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Before starting the myomectomy procedure, the

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surgeon has to pull up the bowel

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with the sterile pack

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so that the bowel will be retracted upwards

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and to facilitate proper and easier visualization

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of the surgical field.

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After proper preparation of retraction of the bowel and

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then insertion of the retractor to widen the surgical field

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then the next step is to apply tonically?

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because the most important step in a myomectomy is to conduct the surgery with

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less blood loss

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thus, hemostatis or decreasing hemhorrage is a very important step in myomectomy

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because myomectomy is going to be a blind x unless you

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conduct in a way which decrease blood loss

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the interoperative blood loss might be very high.

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There are different techniques but the common method which we use is to apply

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tonicity, which is to use a #8 catheter.

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So we open a window on both sides of

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lateral aspect of the utuerus, then tightly

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close it or suture it, or wrapping the catheter

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so that catheter is going to occlude the

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the uterine arteries on both sides and then decrease the blood flow to the upper part of the uterus

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thereby decrease the blood loss.

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So after applying a tonicy on the lower aspect of the utuerus

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sometimes, depending on the need, the size of the myoma, the tonicy ?

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also on the ovarian vessels might be needed

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but usually tonicy applied on the uterine vessels is usually sufficient

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Currently one can apply or inject a vassopressin

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which is a kind of drug which will decrease the blood loss to the myoma

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and then you can conduct the surgery.