Surgical Wound Class

[shag]

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

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[Winged Scapula]

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)?

IV gross contamination.

Ostomy creation (II or III)

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.

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

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.

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.

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.

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

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

 

[opr8n]

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?

 

[opr8n]

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?

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

 

[Winged Scapula]

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

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.

 

[opr8n]

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.

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

 

[Winged Scapula]

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

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

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?

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

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

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.

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

IV - less than 6 or 8 hrs old, bullet presumably clean but also with gross spillage from unprepped bowel. Poop in belly gets a 4.

Perforated duodenal ulcer
III or IV?

Depends on what I find but probably a 4 since there will be some bacteria floating around from the duo and presumably digested food particles as well.