A New Proposal for Learning Curve of TEP Inguinal Hernia Repair: Ability to Complete Operation Endoscopically as a First Phase of Learning Curve

Background. The exact nature of learning curve of totally extraperitoneal inguinal hernia and the number required to master this technique remain controversial. Patients and Methods. We present a retrospective review of a single surgeon experience on patients who underwent totally extraperitoneal inguinal hernia repair. Results. There were 42 hernias (22 left- and 20 right-sided) in 39 patients with a mean age of 48.8 ± 15.1 years. Indirect, direct, and combined hernias were present in 18, 12, and 12 cases, respectively. The mean operative time was 55.1 ± 22.8 minutes. Peritoneal injury occurred in 9 cases (21.4%). Conversion to open surgery was necessitated in 7 cases (16.7%). After grouping of all patients into two groups as cases between 1-21 and 22-42, it was seen that the majority of peritoneal injuries (7 out of 9, 77.8%, P = 0.130) and all conversions (P = 0.001) occurred in the first 21 cases. Conclusions. Learning curve of totally extraperitoneal inguinal hernia repair can be divided into two consequent steps: immediate and late. At least 20 operations are required for gaining anatomical knowledge and surgical pitfalls based on the ability to perform this operation without conversion during immediate phase.