midst of the failing state of Nigeria which can no longer deliver fresh water or electricity to its towns or the hospitals within them. In the Awojobi clinic water is pumped up from dams fashioned by hand. Electricity is provided from cheap generators. All hospital equipment is cheaply produced including Heath Robinson autoclaves, a water distiller, intravenous fluid production, surgical gowns, drapes and materials. Yombo is able to provide comprehensive surgical services for all members of this community at a very low price. At the same time he is dealing with end stage pathology, which requires a large breadth of experience and surgical skill.

During the day we had discussions about how to enter a partnership between Operation Hernia and Awojobi clinic beginning within the next few months.

The following day Saturday 7th March, Yombo took me on a tour of the town which was amongst the poorest I have seen in Africa. There is virtually no visible input from government services. The District Hospital was in a state of desolation and decay with rusting beds and equipment and filthy conditions. Following a traditional lunch of palm nut soup, ground cassava, smoked catfish and a fiery, peppery stew, we visited Igba-Ora District Hospital, which was little improvement on the hospital in Eruwa, although there were some signs of surgical activity, which occurs when there is an electricity supply provided erratically during a random four hours each day.

The following day, which was my day of departure, I was taken to the Ibadan University and the University College Hospital, which had an air of majestic and faded neglect, and where we observed enthusiastic trainee doctors and surgeons. Finally before departure to the airport I visited Layo Model hospital at Ikire in Osun state which is run by Dr Tunji Adenuga. He has built a small medical facility in an isolated rural area together with a school and community based projects. This site may become a second place in Nigeria for Operation Hernia.

Nigeria offers exciting possibilities for Operation Hernia where in spite of the problems, there exists a nucleus of surgeons determined to provide a service for their communities and willing to work with outside agencies. We look forward to our next visit to the Awojobi clinic.

Andrew Kingsnorth

The official opening of the ACE Clinic by the local Oba

ACE clinic in Eruwa, Oyo State, Nigeria

The official opening of the ACE Clinic by the local Oba

The official opening of the ACE Clinic by the local Oba

Jaeck Adamek, Rob Hart and Andrew Kingsnorth, with registrars Jamasp Dastur and Sameer Kadam completed the fifth mission at the ACE clinic in Eruwa, Oyo State, Nigeria during 12-20 November. Seventy patients received mosquito net mesh repair under local anaesthetic.

Operation Hernia also contributed to the International Federation of Rural Surgeons meeting that was taking place simultaneously (picture below shows the official opening by the local Oba), and organised by Dr Awojobi, with the participation of the Association of Rural Surgical Practitioners Of Nigeria.

Local leaders at the opening ceremony.

Local leaders at the opening ceremony.