Dr. Seghers Speach
Part_2 The Second Hour
BEGINNING OF SECOND HOUR TAPE.
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.
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.
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.
SLIDE:
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.
SLIDE:
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.
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 .
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.
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.
SLIDE:
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.
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.
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.
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.
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.
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.
SLIDE:
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.
SLIDE:
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.
SLIDE:
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.
SLIDE:
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
Slide.
SLIDE.
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.
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.
SLIDE:
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.
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.
SLIDE:
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.
SLIDE:
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
slide.
SLIDE:
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.
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.
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
slide.
SLIDE:
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
slide.
Slide:
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:
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.
SLIDE:
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.
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.
SLIDE:
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.
SLIDE:
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.
SLIDE:
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.
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.
SLIDE:
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.
SLIDE:
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.
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.
SLIDE
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.
SLIDE:
Then closure in two or three layers usually. Next one.
SLIDE:
Some pain when it's finished. This case was done under general anesthesia but
the first was combined with some other procedure. Next one.
SLIDE:
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.
RESUME GOOD RECORDING
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)
RESUME GOOD RECORDING
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
complications.
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
please.
SLIDE:
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.
SLIDE:
Yes I saw diffuse bleeding beneath the skin. This gives some temperature
but in the long run it's going very well. Next one.
SLIDE:
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.
SLIDE:
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....
END OF SECOND HOUR'S TAPE
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.
SLIDE:
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.
SLIDE:
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.
SLIDE:
This a larger view of the old part now I think the next one will be... Next
one.
SLIDE:
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.
SLIDE:
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.
SLIDE:
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.
SLIDE:
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.
SLIDE:
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.
SLIDE:
Yes this is the problem I spoke about, it's like the same one like the other
one. Next one.
SLIDE:
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.
END OF SLIDES