Dehiscence, Infection, Seroma, Haematoma (DISH): Development and Validation of a New Classification of Surgical Site Outcomes.

BACKGROUND: Surgical site outcome (SSO) reporting lacks details of management, focuses on infection, and overlooks dehiscence, seroma and haematoma. An international, consensus-driven classification system applicable to a diverse range of surgical incisions and outcomes was developed to address this gap and standardise the reporting of SSOs. METHOD: Concept statements based on a targeted literature review were rated by pan-specialty global experts during a four-round modified Delphi study to create a comprehensive classification of SSOs. Reliability and language validation focused on inter-rater agreement and intra-rater reproducibility by experts applying the classification to case vignettes, created using generative artificial intelligence sampling. Cross-domain agreement was evaluated using a patient-level, double entry, interclass correlation coefficient (DE-ICC). RESULTS: Consensus was achieved on definitions of dehiscence, inflammation/infection, seroma and haematoma ('DISH') within a new classification, comprising five objectifiable grades of clinical intervention (0-4) and four grades of clinical presentation (a-d) for each domain. The DISH 'score' presents all domains collectively, e.g. D1a I2b S0 H0; a snapshot of management and presentation of an incision. Mean patient-level inter-rater DE-ICC was 0.93 (95% confidence interval [CI] 0.91-0.96; median 1.00; very high concordance). Intra-rater DE-ICC was similarly high (mean 0.95; 95% CI 0.93-0.96; median 1.00). CONCLUSION: The proposed cross-specialty, global DISH Classification facilitates more comprehensive surveillance and audit of SSOs in clinical practice and research, by standardising reporting of all relevant grades of clinical presentation and management of SSOs. Very high concordance when applied to case vignettes gives credibility to clinical validation and adoption.