Dr. Seghers Speach
    Part_2 The Second Hour

    You see here the external corpus spongiosum the main erectile tissue is being
    drawn down. This is what gave me trouble because it's an erectile tissue, with
    strangulation it stops but it will have to be removed, because if you have too
    tight ligation it will die. And you see that there is another layer there
    that's the mucosa. So, the progress I had made at that time, it was possible
    to divide and to treat separately. Next Slide.
    You see now, maybe I should, well another time, to put both slides into
    different steps, but I think it's not at all certain so I don't have to
    explain too much exactly the different steps from a surgical point of view.
    You see that I am here busy with the cauter, the electric cauter, I use it but
    I don't like it too much, but I use it because it's a very useful tool. This
    is black now because that's the base of the corpus spongiosum which has been
    coagulated, burned, and it's becoming strong and it's possible to pass sutures
    through it. And there is another layer in the middle, just against the bladder
    catheter which is the urethra. And so I will use running stitches at 2 levels.
    At the deep level attaching this with dexon, some stitch which can be
    dissolved by reuters(?) and on top of that I will do a second layer of
    running stitch covering the first 1 and making very tight with the mucosa.
    That helps me, grieves me, not completely, since some progress has yet to be
    done and at the end of that the stitch, the still stitch, cannot be seen,
    strangulating the base should be removed. The next slide.
    You see now, it's almost complete. Again some blood, but I... Here's the 2
    layers with a running stitch around the delicate place of urination will
    happen after the catheter will be removed. I have ligated to the stitches some
    coagulating gel. We call it "gelcoag" and it's useful, but I'm not convinced
    that it's necessary. It's a coagulating jelly. It helps to make clots too. And
    the reason that is I sleep better because I did my best to stop the bleeding,
    because that's that's one of my main concern, a patient bleeding too much.
    First they don't like to receive blood, they're always afraid to get some HIV
    positive or non-tested or barely tested; they don't like that. But if they are
    too low with the red cells, the transportation of the oxygen is low, the blood
    rate is too fast and they don't feel well, like they cannot breathe and when
    they get up they pick out those pains because they don't have enough blood
    pressure, especially when they get up. You see also again the lines, the
    unique line in the middle which go inside. Maybe this flap, which I'm not
    doing since so long maybe some problem because in hairy patient they have some
    hair growth in the vagina, so maybe that will be a new field, a new area for
    electrologist.[Laughter] The first complaint I had by a patient was coming
    from that because I didn't let her know. Fortunately this was done in Belgium,
    so if it was in the United States, I would be sued in malpractice because
    there was hair in the vagina and I didn't let her know enough. In fact I
    didn't think of that, and I was stupid enough to just answer, "It's not bad,
    it's like a kiss with a mustache." And she didn't like that so she... the
    letters became here angered.
    I have to find where I am now.
    Anyway we will proceed. It's almost complete. We still have a special. Next
    slide please.
    YES, I uh, we are not alone, I am not alone in the operating room. This is Dr.
    Lambert, the lady anesthesiologist who speaks well when she's not wearing
    that. She's not doing like that, no. She's preparing this machinery, it sits
    alone from the table. This is what we call in Europe, "a beastie". You
    certainly have that in the states but in Europe we call that the "Rolls Royce"
    of anesthesia. She doesn't have this operatus since too long. You see the
    patient with the tracheal administration, the IV running here which will stay
    in place for 3 days. Next slide please.
    You see another view, this is with a counter scope, this is an old type of
    system. This is my fault, it's twisted [the slide is revearsed], I didn't see
    it before. And the patient is in the gynecology position but with the head
    lower and the buttocks a little higher. Next slide.
    Yes, I see you maybe will recognize 1 circulating(?) nurse, you see the IV
    running and again doctor Lambert behind. And normally [in] the surgery the
    assistant is here. Next slide .
    Yes. This is what she had to fight to get this new, costing almost a Cadillac.
    This is very fancy, this is the best we can ever get in Europe, it is German
    made, but this is sometimes very confusing, because there are always some type
    of alarm which starts and we don't find any reason. Like airplanes, Eric, my
    pilot son says, sometime the alarm and what we do we cut the alarm, we make up
    reasons. Next slide.
    Here this is a view from the face of the anesthetist. And this is my favorite
    assistant who happens to be my wife. I am doing all surgery myself, but the
    cleaning and the dressing is the only thing that I'm not doing. It's almost
    complete. Eventually if you are in a good mood you will see that there is a
    dimple there where the long abdominal tissue are brought down. They complain a
    lot about that but they are so happy when they... when it's finished. You see
    the electrocoagulation, both legs being like that. These are sheets and paper
    that's used everywhere, now that they are thrown away after one use. The
    IV running. Next one.
    Yes, we are almost at the end, when we {spirably was idofoam}(?) inside. But we
    had to do some compression. Since there has been some bleeding, but we had to
    hold the wall of the vagina and packing inside, and I put some extra gauze
    here in between the lips. This is pushed inside and later on the 2 labia
    majora are tied together with strong stitches. This looks a little barbarious,
    but it's helpful because the bleeding becomes almost impossible, but not
    impossible. The next slide.
    You see that now here, both lips, that both lips are tied together with heavy
    stitch which will stay in place for 5 days. They will be removed, they will be
    removed 1 day before leaving the hospital. 1, 2, 3, 4. This is the place about
    the place where the patient will urinate later on but both lips are tight,
    both lips are tied together. The vagina will be here, and the anus here. You
    see with an infection possible, we try patient not have to have a bowel
    movement for 4 or 5 days. And when it's almost ready we give an enema to
    separate but I'm always amazed though it's not going worse. You see here on
    top, something I do, I do since not too long, because from time to time I had
    patients having bleeding 2 or 3 days after surgery and blood was coming in
    front between the 2 labia majora, despite the fact that it was tied. And now I
    am putting small dressing on top between the lips. This is something easy to
    say, easy to do, but what you have to do to judge the amount of pressure you
    will do, because if you don't push enough, you will have some bleeding. If you
    push too much, certainly no bleeding but you will get necrosis and the inside
    of the lips could die. You could have laceration, I've seen that. When
    patients have that I used to put red ointment on top of that so they don't see
    the difference. Next slide.
    So, this is, this is finished you see. There has been some cleaning after when
    it's finished. That's the last push I did that's in front, that's behind. 2
    silicone tubes which will be removed after 48 hours. You see here's the
    typical compression to avoid bleeding. That's meaning to have silicone tubes
    going to here and there. Yes that's true but it's worse you have to choose,
    bleeding inside or bleeding outside. Bleeding outside is not as bad because
    you can see that when it's running across the floor of the room. Then you know
    you have something to do. Otherwise I will show you a slide, where there was
    no bleeding outside, but diffuse bleeding all around the pelvis with some
    hematoma and this takes time to be it's over so it's blood lost, the same as
    it was before. The blood is thick beneath the skin, it still works but it has
    to be digested and removed. This is seen to be a kind case. Next slide.
    Yes, this is at the end of the procedure you see sometimes it's like after the
    corridine(?) in Spain, you get the ears and the tail and so on. [slide shown
    is of testes and corpus cavernosum]. Both testicles with part of the cord,
    which I cut and ligated. Sometimes for Belgian patients with the social
    security paying, I want always to have some microscopic examination of the
    testicles to prove that they were not working. But other patients without
    Social Security it's just useless money that is thrown away. This is some of
    the shaft of the penis as you can see it's cut to short since the base was
    kept as a clitoris. You see the glans which is discarded. A small amount of
    skin, scrotal skin; it's bigger than it looks, but it shrinks so it's bigger if
    you look. But after that you can expand that certainly 3 times. Next slide.
    That's after surgery. The patient has been in the recovery room, they are not
    going back in their room. They stay where there are 3 or 4 patients for 1
    nurse being used. They can get some oxygen, they can take some blood pressure,
    they can have {sectional gas}(?), and they are checked real close. They stay
    there for 4 to 6 hours. This is in the new facility. Certainly also an
    improvement. Next slide.
    That will be the last box I think.
    Question from the audience:
    **A** Dr. Seghers, for patients who come to your clinic, can we have our own
    blood sent?
    Reply From Dr. Seghers:
    Normally not, and Dr. Lambert, the lady, normally blood transfusions are the
    responsibility of the anesthesiologist; and she would refuse to inject
    something that she wouldn't have taken [drawn] herself, because it can be
    under the sun or exposed to something else, or she will never be sure that
    it's really your blood. But I have to say it's so, so that's not accepted.
    It's rather uncommon to give blood transfusion. It happens, I must say, about
    1 case out of 20. It's not usual.
    Question from the audience:
    **A** Where is the clitoris?
    Reply from Dr. Seghers:
    Yes, the clitoris is still subcutaneous. The base of both corpus cavernosum
    were attached together. This makes kind of a small hill like that and it stays
    subcutaneous. It can be felt with a finger but it cannot be seen. Eventually
    after secondary surgery it can be a little put through the skin but normally
    it is not at the first surgery. But I think that in that field some
    improvement has been done too.
    You see at least the 2 catheters, the 2 silicone tubes, already are still in
    place. This means that we are two days after. Because you see that the suture
    strength closing attaching both lips together are behind the place where she
    will urinate, not in front.
    Where I've had from time to time some prolonged bleeding and now I don't do
    anything with it. In this case this was perfect. It's not too long, some
    hematoma, but not too much. And at this time, this is rather clean case, some
    blood here behind going to, near the anus and the rectum, that's why some have
    after surgery, especially not the younger but the other one, some problem with
    the hemorrhoids. They complained a lot because they've swollen from pushing a
    little around the anus. And these will reform there, they can suffer from
    hemorrhoids. So the tubes will be removed. Next one.
    This is to show where it is better to have external bleeding through the
    catheter but sometimes you see how it can be a huge amount of blood, but I
    don't think the patient has received any blood transfusion, but this, I'm
    sorry for that if some blood lost and even the body has to digest that.
    If you move it this will disappear in 2 weeks, but it has to take time and it
    can become infected even if it's going alright it can leave some blood
    disruption that can break through.
    Another problem with that new camera I use it that you see I use this for
    making pictures for a 40, 45 centimeter and it is difficult to judge to just
    what I want to have. Just in the the midline, not out of focus, just out of
    center. Next one.
    Another case you see, it's going very well. You see the dimple where its
    attached the lower abdominals tissue. Attached down. Sometimes, it goes more
    than that. Depends on my mood or what I ate for breakfast. See, this is on day
    5, 1 day before leaving the hospital. This is very well, this is a little
    above average. And this both labia majora will be separated and you will see
    beneath that the packing from the vagina which in the mean time has changed
    color. Now it's become brown with old blood, but that blood already lost. Next
    Now you see the stitches have been severed. I must say about 3 or 4 days, the
    patient being tied with both lips tied together they start to complain and
    they are so happy when the stitches are cut, so they feel hope. Their hope is
    increasing and from step to step each time something is improving, they are
    happy, they accept that. You see the entrance of the vagina with some of the
    packing has been already removed. It's brown now because it's old blood and
    the smell is soon to be very poor. But there is nothing wrong. And here is the
    place where you see urine, where she will urinate you see the "gelcoag"
    coagulating jelly, which is a little brown, which when old it looks like
    intestinal material. I always tell patient this is a special special jelly
    that I have put and this is not intestinal fistula and we know sometimes they
    are terribly afraid pieces are falling. Next slide.
    Here's another case. You see this time the jelly is being removed. You see,
    the blue stitches, which is nylon for the running stitch external. There's
    another running stitch with dexon deeper. You see the white stuff there, this
    sometimes some patient refuse... About one third of the patients refuse to
    look. I said they will look, maybe and I will be there but it's not a good way
    to do it. Another third, they look when I tell them to look, the other third
    they are looking almost all day long. The white stuff there is some excess
    mucosa, the mucosa are in the depth around the catheter. This thin layer (the
    mucosa) of the urethra but I attached around with a ????. I keep it a little
    too long, and there's some excess tissue which dies and which will fall and
    sometimes patient are a little anxious, you see they are tissue is white and
    white means pus, but it's not that. Just an excess mucosa you see here still
    the packing in the vagina. In the good case when you separate the lips almost
    all packing is staying inside. It's not always the same. When patient's
    coughing you hold your perineum, especially with woman, and it pushes, bulging
    everything out. So they have a tendency to lose their packing. Or if they have
    a bowel movement or some kind of tendency to have diarrhea which we have after
    4 or 5 days with the anesthetic. And if they lose the packing a little too
    early, it's not good either. But, sometimes it's difficult to do... Another
    way I used to put some large dressing on that and to explain to patient to
    hold with their hands for a few more days to keep everything inside. Next
    slide please.
    Yes, this is you see already, 1 stitch out of 2 from the lips has been
    removed. I used to do that in my office on day 8 or so. Eventually after that
    they eventually can fly home. Because the main part is done. You see the gauze
    packing has been done, from time to time. And I first start the patient with a
    plastic holder with plastic dilator to feel inside. Normally the question
    about the clitoris you can see that it's supposed to be here supposed to be
    subcutaneously, and again you see that the anterior ends of both lips are too
    separated, which is not ideal but cannot be... We cannot do a lot with this on
    the main procedure. This is a delicate place where I instruct patients if you
    have fresh blood, red blood coming out, you don't have to let it run, you don't
    have to put thick dressing either because this is just to absorb and you lose
    your strength. You just put a small dressing here around, and to do
    compression for 3 minutes without removing and this always stops. Next slide.
    After that, patient will be have to continue... This is another case.
    Sometimes it's not very clean but it doesn't mean that we run in trouble. You
    see a few stitches have been removed but this is not very clean. This is not
    clean feeling, but when we consider that the anus is there, it's not a real
    problem. It could take some more time. In that case we need some more
    antibiotic through the mouth.
    You see the place where she urinates now since the bladder catheter has been
    removed. Some crusting, but this is going in a good direction. But that's
    not the clear[est] case that I have. Next one.
    Yes, this means, sometimes I realize that it's presented to patient as being a
    one stitch procedure, in fact it is for the main part with 3 forms; removal of
    the testicles, penectomy, vaginoplasty. But in most of the case it was a
    little incorrect or at least which could be improved later on and especially
    for perfectionist patients who know now with disposal, they know how it could
    be and so they learn, I guess, some improvements can still be done and since
    they are asking, demanding from the best. They, more people, more patients are
    requiring to have the best possible, because they know now it's available. So
    I, normally it's supposed to be one stage surgery, but sometimes a question of
    the z-plasty that we will see. Next slide please.
    This is another appearance of another patient not yet with z-plasty. This is
    sometimes the labia majora are a little too thick. They hang a little too
    much, I know I have a tendency to let ???? on this before. To let too much
    tissue because as surgeon I want to keep the maximum possible, and not to
    throw it out. Once it's removed it's removed. Some remaining excess can
    eventually be trimmed to width later on or be used to make some kind of labia
    majora. But now I know if I remove a little more than this because some are
    complaining and more patients complain between each other. They know how it
    should be. Some patients don't know exactly, so everything's well. So, Next
    I think this is an old case without the posterior perineal flap because you
    see its a little close there sometimes. This is penile skin with some
    extrusion and sometimes a split is done there to increase the entrance. It's
    not a bad result. It was so before, and thus we achieve the maximum depth
    possible. But this slide, still with the leg room is to show that the 2 labia.
    That's anterior, that's posterior. That's amazing. The umbilicus is there. But
    the place where she urinates is here, but you see that the 2 are ended up
    separated. But you see in the middle the blood supply going to the vagina
    which is important, to be built, is running, and for me it's a normal plan. I
    know some surgeons, they go to cut a little more in the midline but from time
    to time they have complete failure of the vagina. I have a short vagina from
    time to time, but complete failure I don't think ever. But at my age, I could
    have forgotten. Next slide.
    This is a view still the same case you can see from the inside of the vagina
    which is good depth in this case. The union, another difficult thing, I told
    you earlier is sometimes difficult to put the urinary opening just in the
    middle. We have also the tendency to put the urinary opening a little too much
    forward. And so that patient, they still when they sit they urinate a little
    too much in front, they have to bend to have a direction down, this is also
    something difficult. Because during surgery to avoid trouble, we should put
    the urinary opening almost at the entrance of the vagina. That's for later on
    to have the best result, but during surgery, it's difficult. Next slide.
    This is a sketch to illustrate the z-plasty procedure. You see the urinary
    opening, the vagina behind, the 2 lips with here the stitches, they are
    removed at that time and you they are too separated. It's possible to make 2
    double-zed z-plasties. This is like this here, here, that's 1 "z". The other
    1, that's 1, 1, 1. 3 legs and you see they are 2 triangles with the anterior
    end of the labia majora which are separate and they will be crossed. This and
    that will be attached inside and that will be doing at the other side. And so
    again at the end result you see the same position but, this is going inside,
    it's attached as it should be, the primary vulva is closed in front, both lips
    are going attached together. This makes a little more scar in the area of the
    pubic area, but it's not the same... It's not a problem, but this is leaving a
    good improvement in particular you see this can be done, in my opinion, 6
    months after the main surgery. 6 months or later. There's no urgency for that.
    Most patients are now becoming aware that it's possible to do and at least
    with the ???? case it's easier for those to come back to Brussels and this is
    earning now about 10% of the patients. Sometimes in combination I told you
    that one needs to wait and the pee hole can be brought down, some split can be
    done behind, some minor things or they come to have breast implants at that
    time or to have a tracheal shave at this time of secondary revision. But it's
    not an obligation or necessity, and this can be done back in the states. Next
    You see a real case now with the entrance of the vagina. You see that the
    urinary opening again a little too far away, but will be split and enlarged
    backward. And here the z, 1 leg, the other 1 leg. And these 2 parts are the
    anterior ends of the labia majora will be attached together. Maybe you think
    and I think when I see this slide that the entrance of the vagina is a little
    difficult, but you have to realize that these pictures are done when the
    patient has the thighs flexed which is not always the [best] position. So when
    the legs are hanging, going at the same level, it becomes hole open. Next
    This you see at the end. This is the stitches. Staring straight forward at
    that front sometime. This is the entrance of the vagina there are are stitches
    and I am certain that in this case when I touch that I used to put for 2 or 3
    days there a bladder catheter because this is an absolute dangerous place
    where you can get bleeding. Next slide:
    So not an end result, but after certain healing at the time you can see the
    stitches here at the place where she urinates, but it's a little longer on the
    left. You see the new scar, here they had scar before but that's a small
    increase of the scar in the pubic area. You see that the hair growth is coming
    back again. When there is excess skin on both sides of the entrance of the
    vagina, if you have a good imagination, you can think this can form some kind
    of labia minora. Next one.
    Here's after the removal of the stitches. Here is what I do about the question
    about the clitoris. I use, this is some button, some little that I do there,
    some exteriorization of what's left from the base of the corpus cavernosum.
    I'm not complaints it always survives, but it helps and it can get some
    feeling. This is still a little red but the color always improves in time. The
    next slide.
    Another case with early patient, because early case with some high legs, too
    much labia majora, sometimes an excision can be done. This is a chance to see
    the entrance of the vagina with a split you see how it can move not far away
    from the anus. The next one.
    This is again an early case. It looks as the vagina is closed, but it is
    because of the position of the table. Anyway now it's not never any more like
    this because this kind of a strong hymen, and eventually this lady had to see
    a surgeon if she want to have intercourse with somebody. The place where she
    urinates, that will be like in the midline. Next one.
    Which is maybe I'm not sure in the same place but the same procedure. But you
    see here it's not because it's closed here, with a kind of very strong hymen,
    that you see there was a vagina already though, just the entrance was a little
    difficult. They were hurt to be done. The place where she urinates, this is.
    Yet I didn't do z-plasty at that time. This is the place where the top of the
    clitoris. The next one. We are almost at the end.
    Another one healing. You see when it's open, you see well. The entrance of the
    vagina not sometimes its not going to be ???? but at least it's something. The
    stitches will be removed. Next slide.
    Yes another one I modified something inside. It happens. This means that I
    don't say that I have always the ideal result, it's certainly not at that
    time, maybe even now. You see some increase of the skin. Next one.
    This was not long ago there was some bleeding at the clitoris which when I was
    done it was a maxi clitoris. But I think I suppose it will, that they will
    have a result which is a little big. See the entrance of the vagina with some
    split which had been done. This is already with the posterior flap going
    inside. OK.
    Yes, a secondary ancillary procedure that I do very gladly. It's a tracheal
    shave. Patient lying on her side with a prominent trachea that I refused to do
    that at the time of the main surgery. But sometimes when the patient really
    requires, and sometime they demand it or after surgery. If they are well, if
    they didn't have too much bleeding that they didn't use too much pan killer,
    that they are eating well and not complaining, I accept to do it under local
    anesthesia before leaving the hospital. This is the a case done under general
    anesthesia. Some kind of secondary revision. Next slide.
    This is something very easy because now i am doing as a plastic surgeon. The
    scar, a shorter scar just at the place where you see the prominent tracheal
    capillaries. Before, in my early cases I found it more clever to do it high
    just to be concealed between the maxilla. But this was a tremendous burn, and
    the incision had to be much longer and sometimes it can be seen. So, this was
    just to complicate the life of everybody. You can see now with some
    orthostatic organ and the calculator [a calculus (bone) shaving instrument] in,
    and it will removed with a poxilla(?). Next one.
    This is the .... I don't know how you call this instrument, it's to take
    small piece of cartilage piece by piece. Next one.
    Then closure in two or three layers usually. Next one.
    Some pain when it's finished. This case was done under general anesthesia but
    the first was combined with some other procedure. Next one.
    Yes you see, this was one of my nice looking patients. When you see, she was
    an Italian, she was wonderful. And sometimes I believe the best, the nicest
    looking woman they are men. But even when you look down below in examination
    (Next one.) you see they look competely like a woman, but I would see that she
    was a woman but in fact she was a pre-op, she didn't yet have her surgery
    done. So...
    POOR RECORDING (indistinguisable sounds due to low batteries)
    Next one.
    Next one.
    Next one.
    Some others are very are very dangerous, some maybe look maybe funny, but I
    sometimes, I am also in trouble. Before surgery complications, it happens and
    few examples. You can miss your plane or your connection at Kennedy Airport.
    It arrives and you arrive and there is snow or fog and the airport is closed
    and then you decide to arrive at the last minute, then you are too late.
    Luggage lost at London airport or at Amsterdam, it happens. It usually happens
    that after one or two days you get your luggage. Don't put your travelers
    checks in your luggage. I recommend all your money, passport, travelers
    checks, ....
    POOR RECORDING (indistinguisable sounds due to low batteries)
    Sometimes people change their mind. And 3 days later she calls me back and
    say's "Oh yes would you do the surgery?", I said "NO, "If you change your mind
    just before, I will not change mine." "And I will accept to do it but you have
    to go back home and to be checked by your psychiatrist and ask new advice, I
    can understand that you can be afraid being alone maybe too much". Some
    patients are arriving in Brussels, they have never fly before. When flying on
    business, I am always amazed by the courage of many of these patients.
    Some patients arrive sick, they catch cold, they catch flu, especially when
    they go in Germany. They're sick during the night, those who smoke 4 packs a
    day just before surgery they smoke more and more. And they have a tendency to
    get bronchitis or a new bout of asthma.
    I had chance of another experience with patient who was so excited to be with
    surgery she was during the night in a discotheque and she was involved in a
    fight and brok an ankle. It's not Brussels, it's a safe city, certainly
    safer than most than most U.S. cities but at 3AM anywhere, I think anything is
    possible, especially in a discotheque.
    I have, I receive some kind of phone call from a lady, from a friend canceling
    surgery for somebody else. I said that normally I don't accept that patient I
    had to call myself, but then since I didn't meet them before, I cannot check
    this ever. I canceled the operation because I had, I had a phone call and on
    the day, on the date the patient appeared, I said no, I never called you.
    Maybe yes, it was somebody who didn't like you has the surgery done and wanted
    to cancel it without letting them know. So many there are too many
    I had just somebody a girl who was ready to have the surgery done and she had
    a phone call from home telling that the ex-wife had put fire to the apartment
    or that everything had being stolen from the apartment and the apartment had
    been moved. All kinds of surprises, more for the patients than for me but
    sometimes it's not easy time, and as I mentioned I did a few patients that I
    refused I don't accept, I don't confirm that the surgery can be done at that
    time. (Dr. Seghers now addresses a former patient in the audience - April) At
    the time of the last check in my office. But you must say that you have passed
    the first check and you have been in the hospital and it was canceled the
    morning of the operation after having received a shot for pain for preparing
    for anesthesia. It was a surprise for me but something a making a high peak of
    temperature after that injection. This can just happen for a few hours or it
    can be the beginning of the sickness of several days. So, it's difficult to
    judge that but I think I judge that well since you stayed sick for several
    days. So, I had made the wrong move, the right move.
    I remember another patient being about 60, and so she had difficulty to
    breathe she was very tired from trip that she was coughing all day long. She
    cigarette after dinner, I said I think didn't refuse her but I told her that
    the anesthesiologist would refuse her. And she said "Yes, maybe I shouldn't do
    it and at last I'm happy to have come just before surgery even if it was not
    done". That lady died 1 year later without having her operation. She died in
    Las Vegas. She was well known because she appeared in the movie about a gender
    person done some years ago.
    I had another surprise, a patient arrived from California. She said "Yes
    doctor, I had some surgery one month ago". One month ago it was twenty eight
    days and this was major surgery. She was opened from here to the pubis because
    she had a double bypass of the coronary artery. She said "I had that done
    before". And yes but so. And so it was canceled. So she came 6 months later
    and she had the surgery done.
    This, all the questions which can happen. Now the questions about the AIDS
    test they are checked and not too long ago I had at last a proof that somebody
    had lied to me or arranged to fake, a fake result. I was not too happy about
    that and the position of us and with the agreement with the nurse in the
    hospital staff at the hospital is that it could eventually be done but
    everybody has to know in advance that there is a risky patient and that some
    more precautions should be done. And in my opinion our AIDS / HIV positive
    they should keep their strength to stay well even they can be well they can
    stay well for several years but if you do some kind of major unnecessary
    surgery, that will accelerate the procedure and to reduce their life
    expectancy, I mean. And the other thing is that if they already catch the HIV
    test maybe with the operation they would continue to refuse, to increase the
    risk of other people, because if they want a vagina, that it's maybe needs to
    be used and I want to be... I don't want to be part of that.
    You heavy patients, I told you before I had a surprise last year to see
    somebody being very huge because when I showed you she had sent me pictures
    with the children in front and fortunately she was from the east coast and the
    parents had come for the occasion from the west coast then I had 3 in my
    office which was good because I could call the parents and said "this is
    impossible, have you seen such a mountain?" and fortunately the parents were
    very comprehensive and I remember the father telling, "Oh yes, doctor I know
    the situation is bad, don't make it worse". And I had proof that she knew that
    there was was a 200 pounds limit. I'm not too overwhelmed as I told you before
    I don't weigh patients.
    I think now during surgery complications, that's more important because the
    first complication that I can meet and that I met is that the possibility to
    pass a bladder catheter because the urethra had to be closed by former
    ephretiatus(?) in chronic infection venerial disease being treated or not
    treated. And this was the girl from Califonia. Usually when it's a little
    narrow we can use a thinner catheter, which not a major problem. We are better
    after surgery than before. But in one occasion this was completely impossible
    even a small catheter and I had to call a urologist to make a urethrotomy to
    cut the urethra and to pass a catheter. And after surgery, the surgery had
    been done for her but it took some longer time. And after surgery, she told me
    "Yes doctor, I didn't tell you I forgot but I had passed kidney stones but
    years ago and every year I had to go to the hospital to have my urethra
    dilated under general anesthesia". She knew that it could pose problems but
    she wanted me to save the first operation that she needed before during the
    other one. And finally it turned well, but this is one of the few girl's I
    never had any news from.
    A major complication would be a cardiac failure. I had with a french girl
    after surgery some myocardial infarction which was a narrow escape but she
    went well after some time, and this increased the amount of my grey hair.
    I had another surprise with a girl from Kentucky south from Ohio where I
    trained. They are called hillbilly if I remember. She had told me her
    condition was very poor, but she had insisted to have the surgery and she was
    fortunately not alone. She had some relative being with her and the
    cardiologist disagreed, but Dr. Lambert the anesthesiologist, and I said yes
    we can if she lowered something and it was quickly evident that there was a
    cardiac failure, a cardiac collapse quickly at the beginning of the anesthesia
    fortunately, so the surgery could be stopped. And this finally turned out very
    well. I returned a big part of the amount which had been paid and I learned a
    few weeks after that that she had complained at a TV interview that I had put
    her to sleep to take part of her money and that I knew and I decided that I
    wouldn't do it. This was not finished because I was not too happy but that's
    it and I have already too many patients to do. This is so, but it has been
    interesting. After that she wrote me to ask for a new date and to ask me for
    another try. Even that she would sign an I answered her that I had learned
    that she had complained in front of the TV another patient told me that she
    had seen her on the TV and that she was complaining about the brussels sprout
    taking her money. So I refused to do. I wrote her that.
    With asthma. I have sometimes rare complications. The other major complication
    would be bleeding. Some we use preventive measures during surgery with the
    anesthesiologist to lower the blood pressure, to use a blood substitute. Most
    of the time it's going well but some patients don't respond well and they had
    some small bleeding from everywhere. When it's big bleeding coming from the
    major vessel it's easy to ligate but sometimes it cannot be done. My only
    consolation is that normally [when] the patient's bleeding a little too much
    during surgery, they don't bleed after. Maybe because their blood pressure is
    already low, they don't have too much to lose after but the patient with the
    easy part not bleeding surgery - after surgery, some have a tendency to bleed.
    Maybe when their blood pressure is going up and they have post operative
    bleeding. But less and less I have to use blood. I think it's about once in
    about 60 cases. [After lecture he says 1 in 20]
    I have other difficulties sometimes it's completely impossible to dissect the
    cavity for the vagina. When you go in that, you cannot go past the prostate,
    and that's related because there's a few patients maybe many with more than 1
    I think maybe, they have some sexual activity to the rectum this means
    laceration to the rectum, separation, and which which induces scar tissue and
    packed sometimes impossible to go through or if you force you go through you
    go in the rectum or in the urethra. So sometimes it happens it's surgeries are
    most impossible. And I remember, I still afraid when I think to that a few
    days after her surgery I had a phone call from a physician from Los Angeles
    telling me that such girl couldn't go because she had just been brought to the
    hospital in an emergency because she had what we call astyorectal(?) abscess.
    It means a huge abscess around the rectum. If it could, would have blood in a
    few days later I would be in surgery, inside and be in trouble and would be
    sure to get intestinal fistula, and a poor result so.
    Now the last part. After surgery complications.
    There is a complication like stomach pain with nausea, vomiting. This is easily
    treated with the patient remaining with the IV. They are fed IV for 2 or 3
    days. Some medication will help and sometimes Coca Cola helps a great deal.
    Difficulties to pass gas, some they have a big belly they cannot pass gas it
    hurts. It hurts better to not to use too much pain killer because if you, this
    is another procedure your bowel has to function and you have to pass gas in
    the right way not to got get nausea, and sometimes it hurts especially if you
    have wart or some appendicitis or some infection in your abdomen. It can hurt,
    but not good reason to use too much pain killer because this is stopping the
    procedure. It doesn't hurt, it just postpones the difficulty.
    Bleeding of course, I mentioned there can be bleeding 2 or 3 days after
    starting. I had once a bleeding when I removed the catheter from the lips on
    the 2 or 3 days after surgery for drainage. I don't know only bad luck some
    bleeding started some major bleeding. I had to put this girl asleep and to
    find from where it was coming because she had been very much swollen. This was
    an inside bleeding which is still worse than an outside one.
    I had also to mention that quite more than a few patients are either depressed
    or excited, over excited after surgery. Some are depressed because they are
    weakened by the surgery, they have some depression we treat for that before.
    They should come here with their medication to explain them, to do it this
    means to make a lot of talking to sit at their bedside or to call a
    psychologist to try to arrange things and to gain some time. I don't like too
    much this depressions but I have maybe more problems with the exited people
    who want to who always to get up as soon as early, to smoke in their bed when
    not allowed to smoke in hospital. And sometimes I have a very rough time and
    this is why I have cut the stay at the hospital after surgery to 6 days after
    surgery to make a package one week complete. It means 1 night before surgery
    in the hospital and 6 nights after. Before it was one full week after surgery
    but after 4 or 5 days, many patients are well and they start to walk in the
    hospital and to show what has been done to explain they always find somebody
    speaking english and I have problems with the hospital manager if they are too
    ???? As long as they are in their room, it's OK. It's no problem at the end
    sometimes I have rough time.
    I do rounds. I see patients twice, usually I do rounds alone. Many patients,
    American patients have told me that in the state's it's quite different with
    rounds they come with 3 or 4 and they speak between each other and most are
    looking at the patient. Physicians after surgeries are talking to the nurse
    and then they proceed without asking, being afraid to ask a question or to ask
    the patient if he's well because he start to complain and if complaints he
    cannot proceed.
    I remember another sad case. A girl not talking. She looked depressed but she
    didn't say anything and I asked her if there was a problem if she had a family
    or if she missed some news or I could eventually telephone or to have some
    news or to bring news about her from the states and she said "Oh no doctor you
    know my family they organized my funeral when I decided to go that way to go
    the train they arranged the whole family funeral service and they even went to
    the cemetery and that's alright." It doesn't help to specialize in this
    delicate, delicate moment.
    Another girl had a letter, she was very proud, the ex-wife had given her a
    letter had signed by the children were almost full-grown to be opened after
    surgery. And she had a little fetish about that letter she would show me that
    she didn't open before. The day after surgery, I forgot to ask. The following
    day she was like that I said "How are you doing?" She was not doing well and I
    said "Yes, what about the letter?" "Oh doctor, let me see, this was the ex-
    wife and the children saying that if you had done the surgery this was not
    fair amnd would have to cut everything, and that they didn't want to see her
    again". This is another sad situation. It could be prevented maybe.
    And the last maybe major complication would be, but I never had so far, would
    be rectal-vaginal fistula. To pass the intestinal contents through the vagina
    which is a very sad condition. During surgery from time to time I hit the
    rectum, but I always see it and if you see it then you have some time to
    repair that and to put the flap correctly and maybe not try to make the
    maximum depth possible, it's healing very easy.
    I think I have covered most of the things, maybe our time is passing and I
    could eventually answer maybe we will just past the last slide. The next one
    Yes, this is to illustrate the bleeding. Once again the place around the
    catheter where you have... where Dr. Biber was so helpful in explaining how
    not to have that. This patient has to be brought back because of excessive
    bleeding. But this was several years ago but this can still happen. This means
    that sometimes certain patients have bleeding tendency and I will ask if they
    had a certain tooth removed beforeor if they have had some bleeding through
    the nose during childhood because some have more tendency to bleed than the
    others. It's not fully the responsability of the physician, but it can be too.
    Next one.
    Yes I saw diffuse bleeding beneath the skin. This gives some temperature
    but in the long run it's going very well. Next one.
    Yes, this is the key to success to get a good vagina you have to bring good
    material to work with. You have to bring good banana. [Laughter] So you see
    you have more tissue to work with and so the best case I like to leave it for
    that. Next one.
    When you do injections maybe this was thought about by some patients they have
    silicone injected into the hips as they say. This was a good illustration you
    can run into trouble you see when you inject the pain killer or antibiotic or
    some vitamin or something you can run into trouble usually the lethal dose
    that they have so much they don't know where it's at that we can start an
    infection. And I saw these 2 girls with a huge amount of silicone injected
    directly beneath the skin and in the tissue but this was hard like (knocking
    on the table)like table. This was hard. And after surgery they would lay on
    their side and I think they were bound to have trouble.
    I had one girl I almost refused the operation but I tried this was open. She
    could open her legs so i finally decided. She was from Alaska, the cold state;
    they need good hips.
    This is important, I just remember I had another girl I had refused. She had
    also to comply when at the last examination she said "yes doctor I had
    problems". She had put breast implants with a plastic surgeon done that and
    both buttocks 1 almost alright, the other 1 was first running because it was
    infected. I said I cannot perform the surgery with pus running in great amount
    through to the surgery and your condition is not good. I plan to remove that
    implant or eventually it goes. And eventually in treating her I would agree to
    remove the testicles to do at least something during her trip. This she
    accepted to have the testicles removed which I did. But she refused that I
    remove even the pus running from one buttocks. Because she said "Yes, I have a
    problem with my plastic surgeon. There is some malpractice suit going on with
    him" so. And then she came but it took 1 year because during she had both
    implants removed and instead she had a very large tattoo with an American
    eagle on both.
    Just between plain surgery it will certainly get to know that there are certain
    advantages because the rates in Europe are easier or at least in Belgium
    because we don't charge the operating room. The operating room is included in
    the room at the hospital, with the stay. So, that's why I can perform the
    tracheal shave at almost no extra cost as long as you are an inpatient. If you
    are an outpatient that you are doing at the hospital, you have to pay room in
    order to get access to the operating room. That's one of the advantages, but
    certainly not to be the....
    BEGINNING OF LAST TAPE (about 15 minutes)
    The difference between American and European patients, one is that they don't
    submit well to jet lag. North Americans, they sleep a little during the day
    and not well during the night because they are confused like I am now here.
    But, the other thing is they have a tendency to have a temperature, 2 or 3
    days they have some temperature but higher in the morning but lower at night.
    In Europe we have it reversed, normally it's at the end of the day that we
    have more temperature because we are used to the periodicity between the
    daytime and the night. So, it takes some time to change but I know when I see
    the European patient having temperature in the morning I am concerned because
    I think at night it can be worse. When an American in the morning it should be
    better at night. Next one.
    This is the entrance of the new Foundation Lambert where I work now. This is
    the old part of the hospital. This is the building in which I am going, but I
    don't know where. Next one.
    This is the emergency room open the doors and there are always physicians on
    hand. That's the entrance that a few know or will know. Next one.
    This a larger view of the old part now I think the next one will be... Next
    This will be on the street behind. This is the new wing with obstetrics and
    children's department. Both so far no patients, no exit. There has yet to be
    transgendered, cannot be in that wing so far. This is brand new. This is very
    well but not yet, we are still in the old wing but it was in fact remodeled
    and we have pretty good equipment. Next one.
    Yes, this is the hotel Derby that many know. It's not the nicest hotel, but
    it's located about 8 to 10 minutes walking from my office, 15 minutes from the
    hospital. Even when they have relatives they can walk easily it's not too
    expensive for student rate. It's not very nice, there is no TV in the room but
    you pay for that too. And they are very comprehensive, they are used to that
    and you can feel at peace there. Next one.
    This is a few sights around Brussels that can be visited better before than
    after. This is Waterloo where Napoleon had been defeated in 18 hundred 15
    (1815). 60,000 people died in one day from. Next one.
    This is Brugges. 60 miles outside Brussels for travelling people in Europe,
    There are two musts in Belgium beside me. It's the Grand Place, downtown
    Brugges, a little far away but very nice especially when the weather is good.
    It's like Venecia del Norte [Venice of the North]. With canals, it's very
    nice in fall. Next one.
    Here this is the mascot of Brussels [A peeing boy]. I agreed to perform the
    surgery. [Laughter] They are confused that I come up with question. Next one.
    Yes this is the problem I spoke about, it's like the same one like the other
    one. Next one.
    Yes, that's it. The sunset in front of my home when I was in Kinshasa in
    Zaire. I had many many sunsets there and I think I always love to see them.

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