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 years. Indirect, direct, and combined hernias were present in 18, 12, and 12 cases, respectively. The mean operative time was 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%, ) and all conversions ( ) 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. 1. Introduction Totally extraperitoneal (TEP) inguinal hernia repair has gained popularity in the recent two decades since the first introduction in 1992 by Dulucq [1]. It offers a hernia repair of minimal incisions with more favorable postoperative course including less pain and quicker return to work especially more pronounced in bilateral inguinal hernia [2]. However, this technique requires specialized anatomical knowledge, two-hand manipulation for reduction of hernia sac, and mesh placement within a limited working space. Therefore, acceptance and implementation of this technique have been slow compared to the adoption of other minimal invasive procedures such as cholecystectomy [3, 4]. In addition to the technical dexterity, there are some drawbacks for the common adoption of this technique including increased operative times, complications during the early learning curve, and almost absolute necessity for general anesthesia [5, 6]. Consequently, the learning curve of TEP inguinal hernia repair for the inexperienced surgeons carries paramount importance. However, the exact nature of learning curve and the number required to master the technique are still focus of a debate. There are a limited number of studies evaluating the learning curve for TEP inguinal hernia repair [2, 3, 7, 8]. Although there were some numerical suggestions beginning from 20 cases, the required number
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