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

S. A. H. M. van den Tillaart

Department of Gynaecology K6-P, Leiden College Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands


M. P. H. Busard

Department of Gynaecology K6-P, Leiden College Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands


J. B. M. Z. Trimbos

Department of Gynaecology K6-P, Leiden College Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands


Department of Gynaecology K6-P, Leiden College Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands
Corresponding author.

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This article is spread under the regards to the Creative Commons Attribution Noncommercial License which permits any type of noncommercial use, distribution, and also remanufacturing in any tool, provided the original author(s) and also source are attributed.

Distilled water is used global to examine on hemostasis at the end of pelvic oncological operations. However, reports about this approach are doing not have. The aim of this study wregarding explain the method and also to talk about feasible side results. After the enhancement of distilled water to the surgically exposed pelvis, fast lysis of erythrocytes results in a transparent liquid in which a small source of bleeding is easily recognizable. A possible side impact of the lavage could be contribution to the formation of peritoneal adhesions by confutilizing the abdominal defence mechanism. Systemic side results are not to be intended. Although tumour cells could experience from hypotonic distilled water lavage, the existing usage of distilled water at the finish of surgical treatment is probably not reliable to lyse tumour cells. Our findings assistance the ongoing usage of distilled water lavage to achieve hemostasis after substantial pelvic surgical procedure.


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

Introduction

After extensive pelvic surgery, e.g. oncological operations or surgical treatment for endometriosis, the surgeon can be confronted with a raw, oozing location in the pelvis. Stopping little venous bleeders to attain sufficient hemostasis is often a challenging task in these locations. Distilled water lavage provides the detection of the sources of bleeding much less complicated. While lavage with NaCl 0.9% to clean the operation area after surgery is commonly embraced and also frequently discussed in literature, strangely sufficient we haven’t checked out any kind of publication on the use of distilled water (aquadest). The aim of this report is to describe the usage of distilled water for the function of achieving hemostasis during surgical treatment. Besides indeveloping around its usefulness and also ease, we want to carry out background indevelopment about the device that renders distilled water applicable for this function. Apart from the helpful impacts of distilled water, it is imaginable that the enhancement of a hypotonic fluid as such to the pelvis could not be without any type of side effects. We briefly comment on these aspects.


Mechanism


Clinical application

Before closing the abdomales, 500 cc of distilled water is poured into the abdominal cavity. In comparison to NaCl 0.9%, which provides a blurred view through an opaque liquid, distilled water stays plainly transparent and ensures a bbest sight in the small pelvis. As a consequence, little venous bleeding is quickly recognizable and the bleeding site have the right to be accurately traced. When sources of bleeding have therefore been uncovered, the distilled water is suctioned out of the pelvis and the bleedings are quit in the appropriate method. In basic, two sequential laveras are provided. Figure ​Figure11 shows two examples.


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Physiology

Within a particular array of external solute concentrations, erythrocytes behave as an osmometer: their volume is inversely related to the solute concentration in a tool. The erythrocyte shrinks in hypertonic options and also swells in hypotonic services. When an erythrocyte has swollen to around 1.4 times its original volume, it starts to lyse (burst). At this volume the properties of the cell membrane abruptly change, haemoglobin leaks out of the cell and also the membrane becomes transiently permeable to the majority of molecules <1>.

NaCl is isotonic to the red blood cell at a concentration of 154 mM. This coincides with NaCl 0.9%. The red blood cell has its normal volume in isotonic NaCl. Erythrocytes reprimary undamaged in NaCl 0.9%, bring about an opaque suspension. Distilled water on the other hand also is hypotonic to red blood cells. The red blood cell will therefore swell and also haemoglobin, containing the haem that offers the red colour to erythrocytes, leaks from the cell bring about a transparent red-pink-coloured solution. Apparently, erythrocytes in clear fluid colour the liquid red and also opaque, whereas haemoglobin in clear fluid leaves the fluid transparent.


Laboratory experiment

To further check out the appearance of a traceable blood stream when using distilled water lavage, we perdeveloped an in vitro experiment. Ten microlitres of humale 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. After stirring the tubes both solutions got turbid, but for the distilled water solution this just lasted a moment. Approximately 5 s after the stirring, the distilled water solution turned bbest red-pink, clearly transparent. The NaCl solution remained opaque red-pink. After 30 s, a drop of liquid of both options was examined under the microscopic lense. In the NaCl solution, normal erythrocytes were visible, whereas no normal erythrocytes were visible in the distilled water solution. Subsequently, an additional 10 µl of erythrocytes was included to both remedies. The traceable stream was visible again in the red-pink distilled water solution, whereas a stream can not be seen in the turbine NaCl solution. Some time after stirring, the distilled water solution turned bideal red-pink aget, while the NaCl solution obtained even more opaque. Successively, volumes of 10 µl erythrocytes were added to the tubes. When proceeding the process, it took longer prior to the distilled water solution turned bappropriate red-pink after stirring and the colour of the solution obtained darker. At a concentration of 16:115 (160 µl erythrocytes in 990 µl H2O), the distilled water solution was no longer transparent and a blood stream was not visible anymore.

This experiment mimics the clinical situation and reflects that a traceable blood stream does appear in both distilled water and also NaCl 0.9%, however is just visible in a transparent fluid. In comparison to NaCl, distilled water retains its transparency after the enhancement of blood as a result of the rapid lysis of erythrocytes. The distinction in transparency deserve to be compared with the distinction in between fruit juice (NaCl) and lemonade (distilled water). Erythrocytes included to the solution reason the osmolarity of the solution to rise, and also the distinction in hydrostatic push to decrease, causing a prolonged time of cell lysis. Probably because even more undamaged or swollen erythrocytes will certainly be current in the distilled water solution after constant mixing with blood or various other intra-abdominal fluid, the solution becomes less transparent. This sometimes necessitates even more than one lavage cycle.


Peritoneal damage

Peritoneal mesothelial cells play a major role in the abdominal defence mechanism. They can express specific surchallenge markers that permit them to promote the margicountry and also migration of neutrophil granulocytes and create crucial molecules such as pro-inflammatory cytokines, nitric oxide, growth molecules, tproblem plasminogen activator and also plasminogen activator inhibitor <2>. Peritoneal mast cells have been presented to have a direct effect on peritoneal adhesion formation. Mast cell mediators induce fibroblast proliferation and mast cell hyperplasia has been displayed to be current in human peritoneal adhesions <3>.

It is not recognized through which system peritoneal mesothelial cells behave as soon as exposed to various concentrations of lavage services, but they are damaged by services that are far from physiological, such as peritoneal dialysis fluids. Even services that are even more physiological have actually been shown to reason changes in synthesis of particular molecules <4–6>. In vitro studies proved that peritoneal lavage via normal saline reasons up-regulation of pro-inflammatory cytokines, and that per-operative lavage options influence the peritoneal defence mechanisms. Both antiseptic lavage solutions and physiologic salt caused cell death and also decreased integrity in the mesothelial monolayer <7, 8>.

Polubinska et al. perdeveloped an in vitro study of mesothelial monolayers exposed to NaCl 0.9% and also different peritoneal dialysis fluids, consisting of hypertonic services through low glucose destruction commodities concentration. Although the hypertonic fluid caused damage to the cell membrane, the vicapability of the cells was not decreased and fybrinolytic activity was kept. In comparison, cells exposed to NaCl 0.9% verified changes that can promote the formation of peritoneal adhesion formation. In a rat study of this team, hypertonic lavage solution was reported to suppress intra-peritoneal inflammation and mesothelial hyperplasia as compared to normal saline. The authors advise the use of hypertonic remedies via low glucose degradation assets concentration for both peritoneal dialysis and rinsing of the peritoneal cavity per-operatively <6, 9>. However, hypotonic solutions were not studied and also the results reported in this examine might more than likely be attributed to the glucose dehydration product concentration quite than to osmolarity itself. Adhesion formation was not stupassed away and the examine teams were tiny. Kanakura et al. studied numbers and forms of mast cells in the peritoneal cavity of mice after injection of distilled water or saline. Although the intra-peritoneal injection of saline did not substantially affect the number of peritoneal mast cells, the intra-peritoneal injection of distilled water eradicated small and medium (differentiated) mast cell colony-forming cells, while the variety of large mast cell colonies increased <10>.

The effects of lavage fluid volume and incubation time on the above-defined mechanisms are not well-known, neither is their role in vivo.

Based on the existing literature, we assume that peritoneal lavage with any type of solution will certainly cause disturbance of the homeostasis in the pelvis. Lavage with distilled water might alter the abdominal defence device by up-regulation of pro-inflammatory mediators. This might bring about the formation of adhesions. The extent of this result of distilled water in propercent to other media is not clear. The very same mechanisms could damage the lining of the per-operatively exposed organs and also tproblems, yet we have actually no means to accurately quantify this effect in vivo.


Systemic effects

One can speculate on a systemic effect of distilled water pelvic lavage. The absorption of distilled water supplied as an irrigation fluid in endoscopic actions has actually been reported to disturb the circulatory device and result in clinical symptoms recognized as the transurethral resection (TURP) syndrome. Acute changes in intravascular volume and also plasma solute concentrations can contribute to hypostress and anxiety, and even acute renal failure has actually been reported <11>. Hypotonic distilled water directly entering the circulation through opened veins or soaked up more gradually, have the right to cause haemolysis. Intra-vesicular push over 30 mmHg and raising rearea time have been proposed to increase the absorption of liquid <12, 13>. Averagely, 15 l of watering fluid is offered during a 60-min-lasting TURP procedure <14, 15>. Still, serious transforms in blood values after TURP through distilled water were hardly ever reported and it has actually been shown to be a safe irrigating fluid for TURP <15>.

Since in the procedure we describe just small volumes of distilled water are offered for a short time at the finish of the surgical procedure and without press, we have no factor to suspect systemic side results as an outcome of the application of distilled water in the pelvis at the end of the surgical procedure.


Lysis of tumour cells

Besides feasible negative side impacts, distilled water lavage to achieve hemostasis can likewise have actually an unintentional beneficial impact.

Although tbelow is no agreement around the optimal lavage approach, e.g. incubation time to achieve efficient lysis and also the potential of sequential laveras, several research studies confirmed a harmful effect of distilled water on tumour cells. Human tumour cell lines seem to be sensitive to osmotic shock in vitro. Fechner et al. discovered substantial bladder tumour cell dead after 10 min of exposure to distilled water lavage <16>. Mercill et al. observed a decrease in DNA synthesis in different tumour cell lines after expocertain to distilled water for 1 to 10 min. However, the remaining cells did not lose their replication capacity <17>. In a study of Huguet et al., colorectal cancer cell lines were incubated through distilled water and also no enduring cells were found past 12 min incubation. Water presented into the peritoneal cavity in vivo was contaminated by intra-peritoneal secretions, compromising the osmotic lysis impact. However, this contamicountry was reduced by sequential lavages: after three lavages a final resultant osmolarity of 10 mM was attained. A solution of 10 mM was able to develop 100% cell lysis of colorectal cancer cells in vitro after 32 min of incubation <18>. Lin et al. discovered that the application of 10 l of distilled water divided right into at least 5 cycles preserved for 3 min brought about a far-ranging better survival time after curative liver rearea in patients with spontaneous rupture of hepatocellular carcinoma <19>. Although it is assumed that tumour cell injury is resulted in by osmotic shock, the exact system of potential cell injury by distilled water is not well-known. Selzner et al. assessed the impacts of 1, 3 and 5 min of hypotonic expocertain on cell viability in three different human colon cancer cell lines. All 3 cell lines tested through distilled water showed a dramatic decrease in vicapacity in a time-dependent manner, yet only exposure of >15 min to distilled water was connected with substantial rises in cell lysis. According to Selzner N et al. cell fatality is pertained to temporary cell swelling that triggers activation of apoptosis. Essential receptors for this apoptosis pathmeans were not detected in normal cells (human fibroblasts) after an obstacle with either distilled water or isotonic media <20>.

Based on these reports we assume that the lavage method that we usage to accomplish hemostasis is not adequate for finish tumour cell lysis. The incubation time is short and also numbers of lavages are fairly tiny. However, cost-free tumour cells in the pelvis might to some extent experience from hypotonic distilled water lavage.


Conclusion

Distilled water is a valuable tool to accomplish hemostasis per-operatively. Erythrocytes burst in the hypotonic distilled water, ensuring a transparent solution in which a blood stream deserve to be quickly traced to its beginning. After suctioning the water out of the pelvis, bleedings can be quit.

The affect of the approach on the total amount of blood loss or operating time have the right to not conveniently be approximated because various other per-operative determinants outweigh the impact of distilled water in that respect, yet distilled water is certainly pertinent for surgeons throughout a complicated action of the surgical procedure.

A possible negative side effect of this strategy is damages to the peritoneal mesothelial cells. Distilled water lavage could confuse the abdominal defence system and also can add in this means to the formation of peritoneal adhesions. We could not assess the possible harmful result of distilled water lavage on surgically exposed surencounters. The defined method is not suspected to reason systemic side impacts throughout or quickly after surgical treatment. Distilled water lavage can induce tumour cells lysis, yet the presently used approach is probably not enough to attain this helpful effect.

In the absence of obvious indications on possible negative side effects of distilled water lavage as described above, we consider it sufficiently safe to apply this advantageous method in surgical exercise.

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