DONe: what must be seen before the mesh goes in during eTEP ventral hernia repair

Dissection and Defect: The space reaches its planned limits with room for the planned overlap; the anterior defect is closed.
Openings: The posterior sheath and peritoneum are intact, or every opening is closed; both semilunar lines are preserved.
Neurovascular bundles: The intercostal neurovascular bundles are preserved.
eTEP: The operation: laparoscopic or robotic, with or without transversus abdominis release.

What must be seen before the mesh goes in

DONe will define a concise set of video-verifiable safety criteria for eTEP ventral hernia repair through an international expert consensus.

eTEP needs a check that a viewer can verify

eTEP is now widely used to reach the retromuscular plane, and it is technically demanding. A prospective series of 125 laparoscopic eTEP repairs in three centres reported these intraoperative events.

Injury to the linea alba: 6.4%
Major bleeding during posterior sheath dissection: up to4.8%
Conversion to open (2.4%) or hybrid (5.6%) repair: 8.0%

Two operations already have a critical view

1995Critical view of safetyLaparoscopic cholecystectomy
2017Critical view of the myopectineal orificeLaparoscopic groin hernia repair
NowDONeeTEP ventral hernia repair

Existing eTEP work describes how to perform the operation: ten standardised steps, anatomical signs and landmarks, and robotic procedural steps agreed by 50 surgeons from 20 countries. None of it defines what an independent viewer must be able to confirm on the recording before the irreversible step.

Three domains, checked on the recording

Each domain becomes one or more criteria that an independent viewer can confirm on the video. Before the mesh goes in, the surgeon should be able to say “done” to each of them. The fourth letter names the operation.

The expert consensus will determine the final criteria and their mapping to these domains.

Where each domain is checked: a schematic half-section of the abdominal wall after eTEP Rives–Stoppa repair, not to scale. The mesh crosses the midline behind the linea alba; the bundles enter the rectus at the lateral edge of the space.

BinaryEach criterion is met or not met, with no grading.
VisibleEach criterion can be confirmed on a still frame or a short clip.
TransferableThe set applies to laparoscopic and robotic eTEP, with or without TAR.
ShortA compact set of criteria for use in the operating room.

Two answers for every statement

An anonymous modified e-Delphi with up to three online rounds, a closing virtual meeting and a separate anonymous ratification ballot. Registration of interest is open to abdominal wall surgeons, including those performing open retromuscular repair or TAR. The current Delphi panel is selected separately on the basis of ventral eTEP expertise. Protocol and survey details will be available before the first consensus round. Reporting is planned to follow ACCORD and CREDES.

Example statement I08 Lateral limit

Lateral dissection stops medial to the semilunar line.

The two answers are independent. “Unable to judge” is left out of the verifiability denominator.

How statements qualify as DONe criteria

of submitted eligible ballots rate it 7–9: ≥70%
rate it 1–3: ≤15%
give a determinate video judgment: yes or no: ≥50%
of determinate video judgments are yes: ≥70%

Recommendation: The importance thresholds and determinate-judgment coverage are met, but fewer than 70% of yes/no judgments are yes.
Excluded: At least 70% rate it 1–3.
Re-rated: Other results remain unresolved for possible re-rating.

Conclusive classification requires at least 15 eligible submitted ballots in the round. Insufficient determinate video coverage leaves a statement unresolved. The study has a maximum of three Delphi rounds.

Round 1Twenty-five candidate statements, with space for experts to suggest additional items. Items 23–25 form a separate post-placement block.
FeedbackEach panellist sees the group’s distribution beside their own previous rating.
Round 2Unresolved and newly proposed statements are rated again.
Round 3A final Delphi round for unresolved statements, when needed.
FinalisationA closing meeting discusses wording. A separate anonymous ballot ratifies final proposals under the prespecified rules.

An international panel of eTEP surgeons

Experienced eTEP surgeons assess each proposed criterion independently for clinical importance and video verifiability.

Expertise: Experienced independent ventral eTEP surgeons with teaching, proctoring or research activity.
Balance: At least four world regions, none above 40% of the panel.
Time: 15–20 minutes per round over two or three rounds, plus an optional one-hour closing meeting.
Privacy: Each panellist answers through a personal link under a panel code. Individual ratings are never published in identifiable form.

Registration is also open to surgeons performing open retromuscular repair or TAR who want to hear about future research. The organising committee selects the current Delphi panel separately, considering ventral eTEP experience, academic contributions and geographic representation. Registration does not guarantee an invitation.

From consensus to audit

ReliabilityPlanned evaluation by blinded raters, including a novice, using unedited recordings to measure agreement for each criterion.
ValidityPlanned testing of whether DONe distinguishes experts from surgeons in training and reflects each surgeon’s learning curve.
TrialsPlanned use as a standardisation measure in randomised trials of eTEP Rives–Stoppa repair.
AutomationPlanned use of the reference frames to evaluate automated video assessment.

Study information

Email: info@donestudy.com
Protocol: Protocol and survey details will be available before the first consensus round

DONe: what must be seen before the mesh goes in during eTEP ventral hernia repair DONe