Bopolu Mission Report January 2022 – Surgeons in Action & Hernia International

The first joint mission of the Surgeons in Action and Hernia International Foundations following the Covid-19 pandemic has been conducted in Bopolu City, a small Liberian inland town of 3200 inhabitants located in Gbarpolu County, home to approximately 90000 people. It is the first campaign to be conducted in this destination, and the reason is that this is where Dr. Peter George is now working.
Peter George has been the collaborating physician of our two foundations for years and is now the head and medical director of Jallahlone Hospital, the reference health center for the whole county. This is my third campaign in Liberia that I have coordinated with him and he has always shown great organizational skills and leadership in his country.

The preparation of the campaign has been very complicated since it was suspended on two occasions as a result of the spread of the Covid pandemic and the restrictions on entry to Liberia even for people from countries with a high percentage of vaccination and the possibility of performing routine diagnostic tests for active infection such as PCR or antigenic tests. On two previous occasions during the years 2020 and 2021, the campaign was postponed when everything was organized and the airline tickets were purchased, which is why it has meant a great economic, moral and resilience effort on the part of the team members.

The team members were three surgeons (César Ramírez, Pablo Muriel and Sarai Ayllón), two anesthesiologists (Sandra Casares and Beatriz Fort) and three nurses (Francisco Gómez, Rebeca Sanabria and Julia Cáceres), and we all received authorization from Dr. Peter George from the Medical and Dental Council of Liberia to practice since our professional documentation was sent electronically. The initial expedition included a fourth surgeon, Marta Roldon from Malaga, who was unable to travel due to a positive PCR test the day before departure.

The departure of all team members was on Thursday afternoon, January 20th and we met in Madrid in the evening; Pablo and Beatriz left from Barcelona, Sandra was in Madrid and the rest of the team members from Malaga. The trip was made with Air France (Air Marocq has stopped operating flights to Liberia in the pandemic) and started in the early morning of Friday 21 with the flight Madrid – Paris at 6 a.m. and from Paris we left on Friday 21 at 12.25 p.m. to arrive in Monrovia at Roberts International Airport at 8.25 p.m. on a direct flight. As information on the security protocols we followed in order to arrive in Liberia, all team members traveled with a certificate of having received three doses of messenger RNA vaccine and a certificate of negative PCR test performed at least 48 hours before departure of the flight to Paris. Each member of the team was required to pay US$ 150 for diagnostic tests for active infection upon arrival in Monrovia and for leaving the country, and these tests were performed by airport health personnel upon our arrival and by the laboratory manager of Jallahlone Hospital in Bopolu three days before our departure from Liberia, being in both cases rapid antigen tests.
Once we passed the Covid sanitary control at the airport, Dr. Peter George was waiting for us at the baggage claim wheel (as he always does) to facilitate our logistics of transporting the 23 packages (more than 500 Kg) of material that we have carried, for which we also had to pay 1200 Euros of excess at the Madrid airport. Since it was after 10 pm on the 21st upon our arrival, that night we slept at The Blue Lagoon in Monrovia, an acceptable hotel with a swimming pool available and which is a common place for the Liberian middle class. On the morning of the 22nd we left Monrovia for Bopolu, a drive of almost 5 hours to complete just over 90 km on a road that is terribly bad, full of potholes, rocks and that becomes insufferable at times. We arrived in Bopolu City at 3 pm and were greeted with a big party by the women’s association of the city, there is a feeling of protection of the role of women important and seeking a situation of equality that right now does not yet exist in Liberia, a country where the structure is still very patriarchal. After a warm presentation at the Hospital by the health and administrative authorities, we have unpacked all the material and placed in the hospital facilities and then we have gone to our place of residence to take possession of the rooms and carry the suitcases.

Jallahlone Hospital is a medical-surgical center with the typical structure of small Liberian hospitals located outside the capital, in the style of the one we knew in Ganta City (E&J Medical Center). It has an operating room equipped with a ventilator in which interventions under general anesthesia can be performed; the usual activity of this operating room outside the campaigns are caesarean sections but also herniorrhaphy is performed (I do not know how often), hence the large number of reproduced inguinal hernias that have been operated on in this campaign, easily identifiable by the type of incision and because they had no mesh in place. There is a hospitalization room for men, another one for women, another one for children and a fourth one which is a maternity area. The second physical space that we have set up as an operating room has been a regular medical care room where we have placed two stretchers for transferring somewhat unstable patients, but which have been used to operate on hernias and major outpatient surgery. In the operating rooms there is only one electric scalpel that works irregularly; we have brought two of them from Spain and we have given one as a gift to stay there in the Hospital. In the main operating room there is no air conditioning but there is a ceiling light that works acceptably from 10 o’clock in the morning and often jumps and is interrupted; in the other room there is air conditioning, which makes it more bearable, but there is light and it is essential for the surgeon and assistant to use headlights. There is no wifi network either in the Hospital or in the whole region and in order to be able to connect we had to buy a router at the airport which had to be progressively charged during our stay.

The accommodation site was about 300 meters from the Hospital and is a building that is not used regularly (there are no visitors or tourists there) and has about 25-30 rooms equipped with a bed (with mosquito net but with a base of boards that makes a bed base and usually breaks), a bedside table, a fan and a bathroom that has no light or running water (there is a large bucket of about 100 liters with a ladle that is getting water to take a shower and clean the toilet daily needs). The stench is unbearable in the bathroom since the drains go under the shower tray. The food as always in Liberia is quite acceptable, and Peter makes sure that we always have fresh fruit (pineapple and papaya very tasty), vegetables (especially tomato and cucumber) and a diet based on rice and fried chicken every day. We supplemented each day with cold meats of all kinds, cheese, piquitos and olive oil which gave us a lot of comfort. Each night we had cold beer and carbonated beverages of all kinds at our lodging, where dinner was brought to us. Similarly, we had a refrigerator at the Hospital in Dr. George’s office which was always stocked with water and soft drinks to compensate for sweat and exertion losses. Each day we were picked up by two vans at 7 a.m. and taken to a small room 50 meters from the Hospital where we were served breakfast and by 8 a.m. we were at the Hospital each day. The working day was quite organized and every day we had 20-30 patients there that we were seeing little by little and filtering to indicate the surgeries of the following day, taking advantage of the time between a surgery that ends and another one that begins. The workdays were interrupted by a 30-45 min lunch break in Dr. George’s office and then lasted until approximately 10:30-11 pm. Each day early in the morning we would visit the inpatients to assess for postoperative complications and discharge them.

There have been a total of 7 and a half days of work, including from Sunday, January 23 at 8 a.m. until Sunday, January 30 at 3 p.m. A total of 152 patients have been operated on to whom 185 surgical procedures have been performed, which can be grouped into: 109 inguinal hernioplasties (15% bilateral and another 15% reproduced); 20 umbilical / epigastric hernioplasties; three large eventrations, two of them associating abdominoplasty; nine giant goiters in which five total and four subtotal thyroidectomies have been performed; three splenectomies for giant splenomegalies; ten hydroceles; five cryptorchidectomies; one orchidectomy for testicular neoplasia; one radical hysterectomy and double adnexectomy for giant ovarian neoplasia; one right radical nephrectomy for a 25 cm tumor dependent on the right kidney; two cord cysts; 21 minor surgeries under local anesthesia (lipomas, sebaceous cysts, granulomas and keloids); and one hygienic surgery for the removal of a very advanced acral melanoma.

The only major complication recorded was the need to perform a temporary tracheostomy in a patient with postoperative dyspnea due to paresis of both vocal cords (both recurrent nerves had been preserved and there is an image record). In the rest of the surgeries we have had no major or minor complications recorded. The two surgeons at Jallahlone Hospital (Dr. Dahrly and Dr. Dwanna) have actively participated in most of the surgical procedures as assistants and we have tried to explain as much technical knowledge as possible. The collaboration of the nursing staff, assistants and anesthesia technicians of the Hospital has been excellent and they have made us feel very comfortable.

During our stay we have received the greeting of the “major” of the county of Gbarpolu and we have had audience with the senator of Bopolu, who have thanked us for our presence being the first international team that they have received and who have made me see that Peter George is a very well positioned person before the authorities and a reference of health in the region. I would like to point out that with the sponsorship of the United Arab Emirates a large Hospital is being built in Bopolu, which is very advanced and has all kinds of services, more comfort, more space and more operating rooms. The people in charge of the work, who are Lebanese, have been very kind to us and have invited us to have lunch one day in their facilities.

In short, Jallahlone Hospital is a perfectly prepared site for surgical campaigns and Peter George is an influential person, with great influence among his people and a great organizational capacity. It is to be hoped that many more missions can be held at Bopolu in the future, especially when the new hospital is completed. Overall, it has been a very hard mission from the physical and working conditions point of view, but all the members of the team have been very satisfied and satisfied with the work done and its results. The average cost per volunteer has been almost 2000 Euros per person, including flights, car transportation in Liberia, food and lodging.