Before starting the myomectomy procedure, the

surgeon has to pull up the bowel

with the sterile pack

so that the bowel will be retracted upwards

and to facilitate proper and easier visualization

of the surgical field.

After proper preparation of retraction of the bowel and

then insertion of the retractor to widen the surgical field

then the next step is to apply tonically?

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

less blood loss

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

because myomectomy is going to be a blind x unless you

conduct in a way which decrease blood loss

the interoperative blood loss might be very high.

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

tonicity, which is to use a #8 catheter.

So we open a window on both sides of

lateral aspect of the utuerus, then tightly

close it or suture it, or wrapping the catheter

so that catheter is going to occlude the

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

thereby decrease the blood loss.

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

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

also on the ovarian vessels might be needed

but usually tonicy applied on the uterine vessels is usually sufficient

Currently one can apply or inject a vassopressin

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

and then you can conduct the surgery.