Opportunities forsurgical trainees:project hernia in GhanaDavid Sanders, Francis Oppong and Andrew Kingsnorth, Department of Surgery,Derriford Hospital, Plymouth, UK

Surgical training is currentlyundergoing major reformswithin the UK. The aims of

these reforms are to provide astructured training programmethat allows the trainee to dem-onstrate clinical and surgicalcompetency.1

With clinical governance andpatient safety as an integral partof clinical practice, the age-oldadage ‘see one, do one, teach one’is, rightly, no longer acceptable.This presents a hurdle to traineeand trainer alike as experientiallearning is reduced. In addition,reduced theatre time for traineesand increasing performance pres-sures for consultants mean that itis difficult for trainees to learn

operative surgery in a structuredfashion, on regular theatre listsand on a regular basis. Theseproblems are mirrored to a lesserextent in the USA.2

For surgical training, repeatedexposure under supervision isimportant. Opportunities for thiskind of exposure are increasinglyrare within training programmesand in the current climate of theNational Health Service. There areopportunities, however, in Britishand European-based projectsoverseas. This paper details onesuch surgical trainee elective,funded by the Association ofSurgeons of Great Britain andIreland (ASGBI), in Takoradi,Ghana.

OPERATION HERNIA: THEPROJECT

As in much of Africa, the Ghana-ian health care system is fragileand hanging by a thread becauseof lack of staffing and resources.3

The incidence of inguinoscrotalhernia is significantly higher inGhana than in the UK. Surgery isperformed only on a minority ofthese individuals and the compli-cation rate is high compared withthat in Europe.4 This results inmany longstanding hernia with ahigh incidence of emergencypresentation and morbidity.5 Inmany cases, this prevents work,with a knock-on effect on thelocal economy.

‘See one, doone, teach one’is, rightly, nolongeracceptable

Practicalteaching

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To facilitate managed healthcare in a sustainable fashion, theEuropean Hernia Society, Plym-outh Hospitals NHS Trust and theMinistry of Defence Hospital Unit(MDHU) at Derriford Hospital,Plymouth has set up a link withTakoradi Hospital in Ghana. Afri-ca’s first ‘Hernia Centre’ has beenopened in a disused wing of thehospital. This has been fullyrefurbished, over the past year, to‘European standards’ using fund-ing donated by the British HighCommission and corporate spon-sorship. The Centre will providea base for the delivery of herniaservices in the west of Ghana.

A 2-year teaching programmehas been formulated, tailored tothe needs of the local surgeonsand nurses to develop anintegrated team that will initiallydeliver up to 50 hernia repairseach month. It is planned thatthe Centre will be supported bystructured visits from surgeonsand nurses based in Plymouth, theEuropean Hernia Society and anyother volunteers wishing tosupport the link.

THE TRAINING EXPERIENCE

This project represents a human-itarian effort and it is importantto ensure that the highest possi-

ble standards of care are beingintroduced. With this in mind,these structured visits providefantastic learning opportunitiesfor surgical trainees, in additionto providing a valuable service tothe local community. Repeatedexposure over a concentratedperiod of time can be achievedand there is continuity betweenthe trainee and the trainer.

In October 2006, two surgicaltrainees, one from the Nether-lands and one from the UK, joinedfour consultant surgeons from theEuropean Hernia Society andDerriford Hospital, Plymouth(pictured in Figure 1 with the restof the team). Both trainees hadcompleted 3 years of basic surgi-cal training in their respectivecountries. The trainee from theNetherlands had done six and thetrainee from the UK 32 inguinalhernia repairs, as first surgeons,before this assignment.

For the project, prospectivepatients had been examined andselected by the local surgeons inpreparation for their operation.The patients were mostly fityoung men, with some havingadditional pathologies. Operatingwas carried out on 6 days out ofthe 8-day visit and a typical listconsisted of five or six inguinal

hernia repairs. In total, 141inguinal hernia repairs wereachieved and 13 other operations,made up of a mix of incisional andfemoral hernia repairs, the occa-sional laparotomy and one emer-gency caesarean section. Onepatient suffered a postoperativehaematoma, which resolved withconservative management, but noother complications werereported.

The operating theatres werevery basic; nurse anaesthetistsprovided anaesthetic support, andall instruments were steam steri-lised and were of a very oldvintage. Mesh was easily intro-duced and accepted, but costremains a significant problem.All materials used by the visitingsurgeons had been donated byPlymouth hospitals or industrybefore arrival in Ghana. It ishoped that, with corporate fund-ing, there will be a continuoussupply of mesh and equipment tothe centre.

During the 8-day visit thetrainees had the same level ofsupervision as they would havehad in their home hospitals. Eachtrainee assisted with severaloperations and performed 26 asthe first surgeon. The traineesdiscussed all cases postopera-tively with the consultant trainerand feedback was given.

The trainees conducted aresearch project comparing the‘African’ and ‘European’ hernias,using a standardised scoring sys-tem for the size of inguinoscrotalhernias;6 205 consecutive ingui-nal hernias in the UK were com-pared with the 141 inguinalhernias repaired during the pro-ject. The results showed a statis-tically significant difference, withthe ‘African’ hernia being threegrades larger on average thanthose in the British group.The results of the project are duefor publication in the near future.In addition to the surgical learn-ing experience, trainees were

Figure 1. Project Hernia 2006: The Team.

Thesestructured visits

providefantasticlearning

opportunitiesfor surgical

trainees

All materialsused by the

visitingsurgeons hadbeen donated

34 � Blackwell Publishing Ltd 2008. THE CLINICAL TEACHER 2008; 5: 33–35

exposed to a health care systemthat differed from that in theirhome countries and had anopportunity to work as part of a‘hernia team’, made up of expertsfrom the European Hernia Society.Although not formally evaluated,both trainees reported a hugegain from the project, in terms ofboth technical skills, transferableto their home countries, and lifeexperience.

CONCLUSION

Training opportunities in opera-tive surgery in the current climateof the NHS are limited. OverseasEuropean projects provide theopportunity for surgical traineesto acquire surgical competence ina high-exposure, but supervised,environment. Scholarships such asthe Overseas Surgical FellowshipFund from the ASGBI are availableto help trainees fund theseelectives.

REFERENCES

1. Royal College of Surgeons of Eng-

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Learning and teaching. London:

RCSE, 2006.

2. Sanfey H. General surgery training

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3. Shafqat S, Zaidi AKM. Unwanted

foreign doctors: What is not being

said about the brain drain. J R Soc

Med 2005;98:492–493.

4. Wilhelm T, Anemana S, Kyamanywa P

et al. Anaesthesia for elective

inguinal hernia repair in rural Ghana

– appeal for local anaesthesia in

resource-poor countries. Trop Doct

2006;36:147–149.

5. Ohene-Yeboah M. Strangulated

external hernias in Kumansi. W Afr J

Med 2003;22:310–313.

6. Kingsnorth A. A clinical classifica-

tion for patients with inguinal

hernia. Hernia 2004;8:283–284.

Traineesreported a hugegain from theproject

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