271 When Planes Collide: Technical Challenges in Open Inguinal Hernia Repair Following Robotic-Assisted Laparoscopic Prostatectomy

Abstract As combined minimally invasive procedures become more common, new technical challenges are emerging. We present a case of a 68-year-old male undergoing elective robotic-assisted laparoscopic prostatectomy (RALP) for prostate cancer, followed immediately by an open right-sided inguinal hernia repair in the same session. While intended to streamline patient care by avoiding multiple admissions, the sequence introduced significant operative complexity. The RALP was performed via a transperitoneal approach with standard pelvic and preperitoneal dissection. During the subsequent open hernia repair via a separate groin incision, the surgeon encountered markedly altered anatomy. Preperitoneal dissection from the RALP had disrupted the normal tissue planes, making identification of the spermatic cord structures and the hernia sac difficult. The distorted planes increased operative time and raised the risk of inadvertent injury. A further concern was the theoretical risk of mesh contamination from potential urinary leakage at the urethrovesical anastomosis site. Despite these challenges, the repair was completed successfully using a Lichtenstein technique with mesh. The patient recovered without complication and remained well on follow-up, with no hernia recurrence or mesh-related issues. This case highlights the anatomical disruption caused by RALP and its implications for subsequent hernia repair, particularly regarding mesh safety and technical difficulty. In select patients, a staged approach or pre-prostatectomy laparoscopic hernia repair may be safer alternatives. As synchronous procedures become more frequent, further evidence and surgical guidance are needed to support multidisciplinary decision-making and improve outcomes.