The BFIRST team travelled to Georgetown, Guyana 22nd-28th January 2025 and were based at the Georgetown Public Hospital Corporation (GPHC). Our goals before embarking on this trip, were to nurture relationships with surgeons in the Caribbean, introduce microsurgery techniques to the surgical teams in Guyana, teach and train local surgeons and help to establish a breast reconstruction service in the country.
Date: January 2025
Lead: Mr Maniram Ragbir – consultant plastic surgeon Newcastle Upon Tyne NHS Foundation Trust Hospitals, past president of BAPRAS
Dr Shilindra Rajkumar, plastic surgeon from GPHC, worked with his team to coordinate this visit with patients for surgery across four days.
The cases we planned to cover involved the following topics:
- Microsurgery
- Breast / chest wall reconstruction
- Latissimus dorsi flaps
- Pedicled TRAM flaps
- Free DIEP flaps
Visiting team members:
- Mr Maniram Ragbir – consultant plastic surgeon Newcastle Upon Tyne NHS Foundation Trust Hospitals, past president of BAPRAS
- Mr Naveen Cavale - Consultant Plastic and Reconstructive Surgeon at King’s College Hospital and Chairman of BFIRST
- Dr Rajeev Venugopal – consultant plastic surgeon and plastic surgery training program director, University of West Indies Hospital, Jamaica. Secretary of CAPRAS.
- Dr Stephen Romany – consultant plastic surgeon, Port of Spain General Hospital, Trinidad
- Dr Sarah Lonie – consultant plastic surgeon, Royal Prince Alfred Hospital, Sydney, Australia (previous Newcastle Upon Tyne Microsurgery Fellow)
Day-to-Day Report
Wednesday: Arrival
The team began to assemble in Georgetown, Guyana. We made a short visit to the hospital and had dinner hosted by Dr Rajkumar, which provided an opportunity to discuss the project’s goals and plans for the upcoming week.
Thursday: Planning and patient assessment
The first challenge the team faced with equipment, was that the microscope, donated by Newcastle Upon Tyne NHS Trust, did not arrive this morning as planned. We investigated the neurosurgery microscope, but this had limited lighting and magnification so we found the ophthalmology microscope to be a better alternative, despite requiring foot control and only allowing for a 90 degree assistant view. This microscope still required the hospital staff to build an additional platform, within a matter of hours, to ensure it was positioned high enough to be above the operating table intra-operatively.
The day was dedicated to preparation, we met with theatre nursing staff who would be with us for the upcoming four days and ensured microsurgery and other instruments brought from England would be sterilised and available for necessary cases. The team met all the patients scheduled for surgery over the next four days. We reviewed scans and finalised surgical plans to ensure optimal outcomes. We also met with the hospital CEO to discuss the scope of the visit and explore the long-term goal of introducing and sustaining microsurgery in Guyana.
In the afternoon, during the hospital’s Grand Round, the team presented the projecty’s objectives and discussed the complex cases planned for surgery. This helped to raise awareness amongst general surgical colleagues about the availability of breast reconstruction and importance of considering aesthetics when planning scar placement. Professor Vijay Naraynsingh, general surgeon from Trinidad, also attended the grand round and helped to highlight important learning points from each case.
The day concluded with a formal hospital welcome dinner, with the team and local staff.
Friday: First day in theatre
The first day of surgery had two operating theatres running simultaneously.
In one theatre, we treated a 14-year-old girl who had sustained a devastating boat propeller injury to her face two months earlier. We performed the first-ever anterolateral free flap in Guyana, which was also the first microvascular anastomosis completed by a Guyanese plastic surgeon. For the two veins both sutures and a coupler were used and we were grateful for the equipment provided by Mercian for microsurgery instruments and Gem for the coupler sets.
In the second theatre, two patients underwent unilateral pedicled extended latissimus dorsi flaps for breast reconstruction. These procedures were important in providing local surgeons with hands-on experience and consistency to upskill in these reconstructive techniques.
Saturday: Second day in theatre
The team continued to focus on breast reconstruction across two theatres, with a combination of free and pedicled flap techniques.
In the first theatre, Dr Rajkumar raised a free DIEP flap for a delayed reconstruction, under supervision and assisted in the anastomosis. The theatre nurses were excellent, having learnt from the first day about the microsurgery equipment and process. This case was followed by Dr Rajkumar being taken through a unilateral pedicled TRAM flap reconstruction, to complete the variety of local flaps available for breast reconstruction.
In the second theatre, the focus remained on pedicled extended latissimus dorsi flaps, with two patients undergoing these for reconstruction. These procedures provided further training opportunities for the local surgical team, reinforcing the programme’s emphasis on capacity building.
Sunday: Addressing challenges
We faced an unexpected challenge when the ALT free flap performed on Friday showed signs of compromise. Upon returning the patient to theatre, we found a twisted vein that had compromised the flap. Given the damage, and the need for a successful, well healing flap by the time we left in two days, we decided to raise a new flap from the contralateral thigh to ensure the best possible outcome for the patient. Another ALT flap was raised and anastomosed to the same vessels seamlessly this time.
In the second theatre, a patient with a chronic wound from osteoradionecrosis of the chest wall underwent reconstruction. Due to significant vessels damage in the region of the subscapular axis on CT angiography, we opted for a contralateral pedicled VRAM flap. This was useful to demonstrate the versatility to local surgeons of the VRAM, superiorly or inferiorly based, or pedicled TRAM for local flap reconstruction.
Monday: Final Day of Surgery and Teaching
On the final day, we performed the first right-sided microsurgery case in Guyana, another unilateral delayed DIEP. This required adjustments to the microscope’s positioning, to allow an assistant to view through the 90 degrees lens. A technician from the ophthalmology department was able to troubleshoot this for us after some time and move the eye piece to the opposite side. Despite this challenge, the case was successful, using the last 9-0 nylon suture in the hospital.
Following this final case, we demonstrated the use of chicken models for local surgeons and junior staff to train in microsurgical skills. This will allow them to continue to refine their techniques and gain confidence in microsurgery. The day ended with a final ward round, during which we reviewed postoperative patients and discussed ongoing care with the local staff.
Future Directions
The visit concluded with a shared sense of accomplishment and a clear vision for the future. We discussed the potential for collaboration with surgeons from Jamaica and Trinidad, as well as the development of a Caribbean training program for plastic surgeons, potentially through the University of the West Indies.
We also identified the needs for future trips. Firstly, a day of lectures, teaching and microsurgery skill practice before operating would be a valuable addition. Secondly, we would also like to expand the team on future visits by including a scrub nurse and allied health staff. Thirdly, we faced challenges without our usual equipment and compiled a list of finer instruments, that would make cases smoother for us and trainees learning in Guyana. Finally, we identified a useful area of focus for future visits as orthoplastic lower limb and trauma cases.
The success of the programme was due in no small part to the exceptional coordination by Dr. Shilindra Rajkumar, whose efforts ensured that every aspect of the trip was meticulously organised. We left Guyana with new friendships, shared knowledge, and a commitment to supporting the growth of plastic and reconstructive surgery in the region.