Surgical wounds are created during medical procedures and include incisions made with a scalpel, punctures for a laparoscope or arthroscope, or excisional wounds fashioned for a biopsy.1 There are 4 classifications of surgical wounds, often determined as part of, and included in, a preprocedural process, to better understand risk for surgical site infection. If the surgical and postoperative courses proceed without adverse events, the surgeon may close the surgical wound primarily with sutures or staples, and the wound will ideally resolve during recovery through the expected stages of tissue healing. However, wound care professionals understand that there are many contributing circumstances that determine any wound’s trajectory, and surgical wounds are no exception.1

How Can Clinicians Classify Surgical Wounds?

The Centers for Disease Control and Prevention (CDC) created the following Surgical Wound Classification (SWC), often used as part of a preprocedural surveillance program to prevent surgical site infections (SSI)1-3:

Class 1/Clean: These wounds are usually closed primarily, are not infected, and do not involve significant inflammation. If a drain is necessary, the drain system must be considered closed. These wounds do not involve areas prone to high levels of microorganism colonization, such as the respiratory, alimentary, genital, or urinary tracts.1,3 Risk for infection is usually less than 2%.3 An example of a Class 1 surgical wound is excision of a soft tissue mass on the arm with complete primary closure.
Class 2/Clean-Contaminated: These types of surgical wounds may involve areas such as the respiratory, alimentary, genital, or urinary tracts, however, they do not typically have risk of unusual or unexpected contamination. Instead, these wounds are monitored under planned and controlled conditions.1,3 Infection risk in this class is typically less than 10%.3 An example of a Class 2 surgical wound is creation of an ostomy without adverse event.
Class 3/Contaminated: This class includes fresh, open wounds with an assumed level of contamination due to circumstances. These can also result from an error in sterile technique, accidental creation of a wound, or a leakage of gastrointestinal materials in the wound area. Additionally, incisions that result in acute inflammation (without purulence) are considered class 3 wounds.1,3 The range of infection risk for class 3 surgical wounds is 13-20%, however those with gastrointestinal involvement possibly higher.3 An example of a Class 3 surgical wound would be surgery for an open, traumatic fracture.
Class 4/Dirty-Infected: Class 4 wounds demonstrate devitalized tissue, and they most commonly result from microorganisms present in perforated viscera or in the operative field.1,3 Contamination may already be present at the time of surgery that later results in postoperative infection.3 Risk for infection is around 40%.3 An example of a Class 4 surgical wound is one created for incision and drainage of a deep-space diabetic foot infection.

During the procedure, usually a preoperative assessment or “time out,” a clinician will determine the present level of contamination, and thus the SWC. Each organization’s exact algorithm may vary slightly, but the personnel (many times the surgeon, circulating nurse, or a combination of team members) will lead the identification and documentation of this assessment.1 If events transpire intraoperatively that change this classification, this event should also be documented.

What Guidance Does the Surgical Wound Classification Provide?

The SWC supports the use of pre- and postoperative antibiotics depending on specific factors. For instance, dirty-Infected or Contaminated procedures do not usually necessitate preoperative antibiotic prophylaxis, since they likely require specific postoperative antibiotic therapy.4 Additionally, the surgeon may wish to hold preoperative antibiotics when indicated to aid in a more accurate deep wound or tissue culture.

Preoperatively, clean-contaminated procedures may warrant, at minimum, prophylactic coverage for Staphylococci, and possibly other organisms depending on the anatomic area in question.4 Pending facility protocol and patient factors, this prophylaxis could include weight-adjusted dosing of cefazolin or vancomycin, with the addition of metronidazole, ertapenem, or cefoxitin.4 In the operating room, additional prophylactic antimicrobial doses should not be administered after the surgical incision is closed in clean and clean-contaminated procedures, even in the presence of a drain.5

How Much Do You Know About Surgical Wound Care? Take our quiz to find out! Click here.

Understanding the risk stratification for each type of surgical wound may allow the surgical and postoperative team to make choices that align with SSI prevention tailored to their respective wound class. For instance, a clean, primarily closed surgical wound from a lower-risk procedure is less likely to necessitate specialized intervention. However, a contaminated or dirty surgical wound may spur the team to evaluate available choices that fit the particular case’s risk profile. Are antimicrobial dressings indicated? Might more frequent dressing changes be necessary?

Clinical Cautions to Keep in Mind

The main issue of concern with the current surgical wound classification scheme is that it has low inter-rater reliability among health care providers.2 Additionally, this wound classification scheme has been shown to not work as effectively in neonatal surgical wounds. Clinicians should keep in mind that different tissue types and surgical approaches may warrant different viewpoints on the classification.6 Geographic, biologic, psychologic, and socioeconomic factors also play a role, as does the surgical site’s typical microbial community.6

Conclusion

The clinical significance of proper surgical wound classification lies in its ability to help predict the likelihood of SSIs, postoperative complications, and reoperation.6 Correctly classified surgical wounds also can potentially aid in assessing morbidity, mortality, and quality of life stratification.6 Patients receiving tissue grafts may also benefit from this classification scheme, as it can help evaluate the degree of bacterial contamination at the time of grafting and, by extension, the ability of that graft to heal correctly.6

Overall, the surgical wound classification alone should not guide perioperative or postoperative decisions, but could provide a valuable metric, in conjunction with multiple other factors, in determining risk of SSI and the optimal mitigation steps.

References

Centers for Disease Control and Prevention. National Healthcare Safety Network. Surgical Site Infection Event (SSI). Published January 2023. Accessed June 29, 2023.: https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf.
Onyekwelu I, Yakkanti R, Protzer L, Pinkston CM, Tucker C, Seligson D. Surgical Wound Classification and Surgical Site Infections in the Orthopaedic Patient. J Am Acad Orthop Surg Glob Res Rev. 2017:1(3):e022. doi: 10.5435/JAAOSGlobal-D-17-00022.
American College of Surgeons. Wound Home Skills Kit: Surgical Wounds. Accessed June 29, 2023. https://www.facs.org/media/zr5dimjk/wound_surgical.pdf.
Zabaglo M, Sharman T. Postoperative Wound Infection. In: StatPearls [Internet]. StatPearls Publishing; Updated September 19, 2022. Accessed January 2023. https://www.ncbi.nlm.nih.gov/books/NBK560533/
Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017;152(8):784–791. doi:10.1001/jamasurg.2017.0904
Herman TF. Wound Classification. In: StatPearls [Internet]. StatPearls Publishing; Published April 24, 2023. Accessed June 29, 2023. https://www.statpearls.com/ArticleLibrary/viewarticle/34508.

Further Reading

Gorvetzian JW, Epler KE, Schrader S, et al. Operating room staff and surgeon documentation curriculum improves wound classification accuracy. Heliyon. 2018:4(8):e00728. doi: 10.1016/j.heliyon.2018.e00728.

Kamel C, McGahan L, Mierzwinski-Urban M, et al. Preoperative Skin Antiseptic Preparations and Application Techniques for Preventing Surgical Site Infections: A Systematic Review of the Clinical Evidence and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2011. Accessed June 29, 2023.https://www.ncbi.nlm.nih.gov/books/NBK174534/.

In the United States alone, there are between 160,000 and 300,000 surgical site infections (SSIs) each year, representing $3.5 to $10 billion in annual health care costs.1 Reducing bioburden in surgical wounds is a critical component of preventing such infections and promoting healing. There are multiple strategies that that health care teams can employ to achieve this goal, usually aimed at reducing the levels of bacteria found in the wound and/or optimizing the host immune responses to infection.2 Surgical wounds are susceptible to bacterial contamination, which can lead to postoperative wound complications, including SSI. 

Why is it Important to Reduce Bioburden in Surgical Wounds?

Bioburden refers to the number of bacteria present in a wound that can lead to infection if not managed properly.3 Proactively managing bioburden prior to the onset of infection can decrease the risk of postoperative complications, as high bacterial loads in surgical sites significantly correlate with a greater risk of postoperative complications and delayed healing.3 High bacterial loads (>105 CFU/swab) on postoperative day 2 independently increased the risk of a surgical site infection (SSI). A post hoc analysis of 58 surgical wounds found that early detection of high bacterial burden is crucial in preventing surgical site infections (SSIs).3 

Does Bioburden Reduction Impact Health Care Costs?

SSIs represent $3.3 billion yearly in health care spending and contribute to more than $20,000 in costs.4 By preventing SSI and reducing risk, there is the potential to significantly reduce potential health care expenditure, and any subsequent financial burden. Additionally, avoiding unnecessary antibiotic administration has the potential to save pharmaceutical costs and prevent antimicrobial resistance. Overall, proactive management of bioburden has logical and important potential benefits not only clinically, but economically.

What Can Help Reduce Bioburden in Surgical Wounds?

Overall, early intervention before clinical infection develops and before oral or intravenous antibiotics become necessary is preferrable to manage bioburden in surgical wounds. One strategy may include wound cleansing and debridement. Techniques and agents may vary, but guidance exists that assigns different levels of cleansing intensity to the various tissue types noted upon examination of the surgical wound.5 For instance, necrotic or sloughy tissue may warrant more aggressive cleansing than healthy granulating or epithelializing tissue.5

Some approaches may even take place before the surgical incision is ever made. Recommendations ask patients to shower or bathe with soap or an antiseptic one night prior to surgery.6 Additionally, skin preparation per facility-established protocols prior to draping and beginning the procedure may aid in this effort. 

Advanced therapies may also aid in prevention. Negative pressure wound therapy (NPWT) can remove excess exudate, maintain moisture balance, increase blood flow into the wound, control infection, and modulate immune responses.2 Advanced diagnostic imaging technology, such as fluorescence imaging, may also help clinicians detect and manage high bacterial loads prior to infection.3 Clinicians who are highly familiar with image interpretation have demonstrated the technology’s ability to detect elevated bacterial burden, but there is a learning curve associated with interpreting color-based images.3 However, when a positive signal appears on fluorescence images, studies note that vigorous scrubbing can often remove the signal.3 It is important for professionals to acknowledge that not all technologies will directly address surgical wound bioburden, but instead may provide benefit in early identification and monitoring.    

How Much Do You Know About Surgical Wound Care? Take our quiz to find out! Click here.

Antiseptic agents like octenidine dihydrochloride (OCT), polyhexamethylene biguanide (PHMB), povidone-iodine, super-oxidized hypochlorous acid (HOCl), and sodium hypochlorite (NaOCl) are available in solution form or as functionalized dressings with microbicidal and anti-biofilm properties.2 These features may be helpful in reducing surgical wound bioburden when used in the appropriate scenarios. For instance, using stable hypochlorous acid-preserved wound cleanser as an irrigant in NPWT instead of 0.9% saline resulted in a trend towards fewer operating room visits and shorter length of hospital stay.4

In general, postoperative dressings should be kept clean and dry to avoid creating a hospitable environment for infection to develop in surgical wounds. Dressing materials should, when possible, support skin health and avoid medical adhesive-related skin injury (MARSI) that could contribute to SSI. This may include choosing skin-friendly adhesives, non-adherent materials, and using atraumatic dressing change techniques. For surgical wounds where drainage is expected, use of an appropriate drain system and/or absorbent dressing may be helpful. Specialized antimicrobial dressings are another choice clinicians may employ to reduce bioburden in surgical wounds. Specifically, these antimicrobial dressings may reduce bioburden via agents such as povidone-iodine, medical-grade honey, silver, polyhexamethylene biguanide, chlorhexidine gluconate, or dialkylcarbomoyl chloridedialkylcarbomoyl chloride.7,8

Other strategies for reducing bioburden in surgical wounds may include the use of antibiotic-coated sutures, intraoperative irrigation with or without antimicrobial solutions, and adhering to sterile surgical techniques.  

Conclusion

A proactive approach to managing bacterial burden in surgical wounds may decrease the need for antibiotic usage and reduce the risk of postoperative complications. Technology may aid in early detection of high bacterial burden and allow for prompt intervention. Other peri- and postoperative strategies can also address the risk that bioburden poses, hopefully resulting in better healing outcomes and reduced health care expenditure.

Overall, reducing bioburden in surgical wounds requires a comprehensive approach that incorporates both proactive treatment strategies and advanced technologies. By reducing bacterial levels and optimizing healing processes, health care professionals can promote successful outcomes for patients undergoing surgical procedures

References

Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. J Am Coll Surg. 2017; 224(1): 59-74
Versey Z, da Cruz Nizer WS, Russell E, et al. Biofilm-innate immune interface: contribution to chronic wound formation. Front Immunol. 2021;12:648554. doi: 10.3389/fimmu.2021.648554.
Sandy-Hodgetts K, Andersen CA, Al-Jalodi O, et al. Uncovering the high prevalence of bacterial burden in surgical site wounds with point-of-care fluorescence imaging. Int Wound J. 2022;19(6):1438-1448. doi: 10.1111/iwj.13737. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9493216
Gallagher KE, Alberto EC, Mallow PJ, Hermans MH, Cardenas L. A retrospective health economic analysis of a stable hypochlorous acid preserved wound cleanser versus 0.9% saline solution as instillation for negative-pressure wound therapy in severe and infected wounds. Cureus. 2022;14(4):e24321. doi: 10.7759/cureus.24321. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9123387
National Healthcare Safety Network. Surgical site infection events module. Centers for Disease Control and Prevention; 2023. https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf.
Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017;152(8):784–791. doi:10.1001/jamasurg.2017.0904
Mana TSC, Donskey C, Carty N, et al. Preliminary analysis of the antimicrobial activity of a postoperative wound dressing containing chlorhexidine gluconate against methicillin-resistant Staphylococcus aureus in an in vivo porcine incision wound model. Am J Infect Control. 2019;47:1048-1052
Totty JP, Bua N, Smith GE, Harwood AE, Carradice D, Wallace T, Chetter IC. Dialkylcarbamoyl chloride (DACC)-coated dressings in the management and prevention of wound infection: a systematic review. J Wound Care. 2017;26(3):107-114. doi: 10.12968/jowc.2017.26.3.107. PMID: 28277989.

Introduction

Successful care of surgical wounds begins with a comprehensive assessment of both the wound and the patient, including a clear understanding of the type and class of surgical wound. Psychosocial factors affecting healing and well-being, are essential to consider as well.1

Definitions and Classifications

Surgical wounds can be categorized through the following:

Incisional or excisional
Wound healing type
Infection risk

Surgical wound classification enables wound care professionals to tailor a care plan to each patient’s risk of complications.2

Wound healing type describes the method of wound closure as follows2-4:

Healing Type

Definition

Comments

Primary intention

Closed wound (all layers closed) with approximated wound edges

Most common surgical wound type

Rapid healing

Minimal scarring and tissue loss

Secondary intention

Wound with deep layers. Closed and superficial layers left open to heal from the bottom up because of infection or an inability to approximate wound edges

Slow healing

Higher infection risk 

More extensive scarring

 

Tertiary intention

Delayed primary closure, with the wound left open for several days initially

Exudate drainage

Control of contamination

Preparation for further procedures

The Centers for Disease Control and Prevention (CDC) classifies surgical wounds by the degree of wound contaminants, as shown here2-4:

Class

Definition

Class I/ Clean

Operative wounds (usually skin, eyes, or vascular) with no signs of infection or inflammation

No internal organ involvement

Surgical site infection risk < 2%

Class II/Clean-contaminated

Operative wounds with no outward evidence of infection and no break in sterile technique

Internal organ involvement

Surgical site infection risk <10%

Class III/Contaminated

Open, fresh, accidental wounds involving internal organs or operative wounds with a break in sterile technique, gastrointestinal tract spillage, or incisions with acute, nonpurulent inflammation

Also open traumatic wounds >12-24 hours old

Surgical site infection risk <13%-30%

Class IV/Dirty

Wounds infected during operation, with visceral perforation or acute purulent inflammation

Also delayed presentation of traumatic wounds with contamination and devitalized tissue already present

Surgical site infection risk almost 40%

 

How Much Do You Know About Surgical Wound Care? Take our quiz to find out! Click here.

Assessment Protocol

The following assessment protocol is partly adapted from the South West Regional Wound Care Program (London, Ontario, Canada)1:

Obtain a complete medical history, including medications, nutrition, wound history and pain, wound healing factors, and the patient’s goals and involvement in care.
Perform a general physical examination, including a current pain assessment.
Perform a psychosocial assessment, including the patient’s wound comprehension, financial concerns and support, the patient’s environment, and the patient and family’s functional, cognitive, and emotional ability to manage care.
Note incision anatomic location and length, closure method (sutures, staples, glue, pins, or other external fixation6), closure status, hemorrhage, inflammation, condition of wound bed and periwound, and surgical drains.
Complete a validated wound assessment tool (eg, the National Pressure Injury Advisory Panel PUSH [Pressure Ulcer Scale of Healing] Tool 3.05) and repeat at least weekly to monitor wound healing and care.
Assess the wound for increased bioburden, including hemopurulent or seropurulent wound drainage 48 hours postoperatively, incision site abscess or breakdown, or spontaneous dehiscence.
Assess wound moisture balance and dressing appropriateness.
If the surgical wound is on the lower leg, assess the leg for edema, lymphedema, lipidema, vascular disease, and circulation.
If a patient with diabetes and/or neuropathy has a surgical foot wound, obtain the patient’s treatment history and diabetic complications. Assess the patient’s feet and toenails for deformity, range of motion, neuropathy, and infection. Also assess gait, footwear, and edema, lymphedema, lipidema, vascular disease, and circulation.
Assess and monitor any sutures, staples, and glue sites,7 as well as external fixation devices,6 and make sure an order is in place for removal. Timing of suture (nonabsorbable) or staple removal varies from 3 to 21 days.3
Determine wound healability.
Document all findings meticulously.

Monitoring for Surgical Site Infection

Monitoring can prevent or minimize surgical site infections. Patients with symptoms of infection (surgical site pulling, persistent fatigue and malaise, warmth with pain, and foul odor) should contact their health care provider or surgeon immediately.8 The risk for complications is multifactorial and includes contamination, mechanism of injury contamination, systemic involvement, and presurgical conditions.2 For these reasons, knowledge of definitions, classifications, and assessment protocols for is essential to preventing and managing these challenging wounds effectively.

References

South West Regional Wound Care Program. Surgical wounds assessment guide. 2020. Accessed September 2, 2023. https://www.swrwoundcareprogram.ca/
Surgical wounds 101. Practice Accelerator. WoundSource. 2018. Accessed August 31, 2023. https://www.woundsource.com/blog/surgical-wounds-101
American College of Surgeons. Wound Home Skills Kit: Surgical Wounds. 2018. Accessed August 31, 2023. https://www.facs.org/for-patients/home-skills-for-patients/wound-manage…
Herman TF Bordoni B. Wound classification. In: StatPearls [Internet]; 2022. Accessed August 31, 2023. https://www.ncbi.nlm.nih.gov/books/NBK554456/
Swezey L. Wound assessment tools. WoundSource. 2015. Accessed August 31, 2023. https://www.woundsource.com/blog/wound-assessment-tools-basic-introduct…
Clinical guidelines (nursing): Pin site care for the child with an external fixator. Royal Children’s Hospital Melbourne. Accessed September 3, 2023. https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pin_sit…
Azmat CE, Council M. Wound closure techniques. StatPearls [Internet]. 2023. Accessed September 2, 2023. https://pubmed.ncbi.nlm.nih.gov/29262163/
Assessment of surgical wound infections. Practice Accelerator. WoundSource. 2019. Accessed September 2, 2023. https://www.woundsource.com/blog/assessment-surgical-wound-infections

Introduction

The most common and costly surgical wound complication is surgical site infection (SSI), which has been reported to increase hospital length of stay by approximately 9 days and raise the cost of hospital admissions by more than $20,000.1 Wound dehiscence, seromas, and hematomas,2 as well as cellulitis,3,4 can also complicate surgical wounds. Beyond these wounds, complications include non-SSI hospital-acquired infections,5 deep veinthrombosis,5 shock or hemorrhage,5 and postoperative edema.6

Risk Factors

Proper wound healing requires adequate oxygen delivery to the wound, freedom from bacterial and necrotic contamination, and sufficient nutritional status.7 The following can impair healing and cause complications7:

Bacterial infection
Necrotic tissue
Foreign bodies
Diabetes
Smoking
Malignant disease
Malnutrition
Inadequate blood supply
Hypotension
Hypothermia
Immunosuppression (by medications or diseases)
Emergency surgery
Ascites
Cardiopulmonary disease
Intraoperative contamination

Other risk factors include general debility, radiation therapy, weight loss or obesity, long operations, and female sex,8 as well as smoking, type of surgery, and the anatomic site of the operation.9

Surgical Wound Classification

The Centers for Disease Control and Prevention (CDC) created a surgical wound classification system that categorizes wounds by the degree of contamination (class I, clean; class II, clean/contaminated; class III, contaminated; and class IV, dirty) to identify patients at risk of SSIs.10 This system is used in conjunction with the American Society of Anesthesiologists classification and procedure duration to stratify SSI risk.10 It is reported that the risk of infection in clean wounds is <2%, and it is < 10% in clean-contaminated wounds, <13%-30%in contaminated wounds, and 40% in dirty wounds.7

Surgical Site Infections

Although improvements have occurred in infection control, including operating room ventilation, sterilization methods, surgical technique, and antimicrobial prophylaxis, SSIs remain an important cause of postoperative morbidity.1 A SSI is a postoperative incision or organ or space that becomes infected,12 normally within 30 days after surgery.2 According to the CDC, SSIs must meet the following criteria: (1) occur within 30 days postoperatively (or 1 year for organ/space infection with an implant in situ), (2) include only skin, subcutaneous tissues, deep layers, or distant organs, and (3) have either purulent drainage or organisms isolated from the wound site.13,14 The CDC classifies SSIs as superficial incisional, deep incisional, or organ/space infections.13,14

SSIs are often bacterial infections. Species observed in SSIs may include Staphylococcus, Streptococcus, and Pseudomonas.2 Signs of an SSI include:

Erythema
Delayed healing
Fever
Pain
Warmth
Swelling

Abscesses may also develop.2 Patients should be educated on signs of infection and instructed to seek immediate treatment if these signs occur.2 Treatment with appropriate antimicrobial agents or sometimes additional surgery may be warranted depending on the severity of the infection.2

SSI prevention has become increasingly important with the rise in surgical procedures. Approximately one-half of all SSIs are preventable with evidence-based approaches.12 The night before surgery, patients should shower or bathe with soap or an antiseptic agent. As indicated by clinical practice guidelines, clinicians should administer antimicrobial prophylaxis and time its use for effectiveness during the incision.12

In the operating room, skin should be prepared with an approved agent. During surgery, the patient’s glycemic control and normothermia should be maintained.12

Dehiscence

Dehiscence is the disruption of a wound that was primarily closed. It causes lost barrier and structural functions of the skin and deeper structures. Abdominal fascial dehiscence, for example, can lead to evisceration of abdominal contents.7

Dehiscence management may include antibiotics, debridement, resuturing, and wound closure devices.2,9 Patients should be advised on how to avoid incision dehiscence, including having a balanced diet, staying hydrated, taking care when coughing or sneezing, not smoking, avoiding lifting, following wound care practices, and preventing constipation.2

Hematomas

A hematoma is a collection of blood outside of the vessel that spreads into tissues. Hematomas may cause infection and/or wound dehiscence. Symptoms are headache, neurologic problems, and nail or abdominal pain. Hematomas can take 1 to 4 weeks to resolve.2

How Much Do You Know About Surgical Wound Care? Take our quiz to find out! Click here.

Risk factors include age, sex, body mass index, smoking, combined procedures, and diabetes. Prevention involves drain placement, tissue sealants, and compression stockings. Postoperative management includes warm compress application to facilitate blood reabsorption. Patients should avoid nonsteroidal anti-inflammatory drugs and massaging the area. Surgical drainage may be indicated.2

Seromas

A seroma is a collection of sterile, clear fluid under the skin at the incision site that develops 1-2 weeks postoperatively. Swelling, pain, and tenderness may occur, depending on size. Seromas may require aspiration with a syringe and needle or by drain placement.2,15

Risk factors are extensive surgery, surgical disruption of large amounts of tissue, and a history of seromas. Prevention involves surgical drainage systems and compression garments. Patients should be advised to contact their health care provider if signs of seroma develop.2,15

Cellulitis

Cellulitis is a potentially serious bacterial infection that develops in broken skin and that leads to pain, swelling, edema, and warmth.4,16 It can occur in association with seroma formation.5 Postoperative prophylactic antibiotics were reported to decrease the incidence of this complication.5

Complications Beyond the Wound

Hospital-Acquired Infections Other Than SSIs Catheter-associated urinary tract infections, central line bloodstream infections, pneumonia, and gastrointestinal infections may occur.5

Deep Vein Thrombosis or Pulmonary Embolism

Deep vein thrombosis is blood clots that form in a vein deep inside an arm, leg, or other part of the body. When the clot loosens and moves to the lungs, it becomes a pulmonary embolism, which can be fatal. Surgical procedures increase the risk of these complications.5

Shock or Hemorrhage

Postoperative bleeding from the surgical site occurs if the wound reopens. Rapid blood loss can lead to shock.5

Postoperative Edema

Edema, swelling caused by fluid retention, can be precipitated by surgical intervention. Treatment can include sodium restriction, diuretic therapy, compression stockings, and body positioning.6

Conclusion

In general, treatment of surgical wound complications includes pain management, infection control, and management of wound drainage.14 More specifically, follow the surgeon’s orders, perform continued assessments and monitoring, adhere to prescribed treatment protocols (eg, dressing types and duration, staple, or suture removal), document findings, and communicate any concerns (eg, signs of infection or dehiscence).17 Preoperative and postoperative care planning can reduce the risk of complications. Interdisciplinary involvement helps to reduce complications by providing patient education and counseling.8

Postoperative complications may be reduced or prevented through hand washing procedures, surgical aseptic techniques, early ambulation, pulmonary and leg exercises, and adequate hydration.2,5 Patient education is essential to decrease the incidence and severity of complications.2 The use of advanced wound care products and systems may also prevent some wound complications.5

References

National Healthcare Safety Network. Surgical site infection events module. Centers for Disease Control and Prevention; 2023. https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf.
Surgical wound complications. Practice Accelerator. WoundSource. 2021. Accessed August 31, 2023. https://www.woundsource.com/blog/surgical-wound-complications
Cellulitis. mayoclinic.org. Accessed September 4, 2023. https://www.mayoclinic.org/diseases-conditions/cellulitis/symptoms-caus…
Edwards C, Angstadt J, Whipple O, Grau R. Laparoscopic ventral hernia repair: postoperative antibiotics decrease incidence of seroma-related cellulitis. Am Surg. 2005;71(11):931-935
Preventing post-operative complications. Practice Accelerator. WoundSource.com. 2020. Accessed September 4, 2023. https://www.woundsource.com/blog/preventing-post-operative-complications
Sterns RH, Emmett M, Law K. Patients education: edema (swelling) (beyond the basics). UpToDate. 2023. Accessed September 5, 2023. https://www.uptodate.com/contents/edema-swelling-beyond-the-basics/print
American College of Surgeons Division of Education. ACS/ASE medical student core curriculum: postoperative care. Accessed September 3, 2023. postoperativecare.pdf available through www//facs.org
Surgical wounds 101. Practice Accelerator. WoundSource.com. 2018. Accessed August 31, 2023. https://www.woundsource.com/blog/surgical-wounds-101
Yao K, Bae L, Yew WP. Post-operative wound management. Aust Fam Physician. 2013;42(12):867-870.
Onyekwelu I, Yakkanti R, Protzer L, Pinkston CM, Tucker C, Seligson D. Surgical wound classification and surgical site infections in the orthopaedic patient. J Am Acad Orthop Surg Glob Res Rev. 2017;1(3):e022. doi:10.5435/JAAOSGlobal-D-17-00022
American College of Surgeons. Wound Home Skills Kit: Surgical Wounds. 2018. Accessed August 31, 2023. https://www.facs.org/for-patients/home-skills-for-patients/wound-manage…
Berríos-Torres SI, Umscheid CA, Bratzler DW, et al; Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017;152(8):784-791 [erratum in: JAMA Surg. 2017;152(8):803]. doi:10.1001/jamasurg.2017.0904
Herman TF Bordoni B. Wound classification. In: StatPearls [Internet]; 2022. Accessed August 31, 2023. https://www.ncbi.nlm.nih.gov/books/NBK554456/
Zabaglo M, Sharman T. Postoperative wound infection. In: StatPearls [Internet]. StatPearls Publishing; 2023. Accessed August 31, 2023. https://www.ncbi.nlm.nih.gov/books/NBK560533/
Kazzam ME, NG P. Postoperative Seroma Management. In: StatPearls [Internet]. StatPearls Publishing; 2023: https://www.ncbi.nlm.nih.gov/books/NBK585101/
Brown BD, Watson KLH. Cellulitis. In: StatPearls [Internet]. StatPearls Publishing; 2023: https://www.ncbi.nlm.nih.gov/books/NBK549770/
South West Regional Wound Care Program. Guideline: the management of people with open or closed surgical wounds. 2020. Accessed September 2, 2023. https://www.swrwoundcareprogram.ca/