Standardized surgical technique for single-port totally extraperitoneal inguinal hernia repair using the glove method with an intraumbilical incision

Yoshiro Imai; Yusuke Suzuki; Mitsuhiro Asakuma; Yoshiharu Miyamoto; Hideki Tomiyama; Sang-Woong Lee

doi:10.1371/journal.pone.0334049

Peer Review History

Original SubmissionApril 11, 2025
12 Aug 2025 Decision Letter - Iwaho Kikuchi, Editor Dear Dr. Imai, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Sep 26 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. 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If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Yes Reviewer #2: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: N/A ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: 1. Were pain scores, return-to-work time, or patient satisfaction evaluated??? These metrics would strongly support claims of cosmetic and postoperative pain benefits. 2. Clarify abbreviations at first mention (e.g., STEP, TEP, CTEP). 3. Discuss the learning curve and how this method fits into surgical training more explicitly. 4.Ethical approval is appropriately stated. However, a brief clarification on how patient anonymity and data protection were maintained would be appreciated. Reviewer #2: Dear authors, Thank you for the opportunity to review the paper titled “Standardized Surgical Technique for Single-Port Totally Extraperitoneal Inguinal Hernia Repair Using the Glove Method with an Intraumbilical Incision.” Below are my comments Abstract: line 40-42: we present the surgical outcomes at our institution for a surgeon in their eighth year of practice with 40 cases of experience with STEP in this surgical procedure. Mentioning the volume of cases done before is confusing to the readers. Was the purpose of this to verify that surgeon was beyond the learning curve? If so, please clarify it in the methodology, and perhaps reflect on how that is relevant in general when learning new techniques in the discussion. Line 99: We present a standardized STEP technique.. – Was this described before? Is it standardized internationally or locally in your service This statement doesn’t state the aim of this paper clearly. To me this seems to be a paper assessing feasibility of a technique modification with a young surgeon, this involves ease of learning, and safety (patient related outcomes). Choice of aim will reflect on outcomes. From surgeon’s perspective: discomfort/ease of operating, operative time, #cases during learning curve (reported later), need for conversion or redo From a patient’s perspective, post-op pain, infection, need for admission, need for re-operation. It would be helpful to provide a control group (if real-time is not available, then historical) for CTEP in your institution and how it compares to STEP. Line 117: “From April to October 2023, he performed 29 STEP procedures with the same assistance” - Verify the total number of cases 25 vs 29 Choice of words: it might be better to use standard terminology such as early career surgeon instead of young surgeon. The latter reflects on age more than experience. ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #1: Yes: Sakarie Mustafe Hidig M.D. Reviewer #2: Yes: Noora Alshahwani ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. Attachments Attachment Submitted filename: Step hernia repair.pdf https://doi.org/10.1371/journal.pone.0334049.r001
Revision 1
10 Sep 2025 Author Response Dear Editor: We thank you and the reviewers for your thoughtful suggestions and insights. The manuscript has benefited from these insightful suggestions. I look forward to working with you and the reviewers to move this manuscript closer to publication in PLOSONE. The manuscript has been rechecked and the necessary changes have been made (using track changes mode/red font) in accordance with the reviewers’ suggestions. The responses to all comments have been prepared and attached herewith/given below. We have also had native English speakers check our manuscript. Thank you for your consideration. I look forward to hearing from you. Responses to Reviewer Comments To Reviewer #1 Reviewer’s comment 1 Were pain scores, return-to-work time, or patient satisfaction evaluated??? These metrics would strongly support claims of cosmetic and postoperative pain benefits. Response to comment 1 Thank you very much for your insightful comment. This study describes a surgical technique with minimal incisions; however, postoperative pain scores, return-to-work time, and patient satisfaction were not directly evaluated. We agree that these parameters would strongly support the assessment of cosmetic and pain-related benefits. This limitation has been explicitly acknowledged in the revised limitations section. (lines 300-303) Reviewer’s comment 2 Clarify abbreviations at first mention (e.g., STEP, TEP, CTEP). Response to comment 2 Thank you for pointing this out. We have clarified all abbreviations at their first mention (e.g., STEP, TEP, CTEP) in the revised manuscript. (lines65,66 97,101,102) Reviewer’s comment 3 Discuss the learning curve and how this method fits into surgical training more explicitly. Response to comment 3 Thank you for your valuable suggestion. We have expanded the discussion of the learning curve and surgical training. Specifically, we added the following sentence at the end of the Results section:“Figure 6 shows the learning curve of STEP as performed by the early career surgeon. The operative time decreased gradually after 20 cases and stabilized after 40 cases.” In addition, Figure 6 has been included to illustrate this point more explicitly. (lines 230-232, 439-441) Reviewer’s comment 4 Ethical approval is appropriately stated. However, a brief clarification on how patient anonymity and data protection were maintained would be appreciated. Response to comment 4 Thank you for your valuable suggestion. Patient anonymity and data protection were strictly maintained in accordance with institutional ethics committee approval. To clarify this point, we have added the following sentence to the Materials and Methods section: “All datasets were anonymized before analysis, and no personal identifiers were used.” (line 135) To Reviewer #2 Reviewer’s comment 1 Abstract: line 40-42: we present the surgical outcomes at our institution for a surgeon in their eighth year of practice with 40 cases of experience with STEP in this surgical procedure. Mentioning the volume of cases done before is confusing to the readers. Was the purpose of this to verify that surgeon was beyond the learning curve? If so, please clarify it in the methodology, and perhaps reflect on how that is relevant in general when learning new techniques in the discussion. Choice of words: it might be better to use standard terminology such as early career surgeon instead of young surgeon. The latter reflects on age more than experience. Response to comment 1 Thank you for your pertinent suggestion. As you pointed out, mentioning the number of preoperative cases could be confusing, so we have removed it. The intention was to indicate that the surgeon was not beyond the learning curve of conventional TEP, and we have clarified this point in the revised methodology. Furthermore, as you suggested, we have changed the wording from “young surgeon” to “an early career surgeon.” This revision emphasizes that the technique can be mastered even by an early career surgeon. (lines 78) (lines 85,126,219,287,307) Reviewer’s comment 2 Line 99: We present a standardized STEP technique. – Was this described before? Is it standardized internationally or locally in your service. Response to comment 2 Thank you for your valuable suggestion. The term “standardized” in this context refers to the procedure as it has been standardized within our institution, rather than an internationally established standard. To clarify this, we have revised the sentence to: “We present our institution’s standardized STEP technique.” Furthermore, we have clarified in the Introduction that the purpose of this paper is to assess the feasibility and safety of this technique when performed by an early career surgeon, with particular emphasis on ease of learning and patient-related outcomes. (lines 110, 112-114) Reviewer’s comment 3 Choice of aim will reflect on outcomes. From surgeon’s perspective: discomfort/ease of operating, operative time, #cases during learning curve (reported later), need for conversion or redo From a patient’s perspective, post-op pain, infection, need for admission, need for re-operation. It would be helpful to provide a control group (if real-time is not available, then historical) for CTEP in your institution and how it compares to STEP. Response to comment 3 Thank you for your thoughtful suggestion. While comparison with CTEP would indeed be valuable, our institution has not implemented CTEP, and therefore a direct comparison—either real-time or historical—is not feasible. Instead, we have emphasized in the revised manuscript that the purpose of this study is to demonstrate the feasibility and safety of STEP as performed by an early career surgeon. In addition, we highlight in the Discussion that, although we cannot provide direct institutional CTEP data, our results suggest that the learning curve of STEP does not appear longer than what has been reported for conventional CTEP in the literature. (lines 281-286) Reviewer’s comment 4 “From April to October 2023, he performed 29 STEP procedures with the same assistance” - Verify the total number of cases 25 vs 29 Response to comment 4 I apologize for the previous lack of clarity. We have performed STEP in 29 cases in total, consisting of 25 unilateral inguinal hernias and 4 bilateral inguinal hernias. In other words, STEP was also applied to bilateral cases. To clarify this point, we have revised the statement accordingly in the manuscript. (lines 221-222) Attachments Attachment Submitted filename: Response to Editor - 2.docx https://doi.org/10.1371/journal.pone.0334049.r002
15 Sep 2025 Decision Letter - Iwaho Kikuchi, Editor Standardized Surgical Technique for Single-Port Totally Extraperitoneal Inguinal Hernia Repair Using the Glove Method with an Intraumbilical Incision PLOS ONE Dear Dr. Imai, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Oct 30 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . We look forward to receiving your revised manuscript. Kind regards, Iwaho Kikuchi, Ph. D., M.D. Academic Editor PLOS ONE Journal Requirements: 1. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. [Note: HTML markup is below. Please do not edit.] [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0334049.r003
Revision 2
15 Sep 2025 Author Response Thank you very much for your comment. As no specific references were recommended by the reviewer, we did not make any additional citations. Attachments Attachment Submitted filename: Response to Reviewers 3.docx https://doi.org/10.1371/journal.pone.0334049.r004
23 Sep 2025 Decision Letter - Iwaho Kikuchi, Editor Standardized Surgical Technique for Single-Port Totally Extraperitoneal Inguinal Hernia Repair Using the Glove Method with an Intraumbilical Incision PONE-D-25-16954R2 Dear Dr. Imai, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Iwaho Kikuchi, Ph. D., M.D. Academic Editor PLOS ONE Additional Editor Comments (optional): Thank you for your thorough revisions and thoughtful responses to the reviewers’ and editorial comments. The manuscript has been carefully reviewed and is now considered acceptable for publication in PLOS ONE. We appreciate your contribution and look forward to sharing your work with the broader scientific community. Reviewers' comments: https://doi.org/10.1371/journal.pone.0334049.r005
Formally Accepted
Acceptance Letter - Iwaho Kikuchi, Editor PONE-D-25-16954R2 PLOS ONE Dear Dr. Imai, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Iwaho Kikuchi Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0334049.r006

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