This document reviews the literature on the use of TAPP and TEP procedures for complicated hernias such as scrotal, incarcerated, recurrent, and femoral hernias. It provides recommendations on the use of laparoscopic techniques in different clinical scenarios and complication settings. The recommendations are based on evidence levels ranging from I to IV, with level I evidence existing for use of TAPP and TEP in recurrent hernias compared to open repair. Surgeon experience is emphasized as an important factor for many of the more complex cases.

1. TAPP and TEP in the Complicated Hernia: Scrotal, Strangulated and RecurrentA review of the literature and management recommendations G. Ferzli, MD, USA J. Schwarz, MD, Germany U Steinhilper, MD, Germany

2. Level of evidence (based on AHCPR 1992) Ia - Evidence obtained from meta-analysis of randomized controlled trials. Ib - Evidence obtained from at least one randomized controlled trial. IIa - Evidence obtained from at least one well-designed controlled study without randomization. IIb - Evidence obtained from at least one other type of well-designed quasi-experimental study. III - Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case control studies. IV - Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.

3. Grade of recommendation(based on AHCPR 1994) A (Levels Ia, Ib) - Requires at least one randomized control trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation. B (Levels IIa, IIb, III) - Requires availability of well-conducted clinical studies but no randomized clinical trials on the topic of recommendation. C (Level IV) - Requires evidence from expert committee reports or opinions and/or clinical experience of respected authorities. Indicates absence of directly applicable studies of good quality.

4. 1. TAPP and TEP For Scrotal Hernias? Recommendation: TAPP and TEP may be safely used for scrotal hernias with good results and minimal morbidity when performed by surgeons with a higher level of experience in either technique. 1, 2, 3 Level of evidence: III

5. 2. TAPP and TEP for incarcerated hernia? Recommendation: TAPP may be used in the repair of chronically or acutely incarcerated inguinal hernias with limited recurrence, morbidity or mortality, but the technique should be reserved for surgeons with extensive experience in the TAPP technique. 3, 4, 5, 6, 7, 8 Recommendation: TEP may used for repair of both acutely and chronically incarcerated inguinal hernias, however, data on the subject is scarce. 9, 10, 11 Level of evidence: III

6. 3. TAPP and TEP for incarcerated femoral hernia? Recommendation: Incarcerated femoral hernia may be safely repaired via the TAPP or TEP approach using either a plug in the femoral canal or a preperitoneal mesh. 5, 9, 14, 15, 16 Level of evidence: IV

7. 4. TAPP and TEP in the setting of peritonitis and bowel necrosis ? Recommendation: Laparoscopic repair of incarcerated inguinal hernia should be avoided in the setting of peritonitis or if an infected abdominal wall or intra-abdominal cavity is found on laparoscopic exploration. 4, 6, 9 Level of evidence: IV

8. 5. TAPP and TEP forrecurrent inguinal hernia? Recommendation: TAPP for repair of recurrent inguinal hernia is an excellent alternative to both tissue repair and to the Lichtenstein repair for recurrence after prior anterior repair. TAPP for recurrent hernia should only be performed by surgeons with extensive experience in the TAPP technique. 17, 18, 19, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38 Recommendation: TEP for repair of recurrent inguinal hernia is an excellent alternative to both tissue repair and to the Lichenstein repair for recurrence after prior anterior repair. TEP for recurrent hernia is technically challenging and should only be performed by surgeons with extensive experience in TEP.17, 18, 26, 31, 38, 40, 41, 44, 45, 46, 47, 48, 49, 50, 51, 52 Recommendation: Compared to open repair, TAPP and TEP have a better profile in terms of level of pain and return to regular activity. 24, 25, 26, 27, 28, 42, 53, 54, 55, 56 Level of evidence: Ib

9. 6. TAPP after TAPP? Recommendation: TAPP repair of recurrent inguinal hernia after prior TAPP may be performed with good results but the learning curve is high and it should only be attempted by experts in TAPP inguinal hernia repair. 17, 28, 57, 58, 59 Level of evidence: III

10. 7. TEP after TEP? Extremely difficult Not advisable, except in the setting of re-TEP for controlateral side Level of evidence: IV

11. 8. What to do with the old mesh? Recommendation: Old mesh from prior laparoscopic hernia repair encountered during laparoscopy for recurrence should be left in place in order to avoid injury to the iliac vein or the bladder. A new mesh may placed over the old. When an old plug is encountered which does not allow placement of a flat mesh, the plug may be best cut away with the use of electrocautery. Level of evidence: IV

12. 9. TAPP and TEP for occult synchronous hernia? Recommendation: TAPP and TEP repair of recurrent inguinal hernia allow for easy identification of the occult femoral or obturator hernia, and of concomitant contralateral hernia. Furthermore, the laparoscopic approach obliterates these associated occult synchronous or potential hernias utilizing a single repair without any particular modification to the technique. 30, 60, 61, 62 Level of evidence: IV

13. 10. Recurrence after TAPP or TEP in a patient with prior open mesh repair? Redo TAPP? Level of evidence: IV