Background: Laparoscopic repair of scrotal hernias is often a difficult endeavor to successfully complete. The longstanding nature of these hernias often results in significant adhesions and anatomic distortion of the inguinal floor. These two issues make reduction of the hernia arduous and subsequent reinforcement of the parietal sac difficult. We have previously described techniques to increase the chances of success when attempting laparoscopic repair of scrotal hernias. Here, we describe some of those techniques as well as a combined laparoscopic and open approach to achieve a robust preperitoneal repair of incarcerated scrotal hernias when the usual totally extraperitoneal approach does not work. Patients and methods: We performed a retrospective review of 1890 TEP hernia repairs we performed from 1990 to 2010. Rate of conversion to an open approach or a combined laparoscopic and open approach was examined. Incidence of complications or recurrences was assessed over a 12-month follow-up period. Results: Among the 1890 TEP repairs, 94 large scrotal hernias were identified. Of these, nine cases (9.5 %) required conversion to an open procedure due to an incarcerated and indurated omentum. Three were completed with a conventional open preperitoneal whereas six patients (6.4 %) underwent repair with the combined approach. In this group, no recurrences or complications were found over a 12-month period. Conclusion: In cases where a large scrotal hernia may be difficult or dangerous to reduce laparoscopically, immediate conversion to an open repair may not be necessary. A combined laparoscopic and open approach can greatly assist in the visualization and dissection of the preperitoneal space, thereby facilitating reduction of the hernia and placement of the mesh.