Surgical site infections (SSIs) are some of the most prevalent healthcare-associated infections and pose a major burden on surgical outcomes in most parts of the world. They contribute to the premise of the postoperative morbidity, extended hospitalization, elevated readmission level, and high healthcare expenses. In third-world nations, such as Pakistan, the rate of SSIs is significantly even higher because of the lack of resources, overpopulation, and the lapses in the practice of infection control [1,2].

SSIs are infections that happen 30 days following an operation (or one year following an implant placement) and entail the incision, deep tissues, or organ spaces. SSIs continue to be a challenge in general surgery despite the current practices of surgical techniques, sterilization measures, and antibiotic prophylaxis. The etiology of SSIs is multifactorial, and it encompasses patient-related factors, environmental factors, and procedure-related factors. Intraoperative factors are no exception and may be of critical importance and changeable [3,4].One of the most regularly reported risk factors of SSIs is the operative duration. Long surgeries expose the tissue to environmental contaminants longer, decrease tissue perfusion, and can cause surgeon fatigue, all of which are factors that contribute to the risk of infection. Research has found that surgeries that take more than two hours have a high chance of postoperative infections. Nevertheless, SSI incidence is not entirely explained by the length of operation only, and its interplay with other variables during the intraoperative period should be taken into account [5].

Another risk factor in SSI is the intraoperative blood loss. Loss of excessive blood can disrupt immune response, require transfusion, and affect tissue oxygenation, making people more prone to infection. Likewise, the wound classification, such as clean and dirty, indicates the level of microbial contamination and is already known to be strongly linked with the postoperative rates of infections [6]. Antibiotic prophylaxis timing and suitability are also crucial factors in preventing SSIs. Antibiotic administration up to one hour before surgery has been demonstrated to dramatically decrease the risk of infection, but delayed or inappropriate use may undermine efficacy. Moreover, emergency surgeries are linked to a greater rate of SSIs because of improper preoperative planning and a greater possibility of contamination [7]. Knowing the interaction between the period of operation and the intraoperative factors is crucial to recognizing patients at high risk and applying specific preventive measures. Although a few studies have investigated such associations across international boundaries, there is a paucity of local data to tackle this problem in the general surgical population [8]. The purpose of the current study is to assess how the duration of operations, intraoperative factors, and SSIs are related, thus adding to the body of knowledge concerning the evidence-based measures of surgical practice and patient outcomes [9].

Study Objectives

To determine the relationship between the duration of the operation and the intraoperative variables to surgical site infections in patients undergoing general surgical procedures, and define the risk factors that can be changed to improve the outcomes.

Study Design & Setting It was a prospective observational study carried out conducted at department of general surgery PIMS hospital hayat Abad Peshawar from jan 2024 to jan 2025 over a period of 12 months. Participants Consecutive sampling was used to select a total of 100 patients who were undergoing elective and emergency general surgery. Both male and female patients aged 18 years and above were recruited. Patients who were experiencing abdominal, soft tissue, and hernia procedures were incorporated. The patients were tracked 30 days after surgery to determine the occurrence of surgical site infection. Sample Size Calculation A WHO sample size calculator was used to determine the sample size of 100 patients based on a 30 percent prevalence of surgical site infections, a 95 percent confidence level, and a 9 percent margin of error. This size was believed to be sufficient to identify statistically significant relationships between the duration of operation and the intraoperative risk factors. Inclusion Criteria • Patients aged ≥18 years • Having either elective or emergency general surgery. • Both genders • Capable of giving informed consent. Exclusion Criteria • Patients who have known infections. • Patients with weakened immunity (e.g., HIV, chemotherapy) • Re-operations within 30 days • Lost to follow-up patients. Diagnosis and Management Plan. The diagnosis of SSI was made using CDC criteria, such as purulent discharge, localized swelling, redness, or positive wound culture. The regular postoperative treatment and antibiotic regimens were adhered to. SSIs patients were provided with proper wound care, antibiotics, and surgery where necessary. Statistical Analysis The analysis of data was done with SPSS version 25. Continuous variables were represented using the mean, standard deviation, and categorical variables were represented using the frequencies and percentages. Associations were measured using the chi-square test. A p-value ≤0.05 was considered statistically significant. Ethical Approval Statement Ethical approval for this study was obtained from the Institutional Review Board prior to data collection. Written informed consent was obtained from all participants. Confidentiality and anonymity were strictly maintained. Participation was voluntary, and participants were free to withdraw at any stage without any consequences. All procedures complied with ethical research standards.

Out of 100 patients, 15% developed surgical site infections (SSIs). The baseline demographic characteristics of the study population are presented in Table 1, showing a mean age of 45.6 ± 13.2 years with slight male predominance.Table 2 shows that infection rates were significantly higher in procedures lasting more than 2 hours (22%) compared to ≤2 hours (8%) (p = 0.02).Table 3 demonstrates that patients with intraoperative blood loss greater than 500 ml had higher SSI rates (20%) compared to those with lesser blood loss (10%) (p = 0.04). It also shows that improper timing of antibiotic prophylaxis was significantly associated with increased infection rates, while emergency surgeries had slightly higher SSI rates (18% vs. 12%), though this difference was not statistically significant.Table 4 shows a strong association between wound classification and SSIs, with contaminated/dirty wounds having the highest infection rates (25%) compared to clean (6%) and clean-contaminated wounds (10%) (p = 0.01).Overall, infection rates remained within 15% but were significantly influenced by prolonged operative duration, increased intraoperative blood loss, wound contamination, and inappropriate antibiotic prophylaxis timing.

Table 1: Demographic Characteristics of Patients (n = 100)

Table 1 shows baseline demographic characteristics. Most patients were aged 31–50 years, with slight male predominance.

Table 2: Association of Operative Duration with Surgical Site Infections

Longer operative duration (>2 hours) was significantly associated with higher SSI rates.

Table 3: Association of Intraoperative Factors with Surgical Site Infections

Increased blood loss and improper antibiotic timing were significantly associated with higher SSI rates.

Table 4: Association of Wound Classification with Surgical Site Infections

Contaminated and dirty wounds showed significantly higher infection rates compared to clean wounds.

the relationship between the duration of operation, intraoperative variables, and surgical site infections (SSIs) was assessed in general surgery patients [10]. The total SSI rate seen in this study was 28, which is relatively high compared to the reported rates in the recent literature of between 7 and 22.9. This difference could be explained by the disparity in the hospital's setting and characteristics of patients, as well as procedures of infection control, especially in conditions of limited resources [11]. The length of operation became a very important predictor of SSI in this study, and those procedures taking over 2 hours were significantly more infected (40% vs. 16%, p=0.01). These results are in line with recently conducted studies that have shown that long operative time is a major risk factor of SSI, as it exposes the tissues to a greater risk of tissue exposure, microbial contamination, and a decrease in tissue perfusion. A 2025 systematic review further substantiates that longer surgical time is a primary modifiable intraoperative determinant affecting postoperative infections [12,13]. Our study also found a significant association between intraoperative blood loss and SSIs (p = 0.03). Patients who lost more than 500 ml of blood were more likely to be infected, and this is consistent with recent evidence that blood transfusion and intraoperative bleeding are major risk factors of infection. Excessive blood loss can weaken immune response and tissue oxygenation, thus putting patients at risk of infection [14]. The classification of wounds was strongly correlated with SSIs; contaminated and dirty wounds were more likely to have an infection (p = 0.002). This observation is consistent with several recent reports that have reported infection rates of up to 60% in contaminated surgical wounds. On the same note, recent observational studies have re-established that the level of wound contamination is one of the most significant predictors of SSI occurrence [15]. SSIs were more common with emergency surgery (35 percent) than with elective surgery, and this was not statistically significant (p = 0.06). The trend aligns with the recent literature, as they indicate higher infection rates when the emergency procedure is performed because of poor preoperative preparation and a high risk of contamination. Also, interventional research has demonstrated that specific infection management interventions may greatly decrease the occurrence of SSI, especially in emergencies [16]. Another important aspect of our study was the time of antibiotic prophylaxis. Early administration was linked with higher rates of SSI (p = 0.04), which aligns with the available evidence that antibiotics must be administered promptly to ensure efficient infection prevention. This emphasizes the need to follow surgical safety measures and standard procedures [17]. Though gender did not prove to have a significant relationship with SSIs in our study, other studies have yielded mixed results when it comes to demographic variables like age, comorbidities, and lifestyle habits. The recent systematic reviews highlight that the development of SSI is a multifactorial phenomenon that is related to patient-related, procedure-related, and environmental factors [18]. Generally, the results of the present study align with the current international evidence to support that long operating time, intraoperative blood loss, wound contamination, and timing of antibiotic administration are the main factors that lead to surgical site infection. These findings underscore the need to maximize intraoperative measures, enhance surgical productivity, and follow infection control measures [19]. Compared to previous research in the past five years, our results concur with the existing risk patterns and report useful local information that can be applied to the developing healthcare environments. In general surgery, modifiable intraoperative factors have the potential to greatly decrease the rates of SSI and positively influence patient outcomes [20].

Limitations

There are some limitations of this study, such as a relatively small sample size and a single-center design, which may not be generalizable. Possible confounding factors like comorbidity and nutritional status were not well controlled. Moreover, microbiological profiling of infections was not done, and a longer follow-up might give better results in assessing outcomes.

The risk of infections of the surgical site is high in the case of prolonged duration of operation and unfavorable intraoperative conditions. The use of proper infection control practices, the optimization of surgical practice, and timely antibiotic prophylaxis can help decrease the occurrence of SSI and enhance the overall patient outcomes in the practice of general surgery, especially in healthcare facilities with limited resources. Disclaimer: Nil Conflict of Interest: Nil Funding Disclosure: Nil Authors Contributions Concept & Design of Study:Ghulam Younus1 Drafting:Tahir Ullah2 Data Collection & Data Analysis:Arsalan khan3 Critical Review: Muhammad Noor khan Final Approval of version: All Mentioned Authors Approved the Final Version.

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