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Surgical Wound Classification Wound Class Definition Examples Reminders Class I Clean Operative wound clean Non-traumatic, with no inflammation encountered No break in technique Gastrointestinal, respiratory and genitourinary tracts not entered Neurological procedures Endocrine procedures Eye surgery Orthopedic procedures Penile prosthesis Vascular procedures Skin (mastectomy, lumpectomy, lesions, lipoma, cosmetic Exploratory Lap (no bowel involvement II) Miscellaneous procedures Removing old implants (wires, pins, etc…) Common cases: (Amputation, arthroplasty, blephoroplasty, closed fracture, herniorrhaphy, laminectomy, laparoscopy, lipoma excision, mastectomy, mediastinectomy, orchiopexy, reconstructive (ortho), rhytidectomy (facelift), spleenectomy) Class II Clean Contaminated Operative wound clean-contaminated Thoracic procedure (except mediatinoscopy I) Non-traumatic wound with minor break in technique GI procedures (including: laparoscopy, colonoscopy, gastroscopy), (it is III) Gastrointestinal, respiratory and genitourinary tracts entered without significant spillage. Includes: Hysterectomy GU procedures (infected III) Ear surgery (infected III) Nose/Oropharynx procedures GYN procedures (oophorectomy I, inflammed III, infective IV) Any wound open for drainage II (except total hip/ knee) Re-operation at the same site Common cases: (Appendectomy elective, bowel resection, colostomy closure, cystoscopy, gastrectomy, chronic/basic gallbladder, thoracotomy for lung resection, myringectomy - BMT, nephrotomy, nephrectomy, open lung biopsy (thoracotomy), oral surgery w/o infection, otopharygeal, pyelolithotomy, renal transplant, suprapubic prostatectomy, tuboplasty, salpingoopherectomy) Class III Contaminated Operative wound contaminated Fresh traumatic wound from clean source operative wound with a major break in techique Gross spillage from the gastrointestinal tract Incision encountering acute non-purulent inflamation Inflammation Gross spillage Fresh accidental wound Foreign bodies in a wound (sponge, etc…) Common cases: (Bowel resection w/peritonitis, old burns, open fracture over 4hrs, open traumatic wound) Class IV Operative wound dirty Traumatic wound from dirty source Traumatic wound from dirty source Fecal contamination Infected Foreign body I & D abscess Dirty - infected Retained devitialized tissue Wound debridement Operative wound with acute bacterial inflammation or perforated viscus Operative wound where clean tissue is transected to gain access to a collection of pus Common cases: (Bartholin cyst, bowel resection w/perforation, empyema, sinus infection, pelvic abscess, pilonidal cyst infected) Unclassified When unable to classify accurately an operative wound Communicable disease (aids, hepatitis, TB) is not classified the surgical wound is what is being classified.
