Surgical skills needed for humanitarian missions in resource- limited settings Evan G. Wong, Miguel Trelles, Lynette Dominguez, Shailvi Gupta, Gilbert Burnham, Adam L.Kushner A four year audit of MSF data from 21 countries

Background Surgeons from high-income countries are interested in global surgery and humanitarian missions.

Background Knowledge of the surgical skills needed to respond to humanitarian missions is essential to:  Guide recruitment.  Build capacity of surgeons.  Plan for interventions.

MSF and surgery MSF is providing surgical care for more than 40 years; and between 2008 and 2013, 46 projects in 23 countries performed surgical activities. A global analysis of the kind of needed surgery was not performed before with data available in MSF.

In Sierra Leone, 25% of households reported a surgical condition needing attention, and 25% deaths of the households member in the previous year might have been averted by timely surgical care.

Objectives To review the surgical procedures at MSF-OCB facilities between 2008 and 2012 in order to ascertain: the commonly performed operations. the necessary surgical skills.

Methods Study design: retrospective analysis of standardized surgical databases. Study sites: OCB health facilities in 21 countries. Study period: June 2008 – December Study population: all patients who underwent surgery.

Indications for surgery Trauma  Violence  Accident Obstetrical  Foetal-Maternal  Post partum complications Non-trauma  Infection  Ischemia  Tumor  Haemorrhage  Other

Types of surgical procedures Minor Wound surgery Visceral Orthopaedics Gynaecology, obstetrics & urology Specialized surgery

Patient characteristics n (%) Total no of patients83,911 Average age (years)28 Children < 1 year 1 – 5 years 845 (1) 4,098 (5) Females48,575 (58) Total surgical procedures93,385

Indications for surgery (n=83,911)

Types of surgical procedures (n=93,385)

Commonly performed obstetric, gynaecologic, and urologic procedures Proceduren (%) Caesarean section24,182 (65) Instrumental delivery, episiotomy or perineal laceration 3,002 (9) Curettage2,462 (7) Hysterectomy, oophorectomy, pelvic tumorectomy 2,228 (6) Obstetrical fistula1,585 (5) Urological procedures1,354 (4) Ectopic pregnancy663 (2)

Commonly performed visceral surgical procedures Proceduren (%) Hernia, other anogenital9,873 (47) Bowel resection4,949 (23) Minor tumour resection3,316 (16) Exploratory laparotomy2,498 (12) Repair or resection of spleen, liver, kidney570 (3)

Commonly performed orthopaedic procedures Procedure n (%) Fracture reduction2, 945 (42) External fixation974 (14) Limb amputation841 (12) Internal fixation803 (12) Other (corrective procedure)624 (9) Internal fixation removal464 (7) Others281 (4)

Conclusions Over four years and in 21 countries: MSF-OCB performed about 100,000 surgical procedures of wide diversity. The most common surgical procedures included: Caesarean sections, hernia, bowel resection, and fracture reduction. One in fifteen patients who underwent surgery were under 5 years.

Conclusions All surgeons interested in humanitarian missions must have the surgical skills to manage the most common surgical procedures – but major human resource gaps ! Specific anaesthesia and surgical skills are needed to cater to paediatric needs – remains unaddressed ! MSF should advocate and directly invest in specific training programmes and capacity building to meet our humanitarian surgical needs.

Many thanks To the surgical teams on the ground, the Medical Department, LUXOR and the patients and beneficiaries of MSF