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S. A. H. M. Van den Tillaart, M. P. H. Busard, and J. B. M. Z. Trimbos

S. A. H. M. Valve den Tillaart

Department the Gynaecology K6-P, Leiden University clinical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands


M. P. H. Busard

Department the Gynaecology K6-P, Leiden University clinical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands


J. B. M. Z. Trimbos

Department of Gynaecology K6-P, Leiden University medical Center, P.O. Crate 9600, 2300 RC Leiden, The Netherlands


Department that Gynaecology K6-P, Leiden University clinical Center, P.O. Crate 9600, 2300 RC Leiden, The Netherlands
Corresponding author.

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This article is dispersed under the terms of the an innovative Commons Attribution Noncommercial license which permits any type of noncommercial use, distribution, and also reproduction in any medium, noted the original author(s) and resource are credited.

Distilled water is used worldwide to check on hemostasis at the finish of pelvic oncological operations. Nevertheless, reports about this an approach are lacking. The target of this examine was to describe the method and to discuss possible side effects. ~ the addition of distilled water come the surgically exposed pelvis, rapid lysis the erythrocytes outcomes in a transparent liquid in which a small source of bleeding is quickly recognizable. A possible side result of the lavage can be contribution to the development of peritoneal adhesions through confusing the ab defence system. Systemic side results are not to be expected. Back tumour cells can suffer native hypotonic distilled water lavage, the current use the distilled water at the end of surgical procedure is probably not effective to lyse tumour cells. Ours findings assistance the recurring use the distilled water lavage to achieve hemostasis after extensive pelvic surgery.


Keywords: Lavage, Hemostasis, Distilled water, Water, Aquadest, Gynaecologic oncologic surgery

Introduction

After comprehensive pelvic surgery, e.g. Oncological operations or surgery for endometriosis, the surgeon have the right to be challenged with a raw, oozing area in the pelvis. Stopping small venous bleeders to attain adequate hemostasis is regularly a daunting task in these areas. Distilled water lavage provides the detection that the resources of bleeding much easier. If lavage through NaCl 0.9% to clean the operation ar after surgery is extensively accepted and often discussed in literature, strangely sufficient we haven’t seen any type of publication on the usage of distilled water (aquadest). The aim of this report is to explain the use of distilled water for the objective of achieving hemostasis during surgery. As well as informing about its usefulness and also ease, we desire to provide background information around the device that makes distilled water applicable for this purpose. Except the advantageous effects that distilled water, it is imaginable the the enhancement of a hypotonic fluid as such to the pelvis can not it is in without any type of side effects. Us briefly talk about these elements.


Mechanism


Clinical application

Before closeup of the door the abdomen, 500 cc of distilled water is poured right into the abdominal muscle cavity. In comparison to NaCl 0.9%, which offers a blurred view through an opaque fluid, distilled water remains plainly transparent and ensures a bright sight in the tiny pelvis. Together a consequence, tiny venous bleeding is conveniently recognizable and the bleeding site can be correctly traced. Once sources of bleeding have actually thus been discovered, the distilled water is suctioned the end of the pelvis and the bleedings space stopped in the suitable way. In general, 2 sequential lavages are used. Number ​Figure11 reflects two examples.


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Physiology

Within a details range of external solute concentrations, erythrocytes behave as an osmometer: their volume is inversely pertained to the solute concentration in a medium. The erythrocyte shrinks in hypertonic solutions and also swells in hypotonic solutions. Once an erythrocyte has actually swollen to about 1.4 time its original volume, it starts to lyse (burst). In ~ this volume the properties of the cabinet membrane abruptly change, haemoglobin leaks the end of the cell and also the membrane i do not care transiently permeable to most molecules <1>.

NaCl is isotonic come the red blood cell at a concentration the 154 mM. This coincides with NaCl 0.9%. The red blood cell has actually its normal volume in isotonic NaCl. Erythrocytes remain intact in NaCl 0.9%, causing an opaque suspension. Distilled water on the other hand is hypotonic to red blood cells. The red blood cell will because of this swell and haemoglobin, comprise the haem that provides the red colour to erythrocytes, leaks native the cell causing a transparent red-pink-coloured solution. Apparently, erythrocytes in clear liquid colour the liquid red and also opaque, conversely, haemoglobin in clear fluid leaves the fluid transparent.


Laboratory experiment

To further check out the appearance of a traceable blood stream once using distilled water lavage, us performed one in vitro experiment. Ten microlitres of person erythrocytes was injected in tubes containing 990 µl NaCl 0.9% or distilled water (concentration 1:100). A traceable stream dropping to the bottom was visible in both tubes. ~ stirring the tube both solutions acquired turbid, however for the distilled water solution this only lasted a moment. Approximately 5 s after ~ the stirring, the distilled water equipment turned bright red-pink, plainly transparent. The NaCl solution stayed opaque red-pink. ~ 30 s, a drop of liquid of both solutions was check under the microscope. In the NaCl solution, regular erythrocytes were visible, whereas no common erythrocytes to be visible in the distilled water solution. Subsequently, an additional 10 µl that erythrocytes was added to both solutions. The traceable stream to be visible again in the red-pink distilled water solution, conversely, a stream can not be viewed in the turbine NaCl solution. Some time after stirring, the distilled water equipment turned bright red-pink again, if the NaCl equipment got more opaque. Successively, quantities of 10 µl erythrocytes were added to the tubes. When continuing the process, it take it longer before the distilled water equipment turned shining red-pink ~ stirring and also the colour of the solution got darker. In ~ a concentration that 16:115 (160 µl erythrocytes in 990 µl H2O), the distilled water equipment was no much longer transparent and a blood currently was not visible anymore.

This experiment mimics the clinical situation and also shows that a traceable blood present does show up in both distilled water and NaCl 0.9%, yet is only visible in a transparent fluid. In comparison to NaCl, distilled water maintain its transparency ~ the addition of blood as a an outcome of the fast lysis the erythrocytes. The difference in transparency deserve to be compared with the difference between fruit juice (NaCl) and also lemonade (distilled water). Erythrocytes added to the solution cause the osmolarity that the systems to rise, and also the difference in hydrostatic pressure to decrease, causing a lengthy time of cabinet lysis. More than likely because more intact or swollen erythrocytes will certainly be existing in the distilled water solution after consistent mixing v blood or various other intra-abdominal fluid, the solution becomes much less transparent. This occasionally necessitates an ext than one lavage cycle.


Peritoneal damage

Peritoneal mesothelial cells play a primary duty in the ab defence system. They deserve to express details surface mite that allow them to promote the margination and migration of neutrophil granulocytes and also produce essential molecules such as pro-inflammatory cytokines, nitric oxide, expansion molecules, tissue plasminogen activator and plasminogen activator inhibitor <2>. Peritoneal mast cells have been presented to have actually a straight effect top top peritoneal adhesion formation. Mast cabinet mediators induce fibroblast proliferation and also mast cabinet hyperplasia has actually been shown to be current in person peritoneal adhesions <3>.

It is no known through which mechanism peritoneal mesothelial cell behave as soon as exposed to various concentrations that lavage solutions, however they room damaged by remedies that are much from physiological, such as peritoneal dialysis fluids. Even solutions the are more physiological have been shown to cause changes in synthesis of details molecules <4–6>. In vitro studies showed that peritoneal lavage v normal saline causes up-regulation of pro-inflammatory cytokines, and also that per-operative lavage solutions influence the peritoneal defence mechanisms. Both antiseptic lavage solutions and physiologic salt resulted in cell death and decreased truth in the mesothelial monolayer <7, 8>.

Polubinska et al. Performed an in vitro study of mesothelial monolayers exposed come NaCl 0.9% and also different peritoneal dialysis fluids, including hypertonic services with low glucose degradation assets concentration. Return the hypertonic fluid caused damages to the cell membrane, the viability the the cells was no reduced and fybrinolytic activity was preserved. In contrast, cells exposed come NaCl 0.9% showed changes that might promote the formation of peritoneal adhesion formation. In a rat study of this group, hypertonic lavage systems was reported to suppress intra-peritoneal inflammation and also mesothelial hyperplasia as contrasted to regular saline. The authors advise the use of hypertonic options with low glucose degradation assets concentration for both peritoneal dialysis and rinsing the the peritoneal cavity per-operatively <6, 9>. However, hypotonic options were not studied and also the impacts reported in this study could probably be attributed come the glucose dehydration product concentration rather than come osmolarity itself. Adhesion development was not studied and also the study groups were small. Kanakura et al. Studied numbers and species of mast cells in the peritoneal cavity of mice after injection the distilled water or saline. Return the intra-peritoneal injection that saline did no significantly impact the number of peritoneal mast cells, the intra-peritoneal injection the distilled water eradicated tiny and medium (differentiated) mast cell colony-forming cells, if the number of big mast cell swarms increased <10>.

The effects of lavage liquid volume and incubation time top top the above-described mechanisms space not known, neither is their duty in vivo.

Based ~ above the currently literature, we assume that peritoneal lavage with any solution will an outcome in disturbance the the homeostasis in the pelvis. Lavage through distilled water might transform the abdominal muscle defence mechanism by up-regulation the pro-inflammatory mediators. This could lead come the development of adhesions. The degree of this result of distilled water in ratio to other media is no clear. The exact same mechanisms could damage the lining that the per-operatively exposed organs and also tissues, but we have no means to that s right quantify this result in vivo.


Systemic effects

One can speculate top top a systemic effect of distilled water pelvic lavage. The absorption of distilled water offered as an irrigation fluid in endoscopic procedures has been reported to disturb the circulatory system and also lead to clinical symptoms recognized as the transurethral resection (TURP) syndrome. Acute changes in intravascular volume and also plasma solute concentration might add to hypotension, and even acute renal failure has been report <11>. Hypotonic distilled water directly entering the circulation through opened veins or absorbed an ext slowly, can reason haemolysis. Intra-vesicular pressure above 30 mmHg and also increasing resection time have been proposed to rise the absorption of fluid <12, 13>. Averagely, 15 l of irrigation fluid is used throughout a 60-min-lasting TURP procedure <14, 15>. Still, severe transforms in blood values after TURP with distilled water were hardly ever reported and it has actually been presented to it is in a safe irrigating fluid for TURP <15>.

Since in the procedure we explain only small volumes of distilled water are used for a quick time at the finish of the operation procedure and also without pressure, we have actually no reason to doubt systemic side results as a result of the application of distilled water in the pelvis at the end of the operation procedure.


Lysis that tumour cells

Besides possible an unfavorable side effects, distilled water lavage to achieve hemostasis might likewise have an unintentional advantageous effect.

Although over there is no consensus around the optimal lavage method, e.g. Incubation time to achieve effective lysis and the potential that sequential lavages, number of studies confirmed a harmful effect of distilled water top top tumour cells. Person tumour cell lines seem come be sensitive to osmotic shock in vitro. Fechner et al. Found significant bladder tumour cell dead ~ 10 min that exposure come distilled water lavage <16>. Mercill et al. Observed a diminish in DNA synthesis in various tumour cabinet lines after ~ exposure to distilled water for 1 come 10 min. However, the continuing to be cells did not lose their replication volume <17>. In a study of Huguet et al., colorectal cancer cabinet lines to be incubated v distilled water and also no enduring cells were found past 12 min incubation. Water introduced into the peritoneal cavity in vivo was contaminated by intra-peritoneal secretions, compromising the osmotic lysis effect. However, this contamination was diminished by sequential lavages: after 3 lavages a last resultant osmolarity that 10 mM was attained. A solution of 10 mM to be able to develop 100% cabinet lysis that colorectal cancer cell in vitro after 32 min that incubation <18>. Lin et al. Discovered that the application of 10 l that distilled water separated into in ~ least five cycles preserved for 3 min brought about a significant much better survival time after ~ curative liver resection in patients through spontaneous rupture that hepatocellular carcinoma <19>. Although that is assumed the tumour cabinet injury is resulted in by osmotic shock, the specific mechanism that potential cabinet injury through distilled water is no known. Selzner et al. Assessed the impacts of 1, 3 and also 5 min the hypotonic exposure on cell viability in three various human colon cancer cabinet lines. All three cell lines challenged with distilled water exhibited a dramatic to decrease in viability in a time-dependent manner, however only exposure of >15 min come distilled water was associated with far-reaching increases in cell lysis. According to Selzner N et al. Cell fatality is related to temporary cell swelling that root cause activation that apoptosis. Important receptors because that this apoptosis pathway were not detected in typical cells (human fibroblasts) after ~ a challenge with one of two people distilled water or isotonic media <20>.

Based on these reports we assume the the lavage technique that we usage to accomplish hemostasis is not adequate for complete tumour cell lysis. The incubation time is short and also numbers the lavages are fairly small. Nevertheless, cost-free tumour cells in the pelvis could to some level suffer indigenous hypotonic distilled water lavage.


Conclusion

Distilled water is a helpful tool to achieve hemostasis per-operatively. Erythrocytes explode in the hypotonic distilled water, ensuring a transparent equipment in which a blood stream have the right to be quickly traced to its origin. After suctioning the water out of the pelvis, bleedings can be stopped.

The affect of the technique on the total amount that blood ns or operation time have the right to not quickly be estimated because other per-operative components outweigh the result of distilled water in the respect, however distilled water is definitely relevant for surgeons during a an overwhelming step the the surgical procedure.

A possible negative side effect of this method is damages to the peritoneal mesothelial cells. Distilled water lavage might confuse the ab defence system and might add in this way to the development of peritoneal adhesions. We could not evaluate the feasible harmful result of distilled water lavage on operation exposed surfaces. The described method is no suspected to reason systemic side effects throughout or shortly after surgical treatment. Distilled water lavage could induce tumour cell lysis, yet the currently used method is most likely not sufficient to achieve this beneficial effect.

In the absence of obvious indications on possible an adverse side effects of distilled water lavage as explained above, we consider it sufficiently safe to apply this useful technique in surgical practice.

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This article is distributed under the terms of the an innovative Commons Attribution Noncommercial license which permits any noncommercial use, distribution, and also reproduction in any medium, provided the initial author(s) and resource are credited.