However, mastering the technique mandates not only finishes inhibitor CHIR99021 the operation in short time without conversion but also performs the operation with low recurrence rates. It could be helpful to separate two phases of learning curve as immediate and late. Therefore, we and others propose that an inexperienced beginner surgeon should perform at least 20 cases in accordance with the principles of endoscopic TEP inguinal hernia repair to become a familiar surgeon [9]. The exact number for becoming an experienced surgeon which is most probably more than 20 cases should be evaluated with future prospective studies. Perceived pressure of the surgeons to complete the operations expediently was thought to be responsible for the high conversion rate which has been frequently experienced during endoscopic TEP inguinal hernia repair with an incidence of 2%�C17% [8, 13].

Although our conversion rate during the first 21 cases was higher, we did not encounter any conversion during the second part of this study in accordance with Lal’s findings [7]. Some authors have mentioned that more than 50 cases were required for the surgeons who were unfamiliar with preperitoneal space [7]. However, adequate perception of the preperitoneal anatomy with careful dissection can be gathered during the first 20 cases without causing any morbidity according to the present study. Appropriate patient selection has been shown to be an important parameter for the success of the operation during early period. Irreducible hernias, hernias in patients with previous lower quadrant surgery, have been excluded in several early TEP series [3, 14].

Certain patient characteristics including female gender, higher BMI, previous history of abdominal surgery, and scrotal and bilateral hernias were also shown to be important for the high risk of conversion and intraoperative complications even for experienced surgeons. However, liberal inclusion of the patients in to the study including recurrent and sliding hernias was applied during the learning curve of this study which might affect our high conversion rate. It could be possible to diminish the conversion rate in our study, if the strict inclusion criteria were used. Indeed, it is recommended to select relatively younger and slender male patients less than 60 years of age with unilateral, nonscrotal primary inguinal hernia during the learning period for TEP inguinal hernia repair [8, 14].

It has been also shown that the presence of an experienced endoscopic hernia surgeon or performance of previous Stoppa’s procedures prevents Batimastat unnecessary recurrences caused by surgical errors and helps overcome the difficulty which has been experienced during the learning period [7, 8]. Experience with preperitoneal space anatomy is the most important factor for performing the posterior approaches either through open or endoscopic approaches [7, 15].