Pubic Symphysis Stress Reaction and Pelvic Girdle Myositis Following Robotic-Assisted Inguinal Hernia Repair: A Case Report and Brief Review of the Literature.

This report presents an unusual case of persistent groin and lower abdominal pain following robotic-assisted inguinal hernia repair (R-IHR), along with a brief review of the literature. To our knowledge, this is the first reported case of pubic symphysis stress reaction with adjacent pelvic girdle myositis following R-IHR, a musculoskeletal complication pairing not previously described in the hernia repair or robotic surgery literature. Imaging findings revealed edema and capsular hypertrophy at the pubic symphysis with diffuse pelvic girdle myositis on magnetic resonance imaging (MRI), findings not captured on computed tomography (CT), suggesting a postoperative biomechanical mechanism. The specific robotic surgical technique (transabdominal preperitoneal vs. totally extraperitoneal) used in this case could not be confirmed, as the original operative report was not available to the authors at the time of this report; the general term R-IHR is used throughout to reflect this uncertainty. A 41-year-old physically active man presented more than one year after R-IHR, complaining of progressively worsening right groin and lower abdominal pain. The pain was moderate to severe, dull, and aching, with intermittent sharp, stabbing episodes. It was exacerbated by bending, coughing, bowel movements, prolonged sitting, recumbency, exercise, and sexual activity. He reported no weakness, bowel or bladder dysfunction, or systemic symptoms. Examination revealed focal tenderness in the right inguinal region and right lower abdominal quadrant without rebound tenderness, no signs of psoas involvement, and normal strength, range of motion, neurologic function, and gait. Pelvic CT was unremarkable, showing only bilateral hydroceles. Pelvic MRI demonstrated edema and capsular hypertrophy along both sides of the pubic symphysis, with multifocal intramuscular enhancement in the right gluteus medius, bilateral adductor muscles, and gluteus maximus, consistent with myositis. Inflammatory laboratory workup was negative. The Douleur Neuropathique 4 questionnaire indicated nociceptive rather than neuropathic pain. These findings suggest that biomechanical stress and microtrauma to the pubic symphysis during surgery initiated a local inflammatory cascade. The patient had declined postoperative physical therapy, citing high baseline fitness; prolonged activity restriction over 12 months provided no relief. Persistent groin pain following R-IHR warrants consideration of pubic symphysis stress reaction and adjacent myositis, particularly when CT is nondiagnostic and neurologic examination is normal. MRI may be necessary to identify underlying musculoskeletal pathology and guide management. This case further highlights the clinical risk of physically fit patients declining structured rehabilitation; general conditioning does not substitute for targeted postoperative physical therapy.