MONGOLIA CAMPAIGN 2023

FECHA: OCTOBER 14th-30th  2023

1. TECHNICAL REPORT:

a.         DATES AND LOGISTICS DEPLOYED:

This campaign has been carried out between October 14th and 30th, 2023. The campaign activities are carried out thanks to an agreement of Hernia International (HI) Foundation with the Second State General Hospital in Ulaanbaatar. The last campaign in this location was held in 2019, by a team from HI. After the pandemic, this was the first campaign.

Due to the characteristics of the agreement and because of the locations where the work takes place, the logistics are a bit different from what our Foundation uses to do in other locations. The team consisted exclusively of 3 general surgeons and a nurse, since the rest of the personnel needed to carry out the work corresponds to local staff.  Regarding the necessary material, we have only taken some specific material that has been requested by the local organizers, basically different types of meshes, laparoscopic material and sutures. We must warn, for future campaigns, of the difficulty in transporting the material due to the restrictions in Mongolian customs, which almost detained our material. Only thanks to the efforts of Dr. Ganaa, UB surgeon who came to meet us at the airport, the situation was solved. It is very important, apart from the document issued by the Foundation, which we always carry with us, to have a document issued by the local organization of the campaign, to avoid problems at the airport custom.

b.         ADULT PATIENTS:

This campaign was conducted in two locations:

1.- General Hospital in Erdenet, Orkhon province:

5 patients were operated on in 3 working days, from October 16-18. The situation and the work in that hospital is explained below:

-1 patient with entero-cutaneous fistula included in a huge incisional hernia.

-1 patient with a large hiatal hernia (laparoscopic repair).

-3 patients with complex incisional hernias, 2 lateral and 1 midline.

Second General Hospital of Ulaanbaatar:

20 patients (22 procedures) were operated on from October 23-27. The dynamics of work in this hospital are detailed below:

-1 pancreatoduodenectomy, open, for an ampuloma.

-14 complex incisional hernias, 9 midline and 5 lateral:

-1 Rives+TAR left.

-8 Rives

-1 Rives with associated intestinal resection.

-1 endoscopic e-TEP in lateral eventration after Mc-Burney.

-2 lateral retromuscular repairs (subcostal).

-1 open preperitoneal repair.

-1 diaphragmatic hernia: thoracoscopic repair, with gastric incarceration. This was an emergent procedure, in a patient with a previous liver transplant (Mercedes laparotomy). Thoracoscopic access, chelotomy, reduction of the herniated stomach to the abdominal cavity and diaphragmatic raffia of the defect were performed.

-8 hernias, 6 inguinal hernias and 2 midline hernias:

-4 TEP

-2 Lichtenstein

-1 open preperitoneal

-1 Rives

Total procedures: 27.

Total patients: 25.

c.         COMPLICATIONS:

To date, one hematoma in a Lichtenstein for an inguinoscrotal hernia, and one wound infection in a patient with an enterocutaneous fistula have been reported to us. Both evolved satisfactorily.

2. MEMORY OF THE CAMPAIGN

a.         THE LOCATION

The campaign held in Mongolia, as organized since 2012 in the agreement between Hernia International and the Second State General Hospital, consists of 2 parts. The first part takes place in a rural hospital and the second part at the Second State General Hospital in Ulaanbaatar.

For this year’s campaign, the local partner initially chose a rural hospital about 1,500 km from UB, in an area with poor accessibility and limited medical resources. Due to organizational problems and agreements with the management of that hospital, less than a month before the start of the campaign they decided to change the location to another city, and finally Erdenet was chosen, in the province of Orkhon, which is the second most populated city in Mongolia, with a population of >100,000 inhabitants, and which has a General Hospital with more than enough resources to carry out surgical activity with quality and safety standards, including laparoscopic surgery.

In this hospital we could have carried out a great deal of assistance and training with the local surgical service, as was our intention and as we had agreed during the whole previous organization of the campaign. The main objective was to perform abdominal wall procedures and to train the local staff in open and endoscopic surgery techniques for inguinal hernia and incisional hernias.

Unfortunately, recruitment by the local hospital was very unsatisfactory, to the point that we found ourselves without patients to operate on from the very first day of work. It is important to note that, from UB, it takes about 10 hours of road travel to get to this location (that means 1 full day), and the same time to return. It was very frustrating for the team to find that the recruitment work had not been carried out in a hospital that meets the requirements for a good surgical campaign, according to the principles of our Foundation. For this reason, after 3 days of work there, we decided to return to UB to work at Second State General Hospital. This decision, forced by the absence of patients in Erdenet, meant losing several days of work, which in a campaign is a very serious disruption, because it means not operating on patients who need our care, and because it is a very important personal, economic and vital loss for the volunteers.

The reasons for this situation have not been well explained to us by the local counterpart. As far as we have been able to find out, they cite problems related to the difficulty of recruiting patients because they are nomadic communities, living scattered throughout the province, not able to reach the hospital easily.

The reality is that there are more than 100,000 inhabitants in that city, and the hospital had a lot of daily activity of other pathologies, as we could see in those days.

After trying unsuccessfully to maintain our activity in this place, we decided to return to UB because it made no sense to stay in Orkhon without patients. The whole campaign had to be reorganized, transportation had to be arranged ahead of time, and, most importantly, we had to assume losing days of surgical activity. We returned to UB on Thursday 19th. Although on Friday we were able to get to know the UB Hospital and its professionals, as well as explore the first patients, the reality is that we did not start the surgical activity until Monday 23rd. That meant losing another 4 days (including the weekend, which is true that normally we do not work in two-week campaigns).

Our activity in UB has also been marked by the lack of recruitment. Once again, it is important to point out that the aim of this campaign was to provide care and training in open and endoscopic abdominal wall pathology. The Surgery Department of this Hospital develops its activity in new facilities (this part of the hospital was built 4 years ago) and with an infrastructure and medical equipment worthy of any other hospital in Europe. In accordance with this situation, the Service has surgeons perfectly trained to perform complex surgical procedures, and the surgical activity is constant and organized by training areas.

It is important to point out that, during our stay in both hospitals, and especially in UB where we stayed longer, we have felt very well received, the hospitality of the local staff has been outstanding, and we have always been treated with great respect and consideration.

But I also think it is very important to explain why I believe this campaign should be redirected in the future, if Hernia International deems it appropriate, so that the Surgeons in Action Foundation maintains its interest in participating.

During our stay at Second State General Hospital, our team has maintained a great relationship of collaboration and exchange of knowledge with local surgeons, we have received exquisite treatment, and we have been able to participate in the discussion and treatment of complex cases. Added to that is the possibility of performing highly complex interventions thanks to the equipment available and the training of the local staff, not only surgeons, but also anesthesiologists, intensivists and nurses, to name a few (the Digestive Endoscopy Service, for example, performs an average of 2-3 ERCPs daily and has a specially dedicated operating room, in addition to having a large number of equipment available to perform upper and lower endoscopy).

The problem, as I see it from the point of view of our Foundation, is that these are not the objectives for which we are working. The relationship that we have maintained in this campaign is more typical of agreements between hospitals or universities, to exchange knowledge or establish institutional collaborations to raise the scientific and technical level of their professionals, which results in better patient care. However, the main motivation of our Foundation is quite different, and focuses on surgical care to communities that do not have access to such care, in rural or urban environments without medical resources, where, if we do not reach them, other safe and quality help is not expected. With this fundamental premise of our mission and vision as a foundation in mind, it is perfectly possible to carry out a campaign in Mongolia, in places where medical care is very limited.

In addition to this, there is a problem that also seems to me to be very important, and that is the cost of getting a team there. It is very fair to express our thanks to the local organization, which took care of financing our stay in a hotel in Erdenet. And it is also very fair to acknowledge the work of Enkhee. She was our contact during the process of organizing the campaign, liaising with Dr. Naraa, the head of the campaign and the Second State General Hospital. She was also our driver on the outbound trip to Erdenet, and she was our contact person during the campaign organization process in UB.

But, in spite of that, the 10-day stay at UB, in a hotel very close to the hospital, was too expensive and with comforts far above what we consider usual in other campaigns. It is also fair to acknowledge the work of Dr. Naraa Jr. in accompanying us, who went out of his way to make us comfortable and was very attentive to us throughout the trip.

Regarding the training activity, local surgeons and residents participated in all the surgeries in both hospitals, with different levels of responsibility depending on their experience and the complexity of the case. In addition, we were able to enjoy an academic day in Erdenet on abdominal wall pathology, in which the 3 surgeons of the campaign participated, and where we addressed theoretical and practical issues on inguinal hernia and incisional hernias. Likewise, at the end of the campaign in UB, we were also able to dedicate some time to this same work, which was very well received by the local staff.

During our stay in UB, and thanks to a contact of Sol Perez Cerdeira, we were able to have a pleasant conversation with John Cleaver, an Australian professional with extensive contacts and great knowledge of the reality of Mongolia, after years of professional relationship there in the mining business. He told us about a hospital specially dedicated to the mine workers, in a very remote location with no other health care options. We were also able to talk with Bujin Tserensodnom, a local professional with many years of experience in development and reform projects in the health sector in Mongolia, who dedicates part of his time to collaborate with a local NGO. After comparing the reality of health care in Mongolia, and the objectives of our Foundation, we agreed with them to establish communication channels to relaunch our activity in Mongolia, with more targeted campaigns to environments with scarce health resources where our activity may be more necessary.

THE TEAM

a.         MEMBERS:

-David Fernández Luengas. general surgeon (Coordinator).

-Ana María Gay Fernández, general surgeon.

-Marisol Pérez Cerdeira, general surgeon.

-Nuria Agulló Marín, nurse.

b.         LOCAL STAFF

In the hospital of Erdenet, Orkhon province, we have been supported by the Surgery Service and the Anesthesiology Service of the center, and two surgeons coming from other parts of Mongolia. We also worked with the local nursing staff. In addition, during the stay, we were accompanied by two surgeons (Dr. Ganaa and Dr. Naraa Jr.) and a resident physician (Dr. Megan) from the Second State General Hospital of UB. The disposition, collaboration and treatment has been very hospitable, respectful and warm.

At the UB hospital, we have also had the collaboration of surgeons, anesthesiologists and nursing staff in our activity, who have made our work very easy, always ready to help, and with much respect and consideration.

They treated us as their honored guests, took us out to dinner after work, at their expense, and we received gifts at the end of the campaign. We felt very fortunate. At the UB hospital there was even a solemn opening ceremony for the campaign, very respectful and with the presence of the Hospital executive staff .

a.         THE EQUIPMENT

Both hospitals have more than enough equipment to carry out surgical interventions. In the case of Erdenet hospital, it is feasible to perform low and medium complexity interventions, including laparoscopic procedures, although the instrumentation, also in open surgery, but especially in laparoscopic surgery, was rather scarce and outdated. Despite this, we were able to perform a highly complex surgical intervention such as a giant hiatal hernia by laparoscopy, safely. They do not have advanced energy instruments, but the surgeons who accompanied us from UB had an ultrasonic dissector that we were able to use.

In the UB Hospital the facilities and equipment are very extensive, allowing us to perform highly complex procedures safely, as demonstrated by the pancreatoduodenectomy we performed, with a local surgeon, with the same quality and safety standards as in our hospitals in Spain.

The main limitations of both hospitals have to do with disposable material, especially, in the case of wall pathology, the scarce availability of meshes.

b.         ANESTHESIA

The local anesthesia equipment in both hospitals allows interventions to be performed safely, thanks to the training of their professionals and the equipment available, both for general and regional anesthesia.

c.         ASEPSIA AND SURGICAL MATERIAL

There is not much more to comment on in this regard, both hospitals have perfectly solved this need. It is true that, especially in Erdenet, and to a lesser extent in UB, the surgical instruments are somewhat old and limited, but perfectly useful for maintaining surgical activity.

3.         CONCLUSION

Strengths of this place:

- Undoubtedly, its people. Very hospitable and respectful, always willing to help.

- The Second State General Hospital is a great hospital, with equipment and technology far above the level we are used to in other locations of the Foundation.

- Erdenet General Hospital in the province of Orkhom has all the conditions to carry out a successful campaign of our Foundation.

Improvement objectives:

- The main problem of this campaign has been recruitment. This is a critical objective of any campaign. Despite the organization in the previous months, the reality is that recruitment has been very unsatisfactory.

- The second major problem with this localization is the choice of hospital centers. The one in Erdenet may be perfect for our campaigns, but recruitment needs to improve. Regarding the Second State General Hospital, I think it is not the type of hospital that the Foundation should devote its resources to.

- Considering the needs of this country, I think we could find, for the Foundation’s next campaigns, rural destinations where our work is most needed. I believe that the local organizers have sufficient capacity to achieve this goal. Also, the contacts made during our stay could help us to find new destinations in Mongolia.

4.         BUDGET: (small breakdown of expenses financed by volunteers. The cost of transported material is not included).

BASIC COST PER PARTICIPANT (airplane+hotel): 2.200€.

TOTAL BASIC COST OF THE CAMPAIGN: 9.000€.

David Fernández Luengas

Campaign leader

Surgeons in Action

A selection of photos is available at our Gallery