1. Open abdominal myomectomy steps + key safety points, and
2. Hysterotomy (cesarean-type uterine incision/closure) steps.

1) Myomectomy (uterus-preserving fibroid surgery)

A. Pre-op

• Confirm indication: symptoms, infertility/recurrent loss, cavity distortion, bulk symptoms
• Imaging mapping (US/MRI) for number, size, location (subserosal/intramural/submucosal)
• Optimize Hb/iron; blood availability; consent for bleeding/transfusion and possible conversion

B. Intra-op (open/laparoscopic principles)

1. Abdominal/pelvic entry and assessment
2. Hemorrhage-reduction measures (e.g., vasopressin infiltration, temporary vascular control, uterotonics per protocol)
3. Uterine serosal incision over fibroid (prefer longitudinal/transverse based on access and closure plan)
4. Enucleation: develop pseudocapsule plane and shell out myoma
5. Hemostasis of myoma bed
6. Multilayer myometrial closure to obliterate dead space
7. Serosal closure/re-approximation (anti-adhesion strategy as needed)
8. Repeat for additional fibroids
9. Specimen extraction (mini-lap or contained extraction if minimally invasive)
10. Final hemostasis, irrigation, close abdomen/port sites

C. Post-op focus

• Monitor bleeding, pain, ileus, infection
• Future pregnancy counseling (risk of uterine rupture depends on depth/number of incisions)
• Delivery planning in future pregnancy individualized

2) Hysterectomy (uterus removal)

A. Pre-op

• Confirm indication and route selection
• Cervical screening status, endometrial assessment when indicated
• Counsel on fertility loss, risks (bleeding, urinary tract/bowel/vascular injury), menopausal implications if ovaries removed

B. Core surgical sequence (route-specific details vary)

1. Entry and pelvic survey
2. Divide round ligaments (if abdominal/laparoscopic route) and open broad ligament planes
3. Bladder dissection off lower uterine segment/cervix
4. Control uterine blood supply (uterine vessels) close to uterus
5. Sequentially divide cardinal/uterosacral supports
6. Colpotomy (for total hysterectomy) and remove uterus ± cervix
7. Close vaginal cuff (if total hysterectomy)
8. Ensure hemostasis; check urinary tract integrity when indicated
9. Close incisions/ports

C. Post-op focus

• VTE prophylaxis, pain control, bowel/bladder recovery
• Watch for cuff complications (if total), hemorrhage, infection, urinary injury signs
• Activity and intercourse restrictions until healing complete

Quick comparison

• Myomectomy: keeps uterus, preserves fertility potential, but fibroids can recur; usually higher bleeding risk intra-op than straightforward hysterectomy.
• Hysterectomy: definitive cure for uterine fibroid bleeding/bulk symptoms; no future pregnancy.

1) Myomectomy (open/laparoscopic): step sequence

1. Position + prep + antibiotics + uterine manipulator (if MIS)
2. Abdominal/port entry and map fibroids
3. Bleeding control adjunct (vasopressin/temporary devascularization as planned)
4. Serosal incision directly over dominant fibroid
5. Enucleate fibroid in pseudocapsule plane (traction-countertraction)
6. Hemostasis in myoma bed
7. Close myometrium in layers (obliterate dead space)
8. Serosal closure to reduce adhesions
9. Repeat for other fibroids (largest/deepest first usually)
10. Specimen retrieval (bag/mini-lap as appropriate)
11. Final pelvic hemostasis + irrigation
12. Close ports/laparotomy

“Must mention” viva points

• Main risk: hemorrhage; crossmatch blood
• Convert to laparotomy if unsafe bleeding/poor visualization
• Counsel on recurrence and future pregnancy plan

2) Hysterectomy (total hysterectomy): step sequence

1. Position + prep + antibiotics + catheter
2. Entry and inspect pelvis
3. Round ligament division (abd/lap routes)
4. Open broad ligament spaces and identify ureter course
5. Bladder flap dissection off cervix/lower segment
6. Control adnexal pedicles (utero-ovarian or infundibulopelvic, depending on ovary conservation)
7. Skeletonize, clamp/seal, divide uterine vessels close to uterus
8. Divide cardinal + uterosacral ligaments
9. Colpotomy circumferentially and remove uterus + cervix
10. Close vaginal cuff (include supportive bites as needed)
11. Hemostasis + ureter/bladder check when indicated
12. Closure of abdominal/port incisions

“Must mention” viva points

• Critical safety principle: ureter awareness at every pedicle
• Decide pre-op: total vs supracervical, salpingectomy ± oophorectomy
• Major complications: bleeding, urinary tract injury, bowel injury, cuff issues

One-line memory aid

• Myomectomy: Cut uterus -> shell out fibroid -> layered uterine reconstruction
• Hysterectomy: Take pedicles systematically -> detach cervix/uterus -> close cuff

L-Arginine Side Effects

1. Gastrointestinal (Most Common)

• Nausea, vomiting, diarrhea, bloating, abdominal cramps — especially at higher doses
• The NOAEL (No-Observed Adverse Effect Level) for oral intake is estimated at ~7,531 mg per single dose
• A 2023 systematic review of 34 RCTs (647 participants) found the risk increase for GI symptoms was not statistically significant at doses from 2,000–30,000 mg/day, though symptoms appear dose-dependent [PMID: 37947893]

2. Cardiovascular / Vasodilatory

• L-arginine is a precursor of nitric oxide (NO) via nitric oxide synthase (NOS)
• When NOS is upregulated, excess NO production can cause:
  • Hypotension (vasodilation)
  • Worsened hemodynamic instability in critically ill patients — particularly dangerous in sepsis
• The Canadian Clinical Practice Guidelines do not recommend arginine supplementation in critically ill or septic patients due to potential harm

3. Metabolic / Biochemical

• Can worsen hyperkalemia (arginine HCl used clinically for metabolic alkalosis/chloride replacement carries K⁺-sparing risk)
• In urea cycle disorders: used therapeutically, but high doses may paradoxically affect ammonia balance
• May affect insulin secretion — can cause hypoglycemia in susceptible patients

4. Herpes/Viral Reactivation

• L-arginine promotes replication of herpes simplex virus (HSV); can trigger outbreaks in individuals with latent herpes infection
• Often countered clinically with L-lysine supplementation

5. Coagulation / Immune

• May potentiate immune activation via NO; could theoretically worsen inflammatory states
• Some concern about promoting tumor growth in cancer patients (NO-mediated effects), though data is not definitive

6. Renal / Hepatic Caution

• In renal failure, altered handling of amino acids; use with caution
• Arginine HCl can cause acidosis if used in excess

Safety Summary

• Yamada's Textbook of Gastroenterology, 7e — Section: Arginine
• Schwartz's Principles of Surgery, 11e — Section: Enteral Formulas
• Kuramochi et al. (2023), Amino Acids — Safety of oral L-arginine: systematic review of RCTs [PMID: 37947893]