General Surgery Resident Elective in Kumasi, Ghana
1
Sharita Nagaraj
1Department of Surgery, Robert Wood Johnson Medical School, Piscataway, NJ 08854
Introduction
Surgery has long been neglected in the global public
health arena 1, but evidence is accruing for the enormous
global burden of surgical disease 2. At the same time,
interest has been growing among both practicing and
future surgeons-in-training to improve access to surgical
care in developing countries. A national survey
administered to resident members of the American
College of Surgeons showed that 92% of respondents
would be interested in an international elective during
residency, and 85% plan to offer volunteer services during
their future practice 3. Several formal, structured
international surgery rotations have been implemented
within U.S. surgical residencies, and other fellowship and
volunteer opportunities for global surgery are emerging 4.
Preparation: The IHCV team transports all surgical
supplies – drapes, gowns, gloves, suture, instruments, mesh,
drains, etc. – and medications that will be required for the
mission. Residents are involved in packing for the mission
so they learn to anticipate equipment and supply needs for
various operations. These supplies are stored and inventoried
upon arrival and upon departure (seen below), with extra
items donated to the hospital.
Residents learn to ration these supplies for the expected
number of cases during the mission, picking only what is
necessary for each case. Certain items which are usually
deemed “disposable” in the United States may be reused
after chemical sterilization, such as bovie electrocautery,
drapes, and suction tubing.
KNUST hospital (seen below) is the main teaching
hospital in its region and a high volume
center providing medical, surgical, and
obstetrical services for over 200,000
people in 30 surrounding communities.
Two operating room theatres are available
as well as anesthetic, radiologic, and lab
services. Patients in need of ICU care are
transferred to the nearby Cape Coast
Hospital.
performed 6 inguinal hernia repairs, one in a pediatric
patient, 1 umbilical hernia repair, 4 skin and soft tissue
excisions, 1 thyroidectomy, and 1 laparoscopic
cholecystectomy at KNUST hospital. One laparoscopic
cholecystectomy had to be aborted to due lack of carbon
dioxide for insufflation. Our productivity was limited
compared to prior missions due to an unanticipated nurses’
strike which reduced the availability of operating room,
recovery room, and inpatient staffing, but we were able to
complete some work with the help of local volunteers.
Pathology: International electives offer residents
exposure to a broader range of pathology such as
hydatidosis, salmonella typhi intestinal perforations, and
advanced stage malignancies and hernias.
During our mission, inguinal hernias were the most common
pathology we encountered. Due to limited access to surgical
services, asymptomatic juvenile hernias, which are typically
repaired in Western populations, often develop into large,
chronically incarcerated hernias containing omentum, small
or large bowel, or bladder. They present a significant
surgical dilemma due to the loss of abdominal domain,
especially in Ghanian patients who have a thin body habitus.
We performed the majority of inguinal hernia repairs with
mesh, however local surgeons usually do not use mesh in
their repairs as it is a costly resource not widely available in
the country.
Background
In 2012 the General Surgery Residency Review
Committee implemented criteria for
ACGME approval of international general
surgery electives. The Robert Wood
Johnson general surgery residency
program has obtained this approval for a
PGY-3 or above to participate in the
annual mission with International
Healthcare Volunteers (IHCV) and each
year one of our residents has traveled with
the group to help provide surgical services
while learning about healthcare delivery in
a developing country. Here we present the
results of our two-week experience in
September 2013 at Kwame Nkrumah
University Of Science & Technology
(KNUST) hospital in Kumasi, Ghana.
Productivity: During the 2012 IHCV mission, we
Resident Clinical Experience: All surgical residents
participate in outpatient activities that include a complete
pre-operative evaluation of all patients who will undergo
surgery during the time period of the rotation. Outpatient
encounters take place in the OR holding area as well as in
the medical clinic when surgical consults are requested.
Residents assist with surgeries under the mentorship of a
U.S. board-certified or board eligible surgeon in
collaboration with local surgeons and staff. Lastly, patients
requiring an inpatient stay postoperatively are seen on
morning and afternoon rounds (seen below).
Sustainability: Collaborating with local surgeons (seen
above) and staff ensures that mission efforts offer continuity
of care for patients, who follow-up with local surgeons, as
well as sustainability of the effort as local surgeons learn
new techniques such as hernia repairs with mesh and
laparoscopic approaches. Local surgeons also offer their
experience working in a limited resource setting, relying on
clinical acumen for diagnosis in the absence of advanced
laboratory or radiologic services, dissection without
electrocautery, and creative but effective solutions such as
using foley catheters for drainage when surgical drains are
not available.
Conclusions
Surgical residents gain considerable benefit from
international electives in developing
countries. These electives teach
residents cost-effective management,
basic surgical technique, improve
clinical acumen, and introduce them to
the world of global public health,
where surgery is increasing its
presence as an important issue.
Future efforts can be expanded to include bidirectional
exchanges and training of local
surgeons to improve access to surgical
care. Challenges include a lack of
political and economic support for
systems improvement but can be
overcome by collaboration between
non-profit governmental organizations
and ministries of health, as well as
increased support and funding from
international health organizations.
References
1. Farmer PE, Kim JY. Surgery and global health: a
view from beyond the OR. World J Surg
2008;32:533-6.
2. Ozgediz D, Jamison D, Cherian M, McQueen K.
The burden of surgical conditions and access to
surgical care in low- and middle-income countries.
Bull World Health Organ 2008;86:646-7.
3. Powell AC, Casey K, Liewehr DJ, Hayanga A,
James TA, Cherr GS. Results of a national survey
of surgical resident interest in international
experience, electives, and volunteerism. J Am Coll
Surg 2009;208:304-12.
4. Leow JJ, Kingham TP, Casey KM, Kushner AL.
Global surgery: thoughts on an emerging surgical
subspecialty for students and residents. J Surg Educ
2010;67:143-8.