Operative wound classification: an inaccurate measure of pediatric surgical morbidity

Background Wound classification has catapulted to the forefront of surgical literature and quality care discussions. However, it has not been validated in laparoscopy or children. We analyzed pediatric infection rates based on wound classification and reviewed the most common noninfectious complications which could be a more appropriate measure for quality assessment. Methods We performed a retrospective review of 800 patients from 2011 to 2014 undergoing common procedures at a tertiary pediatric hospital. Demographics, procedure, wound classification and complications were analyzed using descriptive statistics. Results Infection rates were in the expected low range for clean procedures. However, 5% of pyloromyotomy patients required readmission and 10% of circumcision patients developed penile adhesions; 2% required reoperation. Ostomy reversal, a clean contaminated case, had 17% wound infections, whereas acute appendicitis, a contaminated case had only a 4% infection rate. Laparoscopic cholecystectomy (clean-contaminated or contaminated depending on inflammation) had 2% postoperative infections. Perforated appendicitis, a dirty procedure had an 18% infection rate, below the expected > 27% for dirty cases in adults. Conclusions Current wound classifications do not accurately approximate the risk of surgical site infections in children, particularly for laparoscopic procedures. It would be more appropriate to grade hospitals based on disease and procedure specific complications.