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


M. P. H. Busard

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


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

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This short article is spread under the regards to the an imaginative Commons Attribution Noncommercial license which permits any type of noncommercial use, distribution, and reproduction in any medium, detailed the original author(s) and source are credited.

Distilled water is used worldwide to examine on hemostasis in ~ the finish of pelvic oncological operations. Nevertheless, reports about this method are lacking. The aim of this study was to describe the method and come discuss possible side effects. After ~ the enhancement of distilled water to the operation exposed pelvis, fast lysis that erythrocytes results in a transparent fluid in i m sorry a tiny source of bleeding is easily recognizable. A feasible side effect of the lavage can be donation to the development of peritoneal adhesions by confusing the ab defence system. Systemic side results are no to it is in expected. Although tumour cells might suffer native hypotonic distilled water lavage, the present use of distilled water at the end of surgical treatment is most likely not reliable to lyse tumour cells. Ours findings assistance the recurring use of distilled water lavage to attain hemostasis after extensive pelvic surgery.


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

Introduction

After considerable pelvic surgery, e.g. Oncological work or surgical procedure for endometriosis, the surgeon deserve to be faced with a raw, oozing area in the pelvis. Stopping small venous bleeders to achieve adequate hemostasis is frequently a daunting task in this areas. Distilled water lavage renders the detection that the resources of bleeding lot easier. When lavage v NaCl 0.9% come clean the operation ar after surgery is commonly accepted and also often discussed in literature, strangely sufficient we haven’t seen any kind of publication top top the use of distilled water (aquadest). The target of this report is to describe the usage of distilled water for the purpose of achieving hemostasis during surgery. As well as informing around its usefulness and also ease, we desire to carry out background information about the system that provides distilled water applicable for this purpose. Apart from the valuable effects that distilled water, it is imaginable that the enhancement of a hypotonic fluid thus to the pelvis could not it is in without any side effects. We briefly comment on these elements.


Mechanism


Clinical application

Before closeup of the door the abdomen, 500 cc that distilled water is poured into the ab cavity. In comparison to NaCl 0.9%, which provides a blurred view with an opaque fluid, distilled water remains clearly transparent and also ensures a bright vision in the tiny pelvis. Together a consequence, tiny venous bleeding is conveniently recognizable and the bleeding site can be correctly traced. Once sources the bleeding have actually thus to be discovered, the distilled water is suctioned out of the pelvis and also the bleedings space stopped in the suitable way. In general, 2 sequential lavages room used. Number ​Figure11 reflects two examples.


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Physiology

Within a certain range of outside solute concentrations, erythrocytes behave as an osmometer: their volume is inversely related to the solute concentration in a medium. The erythrocyte shrinks in hypertonic solutions and also swells in hypotonic solutions. When an erythrocyte has swollen to about 1.4 time its original volume, it begins to lyse (burst). At this volume the properties of the cell membrane abruptly change, haemoglobin leaks out of the cell and the membrane becomes transiently permeable to many molecules <1>.

NaCl is isotonic to the red blood cell at a concentration that 154 mM. This synchronizes with NaCl 0.9%. The red blood cell has actually its common volume in isotonic NaCl. Erythrocytes remain intact in NaCl 0.9%, causing an opaque suspension. Distilled water at the same time is hypotonic to red blood cells. The red blood cabinet will thus swell and haemoglobin, comprise the haem that provides the red colour come erythrocytes, leaks from the cell bring about a transparent red-pink-coloured solution. Apparently, erythrocytes in clear liquid colour the liquid red and also opaque, vice versa, haemoglobin in clear fluid leaves the liquid transparent.


Laboratory experiment

To further explore the appearance of a traceable blood stream when 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 come the bottom was visible in both tubes. After ~ stirring the pipe both solutions gained turbid, however for the distilled water equipment this only lasted a moment. Around 5 s after the stirring, the distilled water systems turned glowing red-pink, plainly transparent. The NaCl solution remained opaque red-pink. After 30 s, a autumn of liquid of both solutions was check under the microscope. In the NaCl solution, normal erythrocytes were visible, whereas no regular erythrocytes to be visible in the distilled water solution. Subsequently, one more 10 µl that erythrocytes was included to both solutions. The traceable stream was visible again in the red-pink distilled water solution, whereas a stream could not be seen in the turbine NaCl solution. Part time after stirring, the distilled water solution turned shining red-pink again, when 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 prior to the distilled water solution turned bright red-pink after stirring and the colour of the solution got darker. At a concentration of 16:115 (160 µl erythrocytes in 990 µl H2O), the distilled water equipment was no much longer transparent and a blood stream was no visible anymore.

This experiment mimics the clinical situation and shows that a traceable blood currently does appear in both distilled water and NaCl 0.9%, but is just visible in a transparent fluid. In contrast to NaCl, distilled water retains its transparency after ~ the addition of blood together a result of the quick lysis that erythrocytes. The difference in transparency can be contrasted with the difference in between fruit juice (NaCl) and also lemonade (distilled water). Erythrocytes added to the solution cause the osmolarity the the systems to rise, and also the difference in hydrostatic pressure to decrease, resulting in a lengthy time of cell lysis. More than likely because much more intact or swollen erythrocytes will be current in the distilled water equipment after continuous mixing v blood or various other intra-abdominal fluid, the solution becomes less transparent. This occasionally necessitates more than one lavage cycle.


Peritoneal damage

Peritoneal mesothelial cell play a primary duty in the abdominal muscle defence system. They have the right to express certain surface markers that enable them to promote the margination and migration that neutrophil granulocytes and also produce crucial molecules such as pro-inflammatory cytokines, nitric oxide, development molecules, tissue plasminogen activator and also plasminogen activator inhibitor <2>. Peritoneal mast cells have been presented to have a direct effect ~ above peritoneal adhesion formation. Mast cell mediators induce fibroblast proliferation and mast cabinet hyperplasia has actually been displayed to be existing in person peritoneal adhesions <3>.

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

Polubinska et al. Perform an in vitro study of mesothelial monolayers exposed come NaCl 0.9% and also different peritoneal dialysis fluids, consisting of hypertonic remedies with short glucose degradation assets concentration. Back the hypertonic liquid caused damages to the cabinet membrane, the viability of the cells was not reduced and fybrinolytic task was preserved. In contrast, cells exposed to NaCl 0.9% showed transforms that could promote the formation of peritoneal adhesion formation. In a rat examine of this group, hypertonic lavage equipment was reported to suppress intra-peritoneal inflammation and also mesothelial hyperplasia as compared to normal saline. The authors recommend the use of hypertonic remedies with short glucose degradation commodities concentration for both peritoneal dialysis and also rinsing that the peritoneal cavity per-operatively <6, 9>. However, hypotonic options were no studied and also the impacts reported in this study might probably it is in attributed to the glucose dehydration product concentration quite than come osmolarity itself. Adhesion formation was not studied and the study teams were small. Kanakura et al. Studied number and types of mast cell in the peritoneal cavity of mice after injection of distilled water or saline. Back the intra-peritoneal injection of saline did no significantly affect the variety of peritoneal mast cells, the intra-peritoneal injection the distilled water eradicated little and medium (differentiated) mast cabinet colony-forming cells, while the number of big 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 role in vivo.

Based top top the existing literature, us assume that peritoneal lavage with any kind of solution will an outcome in disturbance the the homeostasis in the pelvis. Lavage with distilled water might alter the abdominal defence device by up-regulation the pro-inflammatory mediators. This can lead to the formation of adhesions. The extent of this effect of distilled water in relationship to various other media is no clear. The same mechanisms can damage the lining that the per-operatively exposed organs and also tissues, however we have actually no means to that s right quantify this impact in vivo.


Systemic effects

One have the right to speculate ~ above a systemic effect of distilled water pelvic lavage. The absorption of distilled water offered as an irrigation fluid in endoscopic procedures has actually been report to disturb the circulatory system and lead come clinical symptoms well-known as the transurethral resection (TURP) syndrome. Acute transforms in intravascular volume and plasma solute concentration might contribute to hypotension, and also even acute renal failure has been reported <11>. Hypotonic distilled water straight entering the circulation through opened up veins or absorbed much more slowly, can cause haemolysis. Intra-vesicular pressure above 30 mmHg and also increasing resection time have been proposed to boost the absorb of liquid <12, 13>. Averagely, 15 l that irrigation liquid is used throughout a 60-min-lasting TURP procedure <14, 15>. Still, severe changes in blood values after TURP with distilled water were seldom reported and it has actually been displayed to it is in a for sure irrigating fluid for TURP <15>.

Since in the procedure we define only small volumes the distilled water are supplied for a quick time in ~ the finish of the operation procedure and without pressure, we have no reason to suspect systemic side impacts as a an outcome of the applications of distilled water in the pelvis at the end of the surgical procedure.


Lysis that tumour cells

Besides possible an adverse side effects, distilled water lavage to acquire hemostasis might also have an unintentional advantageous effect.

Although over there is no consensus about the optimal lavage method, e.g. Incubation time to accomplish effective lysis and the potential the sequential lavages, numerous studies showed a harmful result of distilled water top top tumour cells. Human being tumour cell lines seem come be sensitive to osmotic shock in vitro. Fechner et al. Found far-ranging bladder tumour cell dead ~ 10 min the exposure come distilled water lavage <16>. Mercill et al. It was observed a diminish in DNA synthetic in various tumour cabinet lines after exposure to distilled water because that 1 to 10 min. However, the continuing to be cells go not shed their replication volume <17>. In a research of Huguet et al., colorectal cancer cell lines were incubated with distilled water and also no surviving cells were found past 12 min incubation. Water introduced into the peritoneal cavity in vivo was contaminated through intra-peritoneal secretions, compromising the osmotic lysis effect. However, this pollution was lessened by sequential lavages: after 3 lavages a last resultant osmolarity that 10 mM to be attained. A equipment of 10 mM was able to create 100% cell lysis that colorectal cancer cells in vitro after 32 min the incubation <18>. Lin et al. Uncovered that the applications of 10 l that distilled water separated into in ~ least 5 cycles kept for 3 min caused a significant much better survival time after ~ curative liver resection in patients through spontaneous rupture the hepatocellular carcinoma <19>. Although the is assumed that tumour cell injury is caused by osmotic shock, the specific mechanism that potential cell injury by distilled water is no known. Selzner et al. Assessed the results of 1, 3 and also 5 min of hypotonic exposure on cell viability in three various human colon cancer cabinet lines. All 3 cell lines tested with distilled water showed a dramatic to decrease in viability in a time-dependent manner, yet only exposure the >15 min to distilled water was associated with far-ranging increases in cell lysis. Follow to Selzner N et al. Cell death is pertained to temporary cell swelling that triggers activation that apoptosis. Crucial receptors because that this apoptosis pathway were not detected in normal cells (human fibroblasts) after ~ a an obstacle with either distilled water or isotonic media <20>.

Based on these reports we assume that the lavage an approach that we use to accomplish hemostasis is not enough for complete tumour cabinet lysis. The incubation time is short and also numbers that lavages are relatively small. Nevertheless, complimentary tumour cell in the pelvis might to some level suffer from hypotonic distilled water lavage.


Conclusion

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

The affect of the method on the total amount of blood ns or operating time deserve to not quickly be estimated since other per-operative determinants outweigh the effect of distilled water in that respect, however distilled water is certainly relevant for surgeons throughout a complicated step that the operation procedure.

A possible negative side result of this an approach is damage to the peritoneal mesothelial cells. Distilled water lavage could confuse the ab defence system and might add in this method to the development of peritoneal adhesions. We can not assess the feasible harmful impact of distilled water lavage on surgically exposed surfaces. The described technique is not suspected to reason systemic side effects during or shortly after operation treatment. Distilled water lavage might induce tumour cell lysis, yet the right now used method is probably not adequate to accomplish this useful effect.

In the absence of evident indications top top possible an unfavorable side results of distilled water lavage as described above, we consider it sufficiently safe to use this useful an approach in operation practice.

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