Various Classifications and Gradings of Surgery

🥼 Practice and Clinical
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Classification of Incision Contamination Levels

1. Clean incision, represented by “I”, refers to non-traumatic, uninfected wounds; the surgery does not involve entering the respiratory tract, digestive tract, genitourinary tract, or oropharyngeal area. This includes sterile sutured incisions, such as subtotal thyroidectomy.

2. Potentially contaminated incision, represented by “II”, refers to sutured incisions where contamination is possible during surgery, such as major gastric resection. Areas of skin that are difficult to fully disinfect, wounds that have undergone debridement and re-suturing within 6 hours, and incisions that have been re-opened after suturing also belong to this category.

3. Contaminated incision, represented by “III”, refers to incisions near infected areas or where tissue is directly exposed to infectious material, such as surgeries for suppurative appendicitis, intestinal obstruction with necrosis, or chronic wounds with necrotic tissue.

Classification of Wound Healing Levels

1. Grade A healing, represented by “A”, refers to excellent healing with no adverse reactions during the early healing phase.

2. Grade B healing, represented by “B”, indicates suboptimal healing with inflammatory reactions at the healing site such as redness, swelling, induration, hematoma, or effusion without suppuration.

3. Grade C healing, represented by “C”, indicates purulent incision requiring incision and drainage.

Classification of Surgery Levels

1. Level 1 surgery: Simple surgical procedures with low technical difficulty, common minor surgeries.

2. Level 2 surgery: Moderate surgeries with not complex procedures and moderate technical difficulty.

3. Level 3 surgery: Major surgeries with complex procedures and considerable technical difficulty.

4. Level 4 surgery: Surgeries with relatively complex procedures and high technical difficulty.

Note: Minimally invasive (endoscopic) surgeries are categorized according to the complexity of their techniques within these classifications.

Relevant Department Surgery Classification Standards

General Surgery Classification Standards:

Class I surgeries:

  1. First-time simple appendectomy
  2. First-time simple hernia repair
  3. Removal of superficial tumors or foreign bodies
  4. Hemorrhoid and anal fistula surgeries
  5. Incision and drainage of superficial abscesses

Class II surgeries:

  1. Incision and drainage of liver abscess
  2. Intestinal resection
  3. Repair of gastrointestinal perforation
  4. Gastrointestinal stoma and anastomosis
  5. Great saphenous vein ligation, shunting, and stripping
  6. Simple cholecystostomy
  7. Simple mastectomy

Class III surgeries:

  1. Various liver, gallbladder, and pancreas surgeries except Class I
  2. Stomach and duodenal surgeries, gastrointestinal anastomoses
  3. Management of liver and spleen injuries
  4. Rectal resection, ileocecal resection
  5. Colostomy and radical surgery for various colon cancers
  6. Thyroid and parathyroid surgeries excluding Class IV
  7. Radical mastectomy for breast cancer (special surgery)
  8. Various portosystemic shunts and disconnections for portal hypertension
  9. Radical surgeries for various intestinal cancers
  10. Exploratory laparotomy for abdominal trauma

Class IV surgeries:

  1. Total gastrectomy, radical extended gastrectomy for gastric cancer
  2. Left and right hemihepatectomy, left lateral hepatectomy
  3. Radical pancreatic cancer surgery, extended pancreaticoduodenectomy
  4. Repeat biliary tract surgeries
  5. Abdominal aortic aneurysm resection and grafting
  6. Vascularized fetal pancreas transplantation
  7. Extended total pancreatectomy
  8. Neck lymph node dissection for thyroid cancer, parathyroidectomy
  9. Right atrial appendage to inferior vena cava bypass graft
  10. Intra-abdominal tumor resection involving 3 or more organs
  11. Newly developed various surgeries
  12. Exploratory surgeries with unclear diagnosis

Orthopedic Surgery Classification Standards:

Class I surgeries:

  1. Removal of internal fixation for limb fractures
  2. Tendon anastomosis
  3. Debridement and suturing

Class II surgeries:

  1. Open reduction and internal fixation for limb fractures
  2. Joint fusion surgeries
  3. Peripheral nerve anastomosis

Class III surgeries:

  1. Thoracolumbar fractures, dislocations, or paraplegia
  2. Cervical fractures, dislocations, or paralysis, cervical spondylosis, cervical ossification of the posterior longitudinal ligament
  3. Joint replacement surgeries
  4. Complex intra-articular fractures
  5. Multiple pelvic fractures
  6. Free vascularized bone flap transplantation
  7. Spinal tuberculosis with or without paraplegia
  8. Congenital hip dislocation
  9. Orthopedic surgeries for poliomyelitis sequelae and cerebral palsy sequelae
  10. Amputation surgeries (special surgeries)

Class IV surgeries:

  1. Spinal canal tumor resection
  2. Spinal scoliosis correction surgery
  3. Other new surgeries and techniques

Neurosurgery Classification Standards:

Class I surgeries:

  1. Brain tumor resection
  2. Skull osteoma removal
  3. Subgaleal hematoma incision and drainage

Class II surgeries:

  1. Burr hole or craniotomy for epidural hematoma
  2. Ventricular puncture with ventricular drainage
  3. Brain abscess puncture and drainage
  4. Craniotomy for brain injury lesion clearance
  5. Reduction of depressed skull fractures
  6. Decompressive craniectomy
  7. Cranioplasty
  8. Removal of multiple intracranial hematomas
  9. Intracranial hematoma evacuation
  10. Lateral ventricle shunting

Class III surgeries:

  1. Supratentorial superficial lesion resection
  2. Transcranial cerebrospinal fluid ear leak repair
  3. Intracranial aneurysm surgery
  4. Intracranial arteriovenous malformation resection
  5. Intracranial-extracranial arterial bypass
  6. Intramedullary spinal cord lesion resection
  7. Spinal cord exposure repair
  8. Cranial nerve microvascular decompression
  9. Intracranial decompression craniotomy
  10. Meningocele repair
  11. Supratentorial deep lesion resection
  12. Cerebellar tumor resection
  13. Cerebellar hemisphere lesion surgeries
  14. Cerebellopontine angle tumor resection
  15. Pituitary adenoma resection

Class IV surgeries:

  1. Epileptogenic focus resection
  2. Brainstem tumor resection
  3. Sella region mass resection
  4. Skull base tumor resection
  5. Large intracranial aneurysm surgery
  6. Excision after embolization of large intracranial arteriovenous malformation

Urology Surgery Classification Standards:

Class I surgeries:

  1. Bladder incision and stone removal
  2. Cystostomy
  3. Release of incarcerated phimosis
  4. Circumcision
  5. Scrotal mass excision
  6. Testicular tunica vaginalis inversion
  7. High ligation of communicating hydrocele
  8. Orchiectomy
  9. Urethral dilation
  10. Cystoscopy

Class II surgeries:

  1. Ureteroscopic Holmium laser lithotripsy
  2. Bladder tumor fulguration via cystotomy
  3. Urethral fistula repair
  4. Bladder rupture repair
  5. Transurethral bladder stone removal
  6. Urethrotomy for stone removal
  7. High ligation of varicocele
  8. Partial penectomy
  9. Orchiopexy for cryptorchidism
  10. Urethroplasty

Class III surgeries:

  1. Renal rupture repair
  2. Renal tumor enucleation
  3. Nephrectomy (special surgery)
  4. Partial nephrectomy
  5. Renal lithotomy
  6. Pyeloplasty and ureteropelvic anastomosis
  7. Percutaneous nephroscope or ureteroscopy incision and shaping
  8. Ureterotomy for stone removal
  9. Stage I hypospadias repair
  10. Stage II hypospadias repair
  11. Suprapubic prostatectomy
  12. Partial cystectomy
  13. Ileal cystoplasty
  14. Special transurethral bladder tumor treatments
  15. Various complex endoscopic surgeries

Class IV surgeries:

  1. Adrenal transplantation
  2. Radical nephrectomy
  3. Autologous kidney transplantation
  4. Renal tumor with vena cava thrombus resection
  5. Penile reconstruction

Cardiothoracic Surgery Classification Standards:

Class I surgeries:

  1. Pleural adhesion lysis
  2. Pleural fixation
  3. Mediastinal emphysema incision and decompression
  4. Closed thoracic drainage
  5. Empyema omentum packing
  6. Pleural biopsy
  7. Neck tracheostomy reconstruction
  8. Thoracotomy with freezing treatment
  9. Empyema drainage and clearance

Class II surgeries:

  1. Diaphragm repair
  2. Extensive chest wall trauma debridement
  3. Thoracotomy exploration
  4. Pericardial window drainage
  5. Bullectomy and repair
  6. Wedge resection of lung

Class III surgeries:

  1. Mediastinal tumor resection
  2. Closed mitral valvuloplasty
  3. Atrial septal defect repair
  4. Patent ductus arteriosus closure
  5. Class II valve replacement
  6. Aortic valve replacement
  7. Aortic valve replacement (duplicate in list)
  8. Ventricular septal defect repair
  9. Radical lung cancer surgery
  10. Lung segmentectomy
  11. Total pneumonectomy
  12. Esophageal cancer radical surgery
  13. Thymoma resection
  14. Various thoracoscopic surgeries

Class IV surgeries:

  1. Tetralogy of Fallot repair
  2. Coronary artery bypass grafting (CABG)
  3. Complete atrioventricular septal defect repair
  4. Double valve replacement
  5. Major repair of Fallot’s tetralogy
  6. Complex congenital heart defect repair
  7. CABG combined with valve replacement
  8. Total pulmonary artery anastomosis
  9. Double outlet right ventricle repair
  10. Left ventricular outflow tract obstruction relief
  11. Ascending aortic replacement with aortic valve replacement
  12. Autologous lung transplantation

Gynecology Surgery Classification Standards:

Class I surgeries:

  1. Vestibular gland cyst incision and marsupialization
  2. Cervical polyp removal
  3. Submucosal fibroid transvaginal removal
  4. Transabdominal salpingectomy and oophorectomy

Class II surgeries:

  1. Cesarean section
  2. Total or subtotal abdominal hysterectomy (reproductive age women total/subtotal uterus resection, special surgery)
  3. Intrafascial total hysterectomy

Class III surgeries:

  1. Urinary fistula repair
  2. Difficult total abdominal hysterectomy (adhesions, large cervical fibroids)
  3. Microsurgical tubal anastomosis or transplantation
  4. Transvaginal total hysterectomy
  5. Laparoscopic hysterectomy and adnexal surgery
  6. Simple vulvectomy

Class IV surgeries:

  1. Extensive total hysterectomy with pelvic lymphadenectomy
  2. Wide vulvectomy and deep and superficial inguinal lymphadenectomy
  3. Complex urinary fistula repair
  4. Vaginoplasty

Obstetrics Surgery Classification Standards:

Class I surgeries:

  1. Four family planning surgeries
  2. Mid to late pregnancy induction
  3. Episiotomy and suturing
  4. Vacuum extraction
  5. Forceps delivery
  6. Breech maneuvers
  7. Manual placental removal
  8. Repair of first-degree perineal laceration
  9. Cervical tear repair
  10. Postpartum uterine curettage
  11. Cervical and vaginal exploration

Class II surgeries:

  1. Low forceps delivery for abnormal fetal head
  2. Internal version
  3. Therapeutic abortion
  4. Breech traction
  5. Cesarean section
  6. Repair of old second-degree perineal laceration
  7. Incision and suturing of perineal hematoma
  8. Cervical cerclage
  9. Incision and suturing of hematoma in lower third of vaginal wall

Class III surgeries:

  1. Difficult forceps delivery
  2. Extraperitoneal cesarean section
  3. Incision and suturing of hematoma in upper two-thirds of vaginal wall
  4. Repair of uterine rupture in late pregnancy
  5. B-lynch uterine compression sutures
  6. Repair of third-degree perineal laceration
  7. Uterine artery ligation
  8. Subtotal hysterectomy during cesarean
  9. Total hysterectomy during cesarean
  10. Uterine cavity packing with gauze
  11. Mid-pregnancy induction with severe complications

Class IV surgeries:

Extensive total hysterectomy and pelvic clearance during cesarean section

Oral Surgery Classification Standards:

Class I surgeries:

  1. Maxillofacial fracture intermaxillary fixation
  2. Excision of cutaneous fistula on jaw
  3. Removal of jaw cyst
  4. Gingival tumor excision
  5. Removal of small oral/maxillofacial masses
  6. Removal of sublingual gland cyst
  7. Removal of impacted teeth
  8. Alveolar bone trimming
  9. Small oral/maxillofacial soft tissue debridement
  10. Medium oral/maxillofacial soft tissue debridement

Class II surgeries:

  1. Internal fixation with small plates for jaw fractures
  2. Large oral/maxillofacial soft tissue debridement
  3. Old mandibular fracture reduction
  4. Parotid gland tumor and superficial lobe removal
  5. Branchial cleft cyst removal
  6. Sublingual gland removal
  7. Submandibular gland removal
  8. Benign tumor removal of palate
  9. Cleft lip repair
  10. Cleft palate repair

Class III surgeries:

  1. Hemimandibulectomy and bone graft repair
  2. Old mandibular fracture reduction
  3. Zygomatic bone and arch plasty
  4. Total parotidectomy
  5. Lip defect repair
  6. Neck lymphadenectomy
  7. Resection of malignant tumors of tongue and palate
  8. Extended mandibulectomy

Class IV surgeries:

  1. Combined maxillofacial and cervical radical neck dissection
  2. Reconstruction of oral, lip, and cheek defects
  3. Radical oral and maxillofacial cancer surgery with free tissue or bone flap immediate reconstruction
  4. Examination and treatment with temporomandibular arthroscopy
  5. Embolization under DSA for carotid body tumors
  6. Orthognathic surgery for skeletal jaw deformities
  7. Unilateral total maxillectomy
  8. Total glossectomy
  9. Temporomandibular joint plasty
  10. Postoperative cleft palate speech training

Ophthalmology Surgery Classification Standards

Class I surgeries:

  1. Corneal suture removal
  2. Hordeolum excision
  3. Entropion correction
  4. Eyelid and conjunctival laceration suturing
  5. Pterygium excision
  6. Eyelid mass excision
  7. Eyeball laceration suturing
  8. Conjunctival tumor excision
  9. Anterior chamber formation
  10. Conjunctival flap coverage

Class II surgeries:

  1. Enucleation of eyeball
  2. Correction of concomitant strabismus
  3. Iris peripheral resection
  4. Corneal deep foreign body removal
  5. Surface laser trabeculectomy
  6. Intraocular magnetic foreign body removal
  7. Dacryocystectomy
  8. Lacrimal duct anastomosis
  9. Amniotic membrane transplantation
  10. Extracapsular cataract extraction with intraocular lens implantation
  11. Nasolacrimal duct dacryocystorhinostomy

Class III surgeries:

  1. Glaucoma tube implantation
  2. Intraocular non-magnetic foreign body removal
  3. Retinal detachment repair
  4. LASEK
  5. LASIK
  6. Vitrectomy
  7. Phacoemulsification cataract extraction with intraocular lens implantation
  8. Extracapsular cataract extraction combined with glaucoma intraocular lens implantation
  9. Orbital tumor excision
  10. Removal of intraocular foreign body combined with lens and vitrectomy implantation (quadruple surgery)

Class IV surgeries:

  1. Thyroid orbitopathy correction
  2. Corneal transplantation
  3. Orbital decompression for orbital hypertelorism
  4. Maxillectomy combined with orbital content removal

Otolaryngology (ENT) Surgery Classification Standards:

Class I surgeries:

  1. Foreign body removal from ear canal
  2. Incision and drainage of preauricular fistula infection
  3. Tympanic membrane incision
  4. Nasal trauma debridement and suturing
  5. Nasal cavity foreign body removal
  6. Pre-nasal fistula excision
  7. Nasal bone fracture reduction
  8. Partial inferior turbinate resection
  9. Partial middle turbinate resection
  10. Nasal vestibular cyst excision

Class II surgeries:

  1. Branchial cleft fistula removal
  2. Nasal septum correction
  3. Tympanostomy tube insertion
  4. Nasal polypectomy
  5. Nasal septal cartilage harvesting
  6. Radical maxillary sinus surgery
  7. Tracheotomy
  8. Tonsillectomy
  9. Adenoid curettage
  10. Esophageal foreign body removal
  11. Laryngoscopic tumor removal under suspension laryngoscopy

Class III surgeries:

  1. Partial ear amputation replantation
  2. Modified radical mastoidectomy
  3. Nasal defect repair
  4. Anterior ethmoidal artery ligation
  5. Endoscopic nasal sinus surgery
  6. Benign laryngeal tumor excision
  7. Laryngofissure and vocal fold excision
  8. Tracheal and bronchial foreign body removal
  9. Tympanoplasty
  10. Various sinus endoscopic surgeries

Class IV surgeries:

  1. Nasal meningoencephalocele skull base repair
  2. Cochlear implantation
  3. Total laryngectomy
  4. Laryngeal function reconstruction
  5. Subtotal laryngectomy
  6. Three-quarter laryngectomy and laryngeal function reconstruction
  7. Vertical hemilaryngectomy and laryngeal function reconstruction
  8. Supraglottic horizontal laryngectomy
  9. Endoscopic orbital decompression
  10. Nasopharyngeal fibrous vascular tumor excision
  11. Nasal lateral rhinotomy
  12. Neck lymphadenectomy
  13. Ossicular chain reconstruction
  14. Uvulopalatopharyngoplasty
  15. Facial nerve decompression, transplantation, anastomosis
  16. Acoustic neuroma resection
  17. Hypopharyngeal cancer resection
  18. Maxillectomy
  19. Radical middle ear cancer surgery
  20. Laryngotracheal stenosis repair
  21. Transnasal endoscopic pituitary tumor resection

Cardiology Surgery Classification Standards:

Class I surgeries:

  1. Percutaneous selective venography
  2. Percutaneous intravenous thrombolysis
  3. Percutaneous selective arteriography (excluding cerebral and coronary arteries)
  4. Percutaneous selective arterial catheterization (including various drug therapies and embolization)

Class II surgeries:

  1. Percutaneous intravenous filter placement
  2. Percutaneous superselective arteriography
  3. Electrophysiological cardiac studies
  4. Temporary pacemaker implantation

Class III surgeries:

  1. Percutaneous intravenous stent implantation
  2. Percutaneous arterial stent implantation (including limb arteries, carotid artery, renal artery)
  3. Percutaneous laser angioplasty plus balloon dilation
  4. Percutaneous balloon valvuloplasty (including mitral, tricuspid, aortic, pulmonary valves, and atrial septostomy)
  5. Percutaneous endocardial myocardial biopsy (excluding pathological diagnosis and other special examinations)
  6. Congenital heart disease interventional therapy (including patent ductus arteriosus, atrial septal defect)
  7. Coronary angiography
  8. Percutaneous coronary thrombolysis
  9. Radiofrequency ablation (excluding atrial fibrillation)
  10. Permanent pacemaker implantation (excluding ICD)

Class IV surgeries:

  1. Percutaneous large arterial stent implantation (including abdominal aorta, pseudoaneurysm)
  2. Percutaneous transluminal coronary angioplasty (PTCA)
  3. Percutaneous coronary stent implantation (STENT)
  4. Percutaneous coronary laser angioplasty
  5. Coronary artery rotational atherectomy
  6. Directional coronary rotational atherectomy
  7. Intravascular ultrasound examination of coronary vessels (IVUS)
  8. Intravascular angioscopy examination of coronary vessels
  9. Interventional occlusion for congenital ventricular septal defect
  10. Radiofrequency ablation for atrial fibrillation
  11. Permanent pacemaker (ICD) implantation