• Allison Hirst, Yiannis Philippou, Jane Blazeby, Bruce Campbell, Marion Campbell, Joshua Feinberg, Maroeska Rovers, Natalie Blencowe, Christopher Pennell, Tom Quinn, Wendy Rogers, Jonathan Cook, Angelos G Kolias, Riaz Agha, Philipp Dahm, Art Sedrakyan, and Peter McCulloch.
• Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
• Ann. Surg. 2019 Feb 1; 269 (2): 211-220.

ObjectiveTo update, clarify, and extend IDEAL concepts and recommendations.BackgroundNew surgical procedures, devices, and other complex interventions need robust evaluation for safety, efficacy, and effectiveness. Unlike new medicines, there is no internationally agreed evaluation pathway for generating and analyzing data throughout the life cycle of surgical innovations. The IDEAL Framework and Recommendations were designed to provide this pathway and they have been used increasingly since their introduction in 2009. Based on a Delphi survey, expert workshop and major discussions during IDEAL conferences held in Oxford (2016) and New York (2017), this article updates and extends the IDEAL Recommendations, identifies areas for future research, and discusses the ethical problems faced by investigators at each IDEAL stage.MethodsThe IDEAL Framework describes 5 stages of evolution for new surgical therapeutic interventions-Idea, Development, Exploration, Assessment, and Long-term Study. This comprehensive update proposes several modifications. First, a "Pre-IDEAL" stage describing preclinical studies has been added. Second we discuss potential adaptations to expand the scope of IDEAL (originally designed for surgical procedures) to accommodate therapeutic devices, through an IDEAL-D variant. Third, we explicitly recognise the value of comprehensive data collection through registries at all stages in the Framework and fourth, we examine the ethical issues that arise at each stage of IDEAL and underpin the recommendations. The Recommendations for each stage are reviewed, clarified and additional detail added.ConclusionsThe intention of this article is to widen the practical use of IDEAL by clarifying the rationale for and practical details of the Recommendations. Additional research based on the experience of implementing these Recommendations is needed to further improve them.

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