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Dear Editors

Comment on:

Stenstra MHBC, van Workum F, van den Wildenberg FJH, Polat F, Rosman C. Evolution of the surgical technique of minimally invasive Ivor-Lewis esophagectomy: description according to the IDEAL framework. Dis Esophagus. 2018 Sep 21. doi: 10.1093/dote/doy079. [Epub ahead of print] PubMed PMID: 30,247,660.

We would like to commend the authors of this paper on applying the IDEAL Framework1 to their description of the development of a new surgical technique (Ivor–Lewis TMIE). The information for the reader has been considerably enhanced by the details they include about iterative changes made and lessons learned during the experience in consecutive patients. The authors label this study as an IDEAL Stage 2b (Exploration). We would suggest that this study is in fact a very good example of a Stage 2a study (Development). This may not have been clear to the authors due to a number of weaknesses in the descriptions of the stages of evolution of innovation in the original IDEAL publication in 2009.1 In a recent survey of publications citing IDEAL, we noted that authors of IDEAL stage studies found reporting of some key characteristics of surgical innovation challenging.2

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