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Surgical Wound Class

Discussion in 'Surgery and Surgical Subspecialties' started by shag, 01.24.08.

  1. shag

    shag Supreme Procrastinator

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    I am reviewing charts for a project and would appreciate opinions about wound classifications. The current classification system is old, and doesn't specifically address certain cases. The classification that I use is at the end of this post.

    How would you classify a reentry laparotomy with infected mesh but no pus (III or IV)?

    Ostomy creation (II or III)?

    Ventral hernia repair when the patient has a colostomy or ileal conduit in place? Laparoscopic repair?

    Socked in abdomen requiring lysis of adhesions (> 1 or 2 hr)? It is hard to call this class I , though this may be technically correct.

    Repair of fresh fascial dehiscence when the skin is not broken? with noninfected drainage? evisceration?

    Any ideas??

    The classification that I use is a compilation of a few systems I found in the literature or textbooks:

    Clean(Class I):
    • Non-traumatic (surgical wounds following blunt trauma are in this category if they meet all other criteria.
    • No inflammation or infection
    • GI, Resp or GU tract not entered
    • Primary closure +/- drains

    Clean-contaminated (Class II):
    • GI or Resp tract entered under controlled conditions without unusual contamination

    Contaminated (Class III):
    • Gross spillage from the GI tract
    • Open traumatic wounds < 4 hours old
    • Entrance into GU or biliary tract with infected urine or bile
    • Major break in technique

    Dirty and Infected (Class IV):
    • Acute bacterial inflammation encountered, without pus
    • Transsection of "clean" tissue to access pus collection
    • Preoperative perforation of respiratory, gastrointestinal, biliary or genitourinary tract
    • Traumatic wound with retained devitalized tissue, foreign bodies, fecal contamination, and/or > 4 hours old; or from a dirty source
  2. Winged Scapula

    Winged Scapula Cougariffic! Administrator SDN Senior Moderator Lifetime Donor

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    IV gross contamination.

    Depends...elective surgery with prepped bowel and no spillage gets a two. Trauma laparotomy or gross surgical error which entails an large enterotomy without prepped bowel (see ObGyn cases;) ) gets a 3.

    No difference if its open or laparoscopic...still gets a clean/I. I am not expected to have spillage from either ostomy or to injure the conduit.

    Why is this hard to call a 1? Unless you have entered the GI, GU or Resp tracts, it is a 1. Of course, you may certainly inadvertently make enterotomies but you aren't expecting to.

    I find it hard to believe you would have a dehisc without infection, and the skin will be "broken" from the surgical wound...so its probably a 4
  3. opr8n

    opr8n

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    i have a few more that ive found conflicting info on

    lap chole for cholelithiasis (I found one article suggesting this was the exception to clean-contaminated and is actually a clean case??, im not sure about that)
    I or II?

    Lap chole for cholelithiasis, spilled bile in abdomen
    II or III?

    Gunshot wound, perforated colon, less than 4 hours old
    III or IV?

    Perforated duodenal ulcer
    III or IV?
  4. opr8n

    opr8n

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    common people, help me out
    im pretty sure i know the answer to all of these but ineed some input
  5. Winged Scapula

    Winged Scapula Cougariffic! Administrator SDN Senior Moderator Lifetime Donor

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    I guess I (and I suppose others) are confused as to why you are wasting brain space on this information. I've never been asked to classify a wound; its not on the ABSITE nor does anyone in the OR ask.
  6. opr8n

    opr8n

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    im givign a lecture to medical students tommorow
    and ive found very conflicting info on these four questions
    i was pretty sure i knew the answer to all of these, but apparently there is more that one source saying something different
    just curious what other people thought

    3rd year medical students can be relentless sometimes
    i just wanted to make sure i knew what i was going to say and why before i say it

    any input would be appreciated
  7. Winged Scapula

    Winged Scapula Cougariffic! Administrator SDN Senior Moderator Lifetime Donor

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    Tell those pipsqueaks that this is a controversial area with many factors and just as many opinions.

    II - bile is sterile generally but you have entered the biliary/GI tract, so I give it a 2.

    Again, bile is sterile, so I don't know I'd give it a 3, so I choose 2 unless cholecystitis, cholangitis or purulent bile spillage.

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