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

S. A. H. M. Van den Tillaart

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


M. P. H. Busard

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


J. B. M. Z. Trimbos

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


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

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Distilled water is used worldwide to check on hemostasis in ~ the end of pelvic oncological operations. Nevertheless, reports about this technique are lacking. The target of this research was to explain the an approach and to discuss feasible side effects. After ~ the addition of distilled water to the surgically exposed pelvis, rapid lysis of erythrocytes outcomes in a transparent fluid in which a small source the bleeding is quickly recognizable. A possible side effect of the lavage could be contribution to the formation of peritoneal adhesions through confusing the abdominal muscle defence system. Systemic side impacts are not to be expected. Although tumour cells might suffer from hypotonic distilled water lavage, the present use the distilled water at the end of surgical procedure is most likely not efficient to lyse tumour cells. Our findings assistance the recurring use of distilled water lavage to achieve hemostasis after considerable pelvic surgery.


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

Introduction

After extensive pelvic surgery, e.g. Oncological to work or surgical treatment for endometriosis, the surgeon can be confronted with a raw, oozing area in the pelvis. Stopping little venous bleeders to accomplish adequate hemostasis is frequently a an overwhelming task in this areas. Distilled water lavage provides the detection of the resources of bleeding lot easier. While lavage with NaCl 0.9% come clean the operation ar after surgical treatment is widely accepted and also often stated in literature, strangely sufficient we haven’t seen any publication ~ above the usage of distilled water (aquadest). The aim of this report is to describe the use of distilled water for the purpose of afford hemostasis throughout surgery. As well as informing about its usefulness and ease, we want to provide background information around the mechanism that provides distilled water applicable for this purpose. Apart from the valuable effects that distilled water, that is imaginable the the addition of a hypotonic fluid as such to the pelvis can not be without any kind of side effects. Us briefly comment on these elements.


Mechanism


Clinical application

Before close up door the abdomen, 500 cc of distilled water is poured into the abdominal muscle cavity. In comparison to NaCl 0.9%, which gives a blurred view through an opaque fluid, distilled water remains clearly transparent and also ensures a bright vision in the little pelvis. As a consequence, tiny venous bleeding is easily recognizable and also the bleeding site have the right to be correctly traced. As soon as sources of bleeding have actually thus to be discovered, the distilled water is suctioned out of the pelvis and also the bleedings are stopped in the appropriate way. In general, two sequential lavages are used. Number ​Figure11 shows two examples.


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Physiology

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

NaCl is isotonic come the red blood cabinet at a concentration of 154 mM. This corresponds with NaCl 0.9%. The red blood cell has its typical volume in isotonic NaCl. Erythrocytes remain intact in NaCl 0.9%, leading to an opaque suspension. Distilled water meanwhile is hypotonic come red blood cells. The red blood cell will therefore swell and also haemoglobin, comprise the haem that gives the red colour come erythrocytes, leaks from the cell causing a transparent red-pink-coloured solution. Apparently, erythrocytes in clear fluid colour the fluid red and also opaque, conversely, haemoglobin in clear fluid leaves the fluid transparent.


Laboratory experiment

To further explore the illustration 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 present dropping come the bottom was visible in both tubes. After stirring the tubes both solutions obtained turbid, yet for the distilled water equipment this just lasted a moment. Around 5 s after ~ the stirring, the distilled water solution turned shining red-pink, plainly transparent. The NaCl solution remained opaque red-pink. After ~ 30 s, a drop of liquid of both remedies was examined under the microscope. In the NaCl solution, common erythrocytes were visible, whereas no regular erythrocytes to be visible in the distilled water solution. Subsequently, an additional 10 µl of erythrocytes was added to both solutions. The traceable stream was visible again in the red-pink distilled water solution, conversely, a stream could not be watched in the turbine NaCl solution. Some time after ~ stirring, the distilled water solution turned glowing red-pink again, if the NaCl equipment got an ext opaque. Successively, volumes of 10 µl erythrocytes were added to the tubes. When proceeding the process, it take it longer prior to the distilled water solution turned bright red-pink ~ stirring and the color of the solution acquired darker. In ~ a concentration that 16:115 (160 µl erythrocytes in 990 µl H2O), the distilled water equipment was no longer transparent and also a blood currently was no visible anymore.

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


Peritoneal damage

Peritoneal mesothelial cell play a primary role in the abdominal defence system. They have the right to express particular surface mite that allow them to encourage the margination and also migration the neutrophil granulocytes and produce vital molecules such together pro-inflammatory cytokines, nitric oxide, growth molecules, tissue plasminogen activator and also plasminogen activator inhibitor <2>. Peritoneal mast cells have been presented to have a direct effect top top peritoneal adhesion formation. Mast cabinet mediators induce fibroblast proliferation and mast cell hyperplasia has actually been presented to be existing in human being peritoneal adhesions <3>.

It is not known through which mechanism peritoneal mesothelial cell behave when exposed to various concentrations of lavage solutions, however they space damaged by solutions that are much from physiological, such as peritoneal dialysis fluids. Even solutions the are much more physiological have actually been shown to reason changes in synthesis of specific molecules <4–6>. In vitro studies showed that peritoneal lavage with normal saline causes up-regulation the pro-inflammatory cytokines, and that per-operative lavage solutions affect the peritoneal defence mechanisms. Both antiseptic lavage solutions and also physiologic salt led to cell death and also decreased truth in the mesothelial monolayer <7, 8>.

Polubinska et al. Carry out an in vitro study of mesothelial monolayers exposed to NaCl 0.9% and different peritoneal dialysis fluids, including hypertonic services with short glucose degradation commodities concentration. Although the hypertonic fluid caused damage to the cabinet membrane, the viability the the cell was no reduced and also fybrinolytic task was preserved. In contrast, cells exposed come NaCl 0.9% showed alters that can promote the formation of peritoneal adhesion formation. In a rat study of this group, hypertonic lavage systems was report to suppress intra-peritoneal inflammation and also mesothelial hyperplasia as compared to typical saline. The authors advise the usage of hypertonic remedies with low glucose degradation assets concentration for both peritoneal dialysis and rinsing that the peritoneal cavity per-operatively <6, 9>. However, hypotonic solutions were not studied and the impacts reported in this study might probably be attributed come the glucose dehydration product concentration fairly than to osmolarity itself. Adhesion formation was not studied and also the study groups were small. Kanakura et al. Studied numbers and varieties of mast cells in the peritoneal cavity of mice after injection of distilled water or saline. Although the intra-peritoneal injection that saline did not significantly influence the variety of peritoneal mast cells, the intra-peritoneal injection that distilled water eradicated little and tool (differentiated) mast cell colony-forming cells, while the number of large mast cell colonies increased <10>.

The results of lavage fluid volume and also incubation time on the above-described mechanisms space not known, no is their function in vivo.

Based top top the currently literature, we assume the peritoneal lavage with any solution will result in disturbance of the homeostasis in the pelvis. Lavage v distilled water might alter the abdominal muscle defence device by up-regulation of pro-inflammatory mediators. This could lead to the development of adhesions. The degree of this effect of distilled water in relationship to other media is no clear. The very same mechanisms could damage the lining that the per-operatively exposed organs and also tissues, however we have no way to that s right quantify this impact in vivo.


Systemic effects

One can speculate ~ above a systemic result of distilled water pelvic lavage. The absorb of distilled water used as an irrigation liquid in endoscopic procedures has actually been report to disturb the circulatory system and also lead come 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 straight entering the circulation through opened veins or absorbed more slowly, can cause haemolysis. Intra-vesicular pressure over 30 mmHg and also increasing resection time have actually been propose to boost the absorption of fluid <12, 13>. Averagely, 15 l that irrigation fluid is used throughout a 60-min-lasting TURP procedure <14, 15>. Still, severe changes in blood worths after TURP through distilled water were hardly ever reported and also it has actually been shown to be a safe irrigating liquid for TURP <15>.

Since in the procedure we explain only little volumes of distilled water are offered for a brief time at the finish of the surgical procedure and also without pressure, we have actually no factor to doubt systemic side impacts as a result of the applications of distilled water in the pelvis at the finish of the operation procedure.


Lysis that tumour cells

Besides possible an adverse side effects, distilled water lavage to obtain hemostasis might likewise have one unintentional helpful effect.

Although over there is no consensus around the optimal lavage method, e.g. Incubation time to attain effective lysis and also the potential that sequential lavages, number of studies confirmed a harmful effect of distilled water on tumour cells. Human being tumour cabinet lines seem to be sensitive to osmotic shock in vitro. Fechner et al. Found far-reaching bladder tumour cabinet dead after 10 min of exposure to distilled water lavage <16>. Mercill et al. It was observed a diminish in DNA synthetic in various tumour cell lines after exposure come distilled water because that 1 come 10 min. However, the remaining cells did not lose their replication capacity <17>. In a examine of Huguet et al., colorectal cancer cell lines to be incubated with distilled water and also no surviving cells were found beyond 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 decreased by sequential lavages: after three lavages a last resultant osmolarity the 10 mM to be attained. A solution of 10 mM was able to develop 100% cell lysis of colorectal cancer cell in vitro ~ 32 min of incubation <18>. Lin et al. Discovered that the applications of 10 l of distilled water split into at least five cycles retained for 3 min caused a significant better survival time after curative liver resection in patients with spontaneous rupture that hepatocellular carcinoma <19>. Although that is assumed that tumour cabinet injury is resulted in by osmotic shock, the precise mechanism the potential cabinet injury by distilled water is not known. Selzner et al. Assessed the impacts of 1, 3 and 5 min the hypotonic exposure on cell viability in three different human colon cancer cabinet lines. All three cell lines challenged with distilled water showed a dramatic to decrease in viability in a time-dependent manner, yet only exposure of >15 min come distilled water was linked with far-ranging increases in cell lysis. Follow to Selzner N et al. Cell death is related to temporary cell swelling that root cause activation the apoptosis. Necessary receptors because that this apoptosis pathway were not detected in common cells (human fibroblasts) ~ a challenge with one of two people distilled water or isotonic media <20>.

Based on these reports we assume that the lavage an approach that we usage to achieve hemostasis is not enough for complete tumour cabinet lysis. The incubation time is short and also numbers of lavages are fairly small. Nevertheless, complimentary tumour cell in the pelvis can to some extent suffer indigenous hypotonic distilled water lavage.


Conclusion

Distilled water is a advantageous tool to accomplish hemostasis per-operatively. Erythrocytes burst in the hypotonic distilled water, ensuring a transparent systems in which a blood stream have the right to be conveniently traced to its origin. ~ suctioning the water the end of the pelvis, bleedings can be stopped.

The affect of the method on the full amount of blood loss or operation time can not quickly be estimated due to the fact that other per-operative determinants outweigh the effect of distilled water in that respect, yet distilled water is definitely relevant for surgeons during a difficult step of the operation procedure.

A possible an unfavorable side effect of this method is damages to the peritoneal mesothelial cells. Distilled water lavage might confuse the ab defence system and might contribute in this way to the development of peritoneal adhesions. We might not evaluate the possible harmful result of distilled water lavage on operation exposed surfaces. The described an approach is not suspected to cause systemic side effects during or soon after operation treatment. Distilled water lavage could induce tumour cells lysis, however the at this time used technique is probably not adequate to achieve this useful effect.

In the lack of obvious indications on possible an adverse side impacts of distilled water lavage as described above, we take into consideration it sufficiently for sure to apply this useful technique in operation practice.

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This article is spread under the regards to the an innovative Commons Attribution Noncommercial patent which permits any kind of noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.